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I.Patient Injury RateDescription: Number of patient injury events with a severity level of more than minor first aid that occurred for every 1000 inpatient days. July 2019August 2019September 2019DDPC0.000.000.00National Average0.300.420.38Note: Hospitals aren’t required to submit patient and staff injuries to The Joint Commission or CMS, so the national average is only from hospitals that voluntarily submit their data.II.Staff Injury RateDescription: Number of staff injury events with a severity level of more than minor first aid that occurred for every 1000 inpatient days. July 2019August 2019September 2019DDPC0.003.722.16National Average0.630.790.65Note: Hospitals aren’t required to submit patient and staff injuries to The Joint Commission or CMS, so the national average is only from hospitals that voluntarily submit their data.III.Seclusion HoursDescription: Number of hours patients spent in seclusion for every 1,000 inpatient hours. July 2019August 2019September 2019DDPC0.050.130.04National Average0.760.680.22IV.Percent of Patients SecludedDescription: Percent of unique patients who were secluded at least once.July 2019August 2019September 2019DDPC2.633.135.41National Average3.212.552.70V.Restraint HoursDescription: Number of hours patients spent in restraint for every 1,000 inpatient hours. July 2019August 2019September 2019DDPC0.000.000.00National Average0.480.430.27VI.Percent of Patients RestrainedDescription: Percent of unique patients who were restrained at least once.July 2019August 2019September 2019DDPC2.633.135.41National Average7.857.016.05VII.30-Day ReadmissionsDescription: Percent of discharges from the hospital that returned within 30 days of discharge. Patients discharged to a medical hospital and re-admitted are excluded.July 2019August 2019September 2019DDPC0.007.690.00National Average3.804.563.81VIII.Elopement RateDescription: Number of elopements that occurred for every 1000 inpatient days.July 2019August 2019September 2019DDPC0.000.000.00National Average0.110.040.05IX.Medication ErrorsDescription: Number of medication error events that occurred for every 100 episodes of care.July 2019August 2019September 2019DDPC10.5328.135.41National Average2.152.492.37X.Admission ScreeningDescription: Percent of patients screened within 3 days of admission for: risk of violence to self and others, psychological trauma, substance use, and patient strengths.July 2019August 2019September 2019DDPC100%100%100%National Average93%91%92%XI.Multiple Antipsychotic Medications at Discharge with Appropriate JustificationDescription: Percent of patients with appropriate justification for being discharged on multiple antipsychotic medications.July 2019August 2019September 2019DDPC100%N/A100%National Average71%75%63%Patient Discharge SurveyI.Response RateJuly 2019August 2019September 20191Q202064%(9/14)33%(1/3)100%(4/4)67%(14/21)II.Survey ResultsDomainJuly 2019August 2019September 20191Q2020AverageOutcome of Care63%100%50%71%Dignity67%100%100%89%Rights33%100%75%69%Participation in Treatment67%100%75%81%Facility Environment67%100%100%89%Empowerment67%100%25%64%Contract Management1Q2020 ResultsContractorContract AdministratorSummary of PerformanceAffiliated LaboratoryChristine Bellatty, RN, BSNActing Director of NursingAll indicators met prehensive Pharmacy ServicesChristine Bellatty, RN, BSNActing Director of NursingAll indicators met standards.Disability Rights MaineCarolyn Dimek, RN, MSActing SuperintendentAll indicators met standards.Liberty Healthcare Physicians and/or Mid-Levels on CallDr. Daniel Potenza, MDInterim Clinical DirectorAll indicators met standards.Liberty Healthcare Psychiatric Nurse PractitionerDr. Daniel Potenza, MDInterim Clinical DirectorAll indicators met standards.Locum TenensCarolyn Dimek, RN, MSActing SuperintendentAll indicators met standards.Pine Tree LegalDr. Daniel Potenza, MDInterim Clinical DirectorNo services provided this quarter.Project StaffingKatelynn HansonBusiness ManagerAll indicators exceeded standards.SecuritasMark FaulknerDirector of FacilitiesTBDWorldwide Travel StaffingChristine Bellatty, RN, BSNActing Director of NursingAll indicators met standards. ................
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