Transcript Year End 2014 96.9% 227 charts audited

Quality & Patient Satisfaction
Exceeding National Standards
with a Growing Program
Quality Improvement Initiatives Data
Program Growth: Same Day Admission Process
Admissions
Average Daily
Census
Year End 2014
258
47
Year End 2015
365
77
Year-to-date 2016
101
Quality Chart Reviews
Patient’s pain at their SIT within 48 hours
Year End 2014
89.4%
227 charts audited: 42 yes, 5 no, 180 n/a
Year End 2015
93.8%
294 charts audited: 60 yes, 4 no, 230 n/a
CAHPS Data
May 2016 – May 2016
Patient got as much help with pain as needed (Yes, definitely)
Casa Grande
Deyta %
Performance (National Avg.)
88.2%
84.3%
Program initiatives for improvement:
• Created process with local pharmacies to have emergency pain medications
in stock in their pharmacies to ensure availability at time of admission
Quality Chart Reviews
Quality/Service
Patient’s above SIT in the last week of life
Year End 2014
4.3%
116 charts audited: 5 yes, 111 no
Year End 2015
7.4%
294 charts audited: 11 yes, 137 no, 146 n/a
CAHPS Data
May 2016 – May 2016
Patient got as much help with pain as needed (Yes, definitely)
Casa Grande
Deyta %
Performance (National Avg.)
88.2%
84.3%
Program initiatives for improvement:
• New colleague education on initiative, increased GIP admissions at local
hospital had on service for less than 5 days
Quality Chart Reviews
Quality/Service
Bowel regimen initiated within one day of opiod initiation
Year End 2014
94.8%
219 charts audited: 164 yes, 9 no, 54 n/a
Year End 2015
99.5%
294 charts audited: 197 yes, 1 no, 96 n/a
CAHPS Data
May 2016 – May 2016
Patient received help for constipation (Always)
Casa Grande
Deyta %
Performance (National Avg.)
71.3%
56.3%
Program initiatives for improvement:
• Director of Clinical Services reviews medication regimen with admitting
nurse to ensure all patients on opiods have an order for a bowel regimen
Quality Chart Reviews
Quality/Service
Dyspnea improved within one day
Year End 2014
74%
227 charts audited: 91 yes, 32 no, 104 n/a
Year End 2015
88.6%
294 charts audited: 132 yes, 17 no, 145 n/a
CAHPS Data
May 2016 – May 2016
Patient received help for trouble breathing (Always)
Casa Grande
Deyta %
Performance (National Avg.)
86.4%
81.8%
Program initiatives for improvement:
• All patients with dyspnea on admission are reviewed at daily standup, a copy
of admission assessment is give to nurse who performs 24-hour follow-up to
assess effectiveness of admissions interventions
Quality Chart Reviews
Quality/Service
Was there evidence of teaching re: medication, treatment, symptoms?
Year End 2014
96.9%
227 charts audited: 220 yes, 7 no
Year End 2015
97.6%
294 charts audited: 287 yes, 7 no
CAHPS Data
May 2016 – May 2016
Understanding medication side effects
Casa Grande
Deyta %
Performance (National Avg.)
92.3%
73%
Program initiatives for improvement:
• Implemented a medication reconciliation form for patient’s home with stepby-step medication orders in lay terms to ensure patient/caregiver
understanding of doses, indication, frequency and
potential side effects to alert the hospice care team
Quality Chart Reviews
Quality/Service
Was there evidence of teaching re: medication, treatment, symptoms?
Year End 2014
96.9%
227 charts audited: 220 yes, 7 no
Year End 2015
97.6%
294 charts audited: 287 yes, 7 no
CAHPS Data
May 2016 – May 2016
Understanding medication side effects
Casa Grande
Deyta %
Performance (National Avg.)
92.3%
73%
Program initiatives for improvement:
• Medical Director home visits for high-risk patients who need physician
input/reassurance on medication management
2015 Program of the Year
Casa Grande
Cheryse Austin
Laura Stager
Laura Harris
Monica White
Taylor Austin
Brittany Padilla
Kari Davis
Monica Hulsey
Veniece Kennedy
Edward Marquez
Becky Ross
Shari Renner
Rebecca Uhrich
Crystal Battraw
Cynthia Choate-Green
Irisan Manalo
Alexandra Peterson
Cindy Hilgeman
Nikki Ruggles
Tammera Rogers
Gloria Rohl
Ulla Gilliland
Ketia Sanon
Linda Austin
Kyann Carson
Elena Coronado
Miguel Louis
Lora Nunez