Quality Management

Amy Bennett-Staub, R.N., M.P.A., Director

The Quality Management Program (QM) at the New York State Psychiatric Institute coordinates all program evaluation, quality improvement, risk management, medical record, and service utilization activities. The overall purpose of the Quality Management Program is to provide a systematic mechanism for reviewing patient-related processes on a continuous basis to monitor, analyze, and improve patient outcomes. It is expected that the care delivered meet or exceed professional standards of practice and safeguard the patient's individual needs and rights at all times.

Much of the Quality Management and Clinical staff efforts during 2000 were directed at the following initiatives: 1. preparing for a Joint Commission on Hospital Accreditation review scheduled for February 26-28; 2. reorganizing of the Risk Management Program and implementation of the New Incident Management and Reporting System; and, 3. improving the program evaluation and reporting component of the program.

Quality Management Program Accomplishments

The Governing Body, key management, and medical staff leadership were provided summary reports regarding the ongoing evaluation of performance on a wide range of patient care activities. The QM staff in concert with the Clinical departments and Medical Staff committees monitored the safety, appropriateness, accessibility, timeliness, effectiveness, and efficiency of such services, using OMH and industry standards as benchmarks as appropriate. Significant improvements were made in the number and type of reports utilized by staff in their efforts to evaluate and improve programs. Areas of evaluation included: resource utilization measures such as admission and continued stay reviews, occupancy rates, discharges, follow-up after discharge, and the percentage of discharged patients who are readmitted within 30 days. Medical record/clinical pertinence reviews, delinquent medical records, and access requests were reviewed by the Utilization Review/ Medical Record Committee along with focused studies which favorably evaluated contract services including Dental and Presbyterian Hospital Clinic, Consultation, and Radiology. The Medical Record Committee made recommendations to enhance the medical record including the addition of nutrition, trauma, pain management and advance directives prompts to the Screening/Admission Note and Psychiatric Evaluation form. The Core History and Evaluation forms were combined to reduce redundancies. The Coping Agreement was revised to meet new restraint regulations and provide staff with an improved admission assessment tool. A pain management program was implemented and a new pain assessment form was approved. The Medical Record Clinical Pertinence review process was revised to improve the comprehensiveness and timeliness of reviews. The Pharmacy and Therapeutic Committee tracked medication errors, adverse drug reactions, food-drug interactions, and outpatient sample medication practices, and approved several drug usage evaluation studies. The number of medication errors and adverse drug reactions reported was low.

The Infection Control Committee continued to report a low nosocomial infection rate of 0.8 per 1000 patient day. There were no needle-stick injuries reported for the entire calendar year since the staff successfully piloted and implemented the use of safety needles in all clinical areas. The Information Management Committee revised the structure of the committee to focus on clinical systems management. Several needs assessments were conducted for planning purposes as the Institute begins to increase utilization of computer technology and prepare for migration to the electronic medical record (MHARS).

In response to OMH recommendations for improving special investigations and managing high-risk patients, New York State Psychiatric Institute reorganized the Risk Management (RM) Program. The scope of the Incident Management Committee was expanded and the DQA and a representative of the medical staff assumed the committee chairmanship. The committee reviewed a total of 106 incidents representing an overall rate of 5 incidents per 1000 patient days, which was below the OMH statewide mean rate for all adult facilities at 6.41 incidents per 1000 patient days. Ten incidents were subject to special investigation and the Cabinet and MSEC approved all recommendations. The RM Committee reviewed and approved a Clinical Peer Review policy and an Institute-wide policy for the management and review of Sentinel Events.

Of significant note was the June implementation of the New Incident Management and Reporting System (NIMRS). NIMRS is a state-of-the-art computerized system for reporting, reviewing, and analyzing incident data, which represents a significant improvement in the documentation and reporting process. Further enhancements to the system are being developed to link NIMRS to other automated systems (Pharmacy, MHARS) and to make data from the rest of OMH licensed and operated facilities available for benchmarking.

Performance Improvement Initiatives

A restraint and seclusion team was convened to establish practices that reinforce use of the least restrictive methods/interventions in managing crisis behaviors. To date, there has been a significant reduction in the number of hours and number of patients placed in seclusion. Coincidently, there has been a significant reduction in the number of fights and assaults. To assist staff in honing their skills during emergency situations a work group was established to develop a strategy to keep staff knowledgeable about key procedures. The patient orientation process was revised and improved (inclusive of a new brochure) as part of NYSPI's continuing development of its psychoeducational program. In 2000, program developments in the Patient Family Library and Resource Center resulted in an average monthly increase of 75% in visits to the Center by patients and their families.

An Ethics work group has formulated ongoing education initiatives and created an Ethics Consultation Service to enforce an institutional culture which supports the ethical conduct of our work (research-patient care-education)

A project team is working on the development of a PI Intranet to increase clinical staff access to both internal and external data to support their performance in patient-related functions and to assist staff in utilizing computer technology to promote efficiencies in their work.

Needs and Expectations of Patients and Staff

Patient Satisfaction surveys are collected on an ongoing basis on all three inpatient units to measure patient satisfaction with services on several dimensions including, quality of treatment, respectful treatment by staff, satisfaction with OT/RT activities, food, cleanliness of the hospital, and discharge planning. Additionally, for research patients, an explanation of research participation and whether they would participate again in research is assessed. Of the research patients surveyed, 84% would participate in research at another time. An overall collection rate of 48% of patients discharged was attained and overall patient satisfaction with the quality of treatment is 94%. In 2000, as a result of commendations received from patients on the Patient Satisfaction Questionnaires a "Commendation Certificate" signed by the Director of the Institute is given to staff members recognized by the patient in the questionnaire.

A Staff Satisfaction Survey was conducted at the end of the year for all clinical staff. A total of 236 employees out of approximately 295 responded, representing an 80% response rate. Staff reported an overall satisfaction with their job at 82%. The top three reasons for employment longevity were job security, benefits, and job satisfaction.

Physician Credentialing and Privileging

The office of the Director of Quality Management coordinates the New York State Psychiatric Institute Credentialing and Privileging process. Quality Assessment and improvement data are maintained in the files of all physicians in the Quality Management office for use during the reappointment process. This year, all physicians with last names beginning with A-L went through the reappointment process. Twenty-one (21) physicians were given initial appointments, including fifteen (15) as Attending, four (4) as Consultant, and one (1) as an Affiliate. The Physician Appointment and Privileging process was streamlined by reducing redundant requests for information and setting up a system for managing workflow.

Education and Training

Each year the competency of all members of the professional staff is reviewed and summarized in the Human Resources Annual Report. The Departments of Human Resources and Training and Education collaborate with department directors in planning educational opportunities for staff based on ongoing assessment of staff competency or programmatic changes requiring new or updated skills. Educational programs provided by the Department of Education and Training includes mandatory educational topics, competency skills training, new/key policy implementations, ethical and research related issues, and areas assessed by departmental supervisors to improve employee performance. In 2000, 231 new employees received the New Employee Orientation.