Quality Management
Amy Bennett-Staub, R.N., M.P.A., Director
In February 2001 PI completed a Joint Commission Accreditation Survey under the
Hospital and Behavioral Health Standards. Through the hard work of all staff we
received a score of 100 and 99, respectively, reflective of the superior care
and services provided at the Institute.
Throughout 2001, the quality/risk management staff worked in collaboration with
the Cabinet, Medical Staff Organization, Unit Chiefs, Discipline Chiefs, and
Support Service departments to review and evaluate quality, risk management and
resource utilization issues at the Institute. These findings were summarized in
reports and recommendations to the Medical Staff Executive Committee, Director’s
Cabinet and Governing Body to help senior management staff to fulfill their
oversight responsibilities. The QM staff monitored and evaluated the safety,
appropriateness, accessibility, timeliness, effectiveness and efficiencies of
patient care and operational services to ensure that NYSPI met or exceeded
medical practice standards and the requirements of all regulatory agencies. Key
hospital performance measures and performance priorities included medical record
documentation and migration to an electronic medical record; census, occupancy
and utilization rates; reducing adverse patient outcomes and medication errors;
maintaining minimal restraint and seclusion usage; and responding to patient and
staff satisfaction data.
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 discipline activities, food, cleanliness of the hospital, and
discharge planning. Overall rates of satisfaction ranged from 77% to 100%.
Patient Satisfaction Questionnaires were collected from 268 patients or 51% of
the admissions in 2001. In the category of overall satisfaction with the quality
of the treatment received, 54% responded “Excellent” and 40% “Good”.
A total of 117 Patient Suggestions/Complaints were received in 2001, 70% via the
Patient Satisfaction Questionnaire. Suggestions/complaints were received at the
rate of 15.0 per 1000 pt days from GCRU, 8.3 from SRU and 3.6 from WHCS. 28% of
the suggestion/complaints received were staff-related, 19% were related to
clinical care issues, 18% to environmental, 14% to dietary and 12% to
programming. Housekeeping related suggestions/complaints saw the greatest
decrease from 31 received in 2000 to only 6 received in 2001, followed by
dietary related complaints/suggestions: 35 received in 2000 versus 16 received
in 2001.
A revised Staff Satisfaction survey was developed and is scheduled for
administration in early 3rd quarter of 2002.
Other initiatives included focused studies and improvements in the management of
pain and aggressive behavior in inpatients, the development and implementation
of a fall prevention program, and the provision of dental services to patients
most in need.
The QM staff assisted Institute staff in the evaluation, revision and/or
development of data base programs to improve the efficiencies and reporting of
program activities including: 20 Hour Inpatient Programming, Research
Monitoring, Incomplete Medical Record tracking system, Medical record tracking
system, Training and Education Assessments, Social Work Competencies, and the
Patient and Family Library and Resource Center.
In 2001, reappointment of the medical staff physicians, the dentist and
consultants was accomplished following the policies and procedures outlined in
the Medical Staff By-Laws. Recommendations were made to the Medical Staff, the
Executive Director and the Governing Body for final approval. All members of the
Medical Staff Organization are privileged to practice at the New York State
Psychiatric Institute for a two-year period. This year, physicians with last
names beginning with M-Z went through the reappointment process.
The disciplines of Nursing, Social Work, Occupational and Recreational
Therapies, and Pharmacy and the departments such as Housekeeping and Nutrition
conduct quality assessment and improvement programs specific to their areas of
practice or responsibility. Review and analysis of the data collected and the
development of any corrective action plans required are conducted during regular
department meetings. Regular feedback is provided to the Medical Staff, the
Director of Quality Assurance and the Clinical Director. Annual program
evaluations are conducted, presented to the Medical staff and forwarded to the
Governing Body for its review, recommendations and approval.
Each year the competency of all member of the professional staff are 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. In
2001, new employees received the New Employee Orientation. 85% of the
participants rated the content as either “excellent” or “very good” or “good”,
with the significant majority in the latter two categories. Ratings/comments
from the orientation assist the staff in making ongoing improvements to the
format and content. This year several changes were made. Educational programs
provided by Education and Training included 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 2002-03 the Quality Management and Institute staff will continue to
collaborate on the development of information infrastructures. A part time staff
has been hired to assist in the planning for the development of a PI Intranet.
Efforts to expand the design and implementation of research into the areas of
outcome management and program evaluation have begun and two research grants
have been prepared and submitted for 2002-03. In addition, the QM staff will
continue efforts to educate staff regarding process design, evaluation and
implementation of systems to improve patient care and safety. Efforts are
currently under way to minimize the risk of error in medication administration.
Of note, the electronic medical record (MHARS) will be implemented in 3rd
quarter 2002 and the Institute is actively working toward implementing the
requirements under the Federal Health Insurance Portability and Accountability
Act.