NR Quality Performance
As part of Nursing Resources’ commitment to the highest standards
in patient care, the Director of Clinical Services oversees all
quality initiatives coordinated by the Performance Improvement Coordinator.
Quality performance of the agency's clinical operations and compliance
with documentation and regulations are monitored, tracked and
analyzed in the following areas throughout the year and statistical
results are presented to the Professional Advisory Board for review
and approval bi-annually:
• Patient Satisfaction Survey
• Physician Satisfaction Survey
• Referral Source Satisfaction Survey
• Patient Complaints
• Clinical Record Audits
• Infection Control
• Hospitalizations
• Incidents
• OASIS Outcomes (OBQM,OBQI)
• Home Health Compare
• Diabetic Management
Below, we are proud to share with you some of the excerpts from
our 2010 Year End Evaluation Report submitted to the Professional
Advisory Board.
Patient Satisfaction Surveys - 37 surveys
were mailed with a %78 response rate and with a rate of 100% satisfaction.
Physician Satisfaction Surveys – 35
surveys were mailed with a response rate of 62%. Rating breakdown
was 54% Excellent; 46% Good.
Referral Source Satisfaction Surveys
– 71% response rate on the surveys with excellent approval rate
which included comments such as: “They always have done their
best to ensure our patients’ needs are met.”
Clinical Record Audits to ensure conformance with
regulations – Audits are conducted in accordance
with Title 22 Regulations. A sample size of 5% of the total patient
census or a minimum of 20; a maximum of 100 patient records are
reviewed quarterly. The audits are based on pre-set criteria and
are to be reviewed with participation by each discipline providing
care.
The audit results for 2010 – included both concurrent
and retrospective reviews.
| |
|
Compliance Score (%) |
|
|
|
|
|
Compliance Score
Average (%) |
|
Performance Measures / Criteria's |
1st QTR |
2nd QTR |
3rd QTR |
4th QTR |
1st QTR |
2nd QTR |
Year 2009 |
| 1 |
Referral |
92.3 |
93 |
95.2 |
96.35 |
98.37 |
97.89 |
94.21 |
| 2 |
Initial Assessment |
100 |
100 |
100 |
100 |
100 |
100 |
100 |
| 3 |
Plan of Care |
100 |
99 |
100 |
98.08 |
99.06 |
100 |
99.27 |
| 4 |
Medication Profile |
100 |
100 |
100 |
100 |
99.61 |
100 |
100 |
| 5 |
Visit Notes |
97.2 |
938.35 |
99.3 |
98.44 |
98 |
100 |
98.32 |
| 6 |
Therapies |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 7 |
Home Health Aide |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
| 8 |
Care Coordination |
100 |
100 |
100 |
100 |
100 |
100 |
100 |
| 9 |
60 Day Summary |
100 |
100 |
100 |
100 |
100 |
100 |
100 |
10 |
Discharge |
100 |
92 |
100 |
100 |
100 |
100 |
98 |
11 |
Utilization |
97.7 |
97.7 |
100 |
97 |
95.9 |
100 |
98.10 |
|
Average Quarterly Score |
98.58 |
97.78 |
99.39 |
98.99 |
98.99 |
99.76 |
|
Diabetes Management – Our diabetic patients
made up 26% of the 2010 census. 2010 was a very productive year
of excellence in our standards of care for diabetes. Under the
direction of our new Medical Director, we elicited and received
target A1C levels from the physicians caring for our diabetic
patient population; we have been very successful in achieving
those targets. Our field staff caring for our diabetic patients
has demonstrated tremendous ability in their assessment skills
and their ability to look at the whole picture during their patient
visits.
In summary, 2010 and the first and second Quarters of 2011 had
very positive trends toward reaching goals for providing care
in accordance with Title 22 Regulations. Nursing Resources is
continually striving to provide excellence in the care of diabetic
patients under the direction of our Director of Clinical Services
and the Medical Director – Report by Cynthia Senior, RN, CD, CCM,
Diabetic Educator & Clinical Case Manager of Nursing Resources.
