CARF Continuous Quality & Survey Readiness: Leadership Meeting Agenda

Transcription

1 March 18, 2016 CARF Continuous Quality & Survey Readiness: Leadership Meeting Agenda The following information may or may not be appropriate to your clinical setting. Please review the information and determine the appropriateness of the content prior to sharing with your staff. Eligible for LMS Credit: Yes The CARF Standards Manuals have been shipped to all ARU/IRFs. A special thanks to KRS for providing these manuals as our roadmap to attaining the highest standard of quality for inpatient medical rehabilitation. You may also visit the CARF document repository for the latest standards worksheet checklists, plans and templates, and preparation tools The documents are loaded and ready for use! Just go to: Knect >Kindred Rehabilitation Services(KRS) >Clinical Services >Hospital >IRF Clinical Services >CARF More updates will be added throughout the year, so while in preparation for your survey, be sure to visit this site more than once! This year we have focused on standards conformance through definitive templates, rather than field examples, for better accuracy. Any suggestions for additional tools needed are welcome! This FFF is a follow up to the FFF on 2016 KHRS Measurement and Improvement for ARU s. This week, we provide a focused way of addressing continuous quality and CARF survey- readiness through a monthly process on your rehabilitation unit. Please review the attachment: ARU Monthly Leadership Meeting Agenda. This is a working tool to be used each month in the documentation of meeting minutes from the rehabilitation department s team of decision-makers. A Rehabilitation Leadership Committee should combine with the Rehabilitation Quality and Improvement Committee to fully expedite first-level committee planning. Monthly meetings may follow this agenda tool, keeping minutes in a hardcopy or electronic format for ongoing reference. Additional KPI s or key talking points may be included as needed for customization to your own rehabilitation site, but the items provided in this template relate to specific requirements of CARF standards in quality care. While all required items are mentioned for monthly review, some may not be current issues or may only need to be addressed quarterly, semi annually, or annually. The agenda will serve as your tracking log of items that require further PI, education, action plans, and follow up. At year s end, the monthly minutes will serve you to further develop the annual summarization of each section for tracking, trending, analysis, action planning, education, and reporting required by CARF in meaningful, durable data collection and use. The last three pages of the document pertain to the requirements of the most commonly achieved specialty accreditations in Stroke, Amputation, or Brain Injury. The consolidation of key data points required for conformance to standards by CARF, can be a hit or miss proposition. This monthly leadership agenda tool puts your quality review and process improvements at the forefront of all your quality and strategic discussions. It focuses, organizes, and systematically addresses all items for your team leaders and helps define further investigation and action plans on an annual basis. 1 Page

2 ARU Monthly Leadership Meeting Agenda Facility: ARU Monthly Leadership Meeting Agenda Leadership Meeting may include: Program Director, Improvement Team Members, Medical Director, Nursing Director, Clinical Coordinator, Therapy Director, Clinical Liaisons, Safety Committee Team Members, Education Coordinator, Stroke / BI / Amputee Program Coordinator(s), etc. Attach: Monthly BW Report and Attendee Sign-In Sheet Date: / / Monthly Rehab New Business & Host Hospital Updates: Key DC to Community FIM Gain FIM Efficiency ALOS Admission FIM CMI Truncation LOS % of CMG LOS ADC Admissions Discharges 60% & Compliance Month Pt. Satisfaction Scores and Comments reviewed Compliance Chart Audits Hospital Quality Measures: Fall Rate / Medication Errors / CAUTI s / PU s / C Diff / MRSA / 30 Day ReAdmissions / etc. ARU Monthly Leadership Meeting Agenda Page 1 of

3 Key Denials and Interrupted Stays Admission Denials: Too Impaired Admission Denials: Pt. / Family Refusal Admission Denials: Too High Functioning Interrupted Stays Complaints and Grievances # of Complaints # of Grievances Safety and Critical Incidents Medication Errors Use of seclusion Use of restraint Incidents involving injury Communicable Diseases Infection Control Violence or Aggression Use & Unauthorized Possession of Weapons Wandering Elopement Vehicular Accidents, if the dept. provides transportation. Bio-hazardous accidents Unauthorized use or possession of licit or illicit substances. Abuse Neglect Suicide or attempted suicide Sexual assault Other sentinel events Durability of Outcomes: Follow Up Calls Ratio of # of completed patient calls to # of DC patients. Activity Status Environment Needs ARU Monthly Leadership Meeting Agenda Page 2 of

4 Key Health Status Participation Status Quarterly Billing Audits # of discrepancies Q1 # of discrepancies Q2 # of discrepancies Q3 # of discrepancies Q4 CARF required Annual Rehab Safety Drills / Each Shift Schedule / Conduct Each: Day.Evening.Night Schedule Evacuation Drill Semi-Annual Rehab Inspections / Each Shift Schedule / Conduct Each: Day.Evening.Night CARF Required Annual Plan Update / Review Plan Month Scheduled for Annual Update/Review/ Completion / Summary Annual Rehab External Safety Inspections. Annual Cultural Diversity Plan Review / Update. Annual Accessibility Plan Review / Update. Annual Risk Management Plan Review / Update. Annual Technology Plan Review / Update. Annual Improvement Plan Review / Update. Annual Policy and Procedure Review, updates documented For All Persons Served with SCI: Documented Follow Up Plans, s/p Discharge For All Persons Served under 18 Years of Age: Education Plan ARU Monthly Leadership Meeting Agenda Page 3 of

5 Key Documented Individualized Community Transition Plan for the Person Served. Stroke Specialty Program: Documentation of Wellness Activities of each person served Individualized Community Transition Plan for the Person Served. Written follow up plans created prior to patient discharge. Stroke Follow Up Calls and PI, detailing: Aspiration Pneumonia Falls Falls with injuries Other injuries Re-hospitalizations Unplanned medical needs / visits / encounters Stroke Program PI: managing Diabetes. managing Hyperlipidemia. managing Hypertension. managing Stroke Prevention. Amputation Specialty Program: Documented Training of Amputee Peer Supporters Individualized Community Transition/Discharge ARU Monthly Leadership Meeting Agenda Page 4 of

6 Key Plan for the Person Served. Written follow up plans created prior to patient discharge. Amputee Follow Up Calls & PI, detailing: # of Persons served with Upper Limb Loss # of Persons served with Lower Limb Loss # of those with additional amputations after admission involving the residual limb # of those with additional amputations after admission involving the contralateral limb # of those with new foot ulcers after admission # of those using prosthesis s/p DC Brain Injury Specialty Program: Documentation of Wellness Activities of each person served Contingency Plans, documented in Discharge/Transition Plan Written follow up plans created prior to patient discharge/transition. Follow Up Calls & PI, detailing: Satisfaction with clinical practice / behaviors: from patient/family/others Satisfaction with inclusion of persons served: from ARU Monthly Leadership Meeting Agenda Page 5 of

7 Key patient/family/others Satisfaction with Outcomes: from patient/family/others Satisfaction with accuracy / usefulness of information provided: from patient/ family/others Additional Notes and Items for Follow up: ARU Monthly Leadership Meeting Agenda Page 6 of