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Performance Management/Quality Improvement MeetingDate:November 18, 2019Time / Location:PH Conference Room 10:00 AM - 11:00AMPresent:Krystal Potter, Darlene Smith, Diane Kiff, Chris Congdon, Kim Cady, Gail Wechsler Lorelei Wagner, Terry MossAbsent:Scribe:Terry MossAgenda ItemDiscussionOwnerStatus (open/ closed)Approval of minutesMinutes of previous meeting were distributed and approved.KatClosedPerformance Measures4th Quarter Review will be held January 2020. AllClosedPolicy UpdatesInfection controlNo changes in procedures. No major changes other than making sure definition match CDC. Moving forms and replacing with links.Nursing procedures and Equipment and supplies Vital Sign Parameters Physician Reporting policy removed from manual Added NA to Lead Care ll, PH does not do Lead Care ll.Added Standards for Agencies Performing CLIA-Waived testing including training checklists, annual competency checklists and annual attestation by the lab director.Added Biometric Screening-Alere Cholestech LDX Analyzer Protocols.LeadMultiple changes to align with the new guidance of greater than 5 levels.Changing follow-up and daily activities to match what is being done now.Change in the discharge criteria to the new guidelines.Took out lead web documentation and replaced it with updated county contacts.No revisions to orientation checklist or audit tools because it is on the agenda to do again shortly.MCHSteuben has their own policy and does not necessarily reflect the changes that S2AY has for the other agencies.Opioid OD PreventionCorrection in grammar in a few places.Added statement: The Enrollment Forms will be maintained in a file at the Agency. Under the paragraph of handling the logistics for conducting training; added to have the available items available; Training Evaluation pare Steuben Specific policy with the S2AY policy and bring to next meeting.ClosedAuditsLead LHCSA- No patients.Immunizations Chart1 questionnaire was not complete, 1 question was unanswered3 questionnaires did not address the Yes or Don’t Know questions1 questionnaire was missing VFC/VFA eligibility screening2 missed opportunities2 questionnaires did not have the VIS publication dates on them STD Disease Reports1 Chlamydia case and 1 Gonorrhea case did not receive appropriate treatment. Both were lost to follow up after 1 month of provider and NYSDOH trying to contact patient. The Chlamydia case did not receive any medication and the Gonorrhea case received only the Rocephin injection, no azithromycin. EI IPRO- 100%MCH Review- Over sight of last box checked on forms.- Missed checking no further visits on form. ActivitiesTest emergency buttonTested with no complications. Is in good working order.ClosedAudits Next MeetingLatent TBSTD/HIV clinicGail/KimSatisfaction SurveysNoneTerryClosedSurveys Due Next MeetingNDDP Hornell and County classes.TerryAccidents/Incidents/ComplaintsHIPAA Review due to possible breach of HIPPA. After several meetings and review it was determined that there was no HIPPA breach but was more a corrective reinforcement of the HIPPA policy for encryption.ChrisClosedStrategic Plan/CHIP3rd Quarterly Review-October 2019- Darlene was not present for the October meeting. She sent out the updated version for review. No questions or concerns.Darlene/LoreleiClosedEthics CommitteeNone identifiedDarleneOngoingOther OutstandingRabies QI project-Complete and on O:MCH QI project- Have group meeting scheduled to look at numbers and improvements. Will close project after the meeting if everything is satisfactory. Surveys –EI simplified survey creation- pending in progress.KatKatDianeClosedOpenOpenRegional PMQI Committee MeetingNo Regional Meeting to report.Kat/DarleneOngoingRegional Committee PMQI ProjectWork on vaping issue.EPT performance incentive.Had input from some school officials on the vaping issues. They feel it should be more an individual school project versus a regional project.OngoingOther Improvement IdentifiedNoneOngoingNEXT MEETING:December 16, 201910:00 AMPH Conference RoomEmailed to members XX/XX/19 ................
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