Inpatient QI

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Quality Improvement Protocol

  Date

Special Review 524, 580.5(b)(5), 582.5(b)(5)

• Sentinel Events/Root Cause Analysis, Incident Review Meeitngs (committee composition, quarterly or when necessary, reflect description of incident, discussion, recommendations, follow-up, feedback to staff involved), Investigations (thorough/timely), Reporting (OMH, CQC), Trending/Patterning Analysis

  Yes

  No

  N/A

Complaints 527

• Documentation (log), Investigation/Follow up, Response to Complainant (timelines), Trending

  Yes

  No

  N/A

QI Indicators 580.5(a)(3), 580.5(b)(1), 580.8(c ), 582.5(a)(3), 582.5(b)(1), 582.8(c )

• How conducted (unit/discipline/agency), How are problems identified, are outcomes relevant, Reviewed and revised periodically against attainment, progream changes, best practices, Outcomes/feedback/resolution

  Yes

  No

  N/A

Utilization Review Part 27.3(d)

• Length of stay, Alternate levels of care, Related to discharge planning (bed blockers), Recidivism reviewed, Record Monitoring

  Yes

  No

  N/A

Satisfaction 527

• Solicited from Patient/Family/Providers (see Patient Interview), Surveys, Letters, Telephone calls, Meetings, Analysis of Information, Feedback to staff, patients, family

  Yes

  No

  N/A

Restraint 27.7, MHL 33.04

• Restraint Policy current, Policy and Procedure consistent with patients medical records and facility's restraint log, Staff training available, Staff interviews indicate staff understand issues on use of restraint, QI/QM has focused on restraint, Medical records are comprehensive including dated and signed physician orders, Physician orders based upon personal evaluations of patients done before restraints ordered, orders contain rationale, Orders written for no more than 4 hours, Documentation that patients were monitored, assessments done minimum every 30 mins, and half hour assessment notes present, Restraints approved by OMH, Documentation that patients released at least every two hours except when asleep, When released after two hours, restraints discontinued if patient does not exhibit threatening behavior. If so, is physician notified immediately, Were there any cases of an emergency requiring restraint authorized by senior professional staff where a physician was not available, Did a physician arrive within 30 mins to personally assess the patient and write the order, IF delayed, is the reason documented, Families notified as appropriate (families must be notified for children), Documentation present that patients were debriefed.

  Yes

  No

  N/A

• Seclusion Policy current, Do records verify that seclusion is used only to prevent patients from serious self-injury or injury to others and that less restrictive techniques would be ineffectual, Are seclusion orders written on a daily basis and after examination by a physician, Are seclusion orders signed, dated and written for no more than three hours duration unless patient is asleep, Are patients in seclusion appropriately monitored, and in no case monitored less than hourly day or night

  Yes

  No

  N/A

ECT Policies and Procedures OMH ECT Guidelines 1/13/03

• Were revisions to policies previously cited made in compliance with APA, Description of how ECT will be used in treatment, Duties and qualifications of psychiatrist in charge, list of staff members by title with responsibilities, availability of anesthesiologist, Description of ECT equipment adn treatment site, Description of informed consent processes, Requirements for pre-ECT evaluations and a written summaryof the indications for ECT, Treatment Procedures: the device (its use and maintenance), airway management, use of medications, policies for stimulus dosing and electrode placement, how patients are monitored, seizure management, assessment and treatment of adverse effects, and post ECT treatment, Process used to monitor therapeutic responses and adverse effects, Required ECT documentation in medical record.

  Yes

  No

  N/A

• During the course of the visit, collect the following data: The TOTAL number of ECT devices operated by the facility, The brand name, model, serial number, and location for ALL devices operated by the facility, The number of ECT treatment sessions provided using each device, including a breakdown of how many sessoin were administered on an inpatient basis and how many session were administered on an outpatient basis, Age of individuals served (If child is receiving ECT, report to BIC)

  Yes

  No

  N/A

• Staffing for ECT: Verify names, titles, qualifications and responsibilities of ECT team members, For all fcilities which provide fewer than 50 ECT sessions per year (and larger for ECT providers as time permits), review the facility's documentation of the competency of ECT team members to include privileging and credentialing records.

  Yes

  No

  N/A

• Incidents/Complaints: Determine whether there have been any invidents of complaints in regard to ECT. Use the ECT log, staff interviews, and complaint files as necessary. Pull as part of case sample to be reviewed files which resulted in substantial incidents.

  Yes

  No

  N/A