Data obtained from MMR, Outcome Measures, SQA Monitoring Visits, Sargent House Data.
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Transcript of Data obtained from MMR, Outcome Measures, SQA Monitoring Visits, Sargent House Data.
COMPREHENSIVE PROGRAM REVIEWNOVEMBER 18 T H , 2011
SARGENT HOUSE
Data obtained from MMR, Outcome Measures, SQA Monitoring Visits, Sargent House Data
PROGRAM HIGHLIGHTS & KEY MMR RESULTS
- New Director Len Andrews started in August & Clinician, Jacqueline Diaz, began work in July. At the time of this CPR, all residents have been meeting with her routinely.
- For the first time, a Sargent resident will soon be transferring to a CS program!
- The percentage of competitively employed clients rose from 17% in April to 67% in August.
- Sargent is at Capacity with 6 residents and is also fully staffed (0 vacancies).
- Staff is able to de-escalate most situations before utilizing restraint (82:1 ratio of de-escalation: restraint over 6 month period).
- Decrease in medication incidents/occurrences since last CPR. (Nov 2010-April 2011: 15 over 6 months.
April 2011-Sept 2011: 3 over 6 months).AREAS IN NEED OF IMPROVEMENT- 5 out of 6 residents claim they have had personal property stolen while in the program.
- Sargent is unable to enlist the services of a nutritionist to review menus (more funding needed?)
- Only 33% of clients indicated that they “always” or “most times” feel safe in the program. 67% of clients stated that they “never” or only “sometimes” feel safe.
- Staff often fills out or completes logs and reports incorrectly and illegibly. Sargent Staff need to attend a Report Writing Refresher Training.
STAFFING
Data obtained from HR Department & HR Personnel Summary
STAFF TURNOVER RATE(10/1/10 – 9/30/11)
OVERDUE PERFORMACE EVALUATIONS
APRIL 6 FT 0 PT
MAY 7 FT 0 PT
JUNE 3 FT 0 PT
JULY 2 FT 0 PT
AUG. 3 FT 0 PT
SEPT. 4 FT 0 PT
-Sargent is currently fully staffed-
14 Budgeted Positions, 0 vacancies.
Sargent
SJS CRJ22%
23%
24%
25%
26%
27%
28%
25.0%
25.8%
24.1%
Average of 4.2 Overdue Performance Evaluations April-
September
UTILIZATION
Data obtained from Sargent House
April May June July August September0%
20%
40%
60%
80%
100%
120%
100%90%
75% 79%
100% 100%
Utilization Rate By Month April-September
Average Utilization Rate April-September 2011: 91%
Sargent Is Currently At Capacity
MAINSTREAM COMMUNITY ACTIVITIES
Data obtained from MMRs
An average of 12 mainstream community activities were participated in per client
April-September
At the time of the last CPR, there was an average of 13 mainstream community activities per client over a 6 month period.
Average activities per client each month.
April
May
June
July
August
Septe
mbe
r0
2
4
6
8
10
12
14
16
18
0.5
13
1716
1314
CLINICAL HOURS
There was an average of 5 clinical hours* per client each month. * clinical hours include in-house clinical individual service hours and in-house clinical group service hours.
Data obtained from MMRs
April May June July August September
There were 167 clinical hours total 4/11-9/11.
At the time of last CPR, there was an average of 13 clinical hours per client each month. 0
2
4
6
8
10
12
2
0 0
4
11 11Per Client Each Month
MEDICATION INCIDENTS & OCCURENCES
Data obtained from MMRs
There was a total of 3 medication incidents
or occurrences4/11-9/11
Per Client Each Month
At the time of the last CPR, there was a total of 15 medication incidents or occurrences over a 6 month period.
April May June July August September0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.2
0 0 0 0
0.3Chart Title
DE-ESCALATIONS & RESTRAINTS
De-escalation: Restraints APRIL 38.5:1 MAY 71:1 JUNE 40:1 JULY 98:1 AUGUST 82:0 SEPTEMBER 84:0
82:1 For 6 Months
Data obtained from the MMRs
Last CPR (November-April)November: 57:0December: 71:1January 34.5:1February: 74:0March: 82:1April: 38.5:1
71.6:6 For 6 Months
-There was 1 elopement in May.
- At the time of the last CPR, there were 0 elopements over a 6 month period.
April May June July August September0
1
2
3
2
1
2
1
0 0
There was a total of 6 restraints over a 6 month period.
At time of last CPR, there was a total of 6 restraints over a 6 month period.
PROGRAM TRAINING HOURS
Data obtained from Sargent Training Reports
April May June July August Sept.
Training Hours Completed Per Staff Member Per Month
Total Training Hours April-Sept: 190
Total Training Hours
Per Month
APRIL 0MAY 20.5JUNE 42JULY 0AUGUST 3.5SEPTEMBER 124
0
1
2
3
4
5
6
7
8
9
10
0
1.7
3
0 0.3
8.9
RESULTS OF MONITORING VISITS (SQA)
Positives:- Staff are always helpful during visits. All necessary files, logs and information are always readily available.- There has been recent improvement regarding the cleanliness of the main floor (common room, computer
room, etc.) and the kitchen/pantry area.- During a past visit, there was useful nutritional information posted for clients in the kitchen.
- Minus a few exceptions, most client bedrooms have been organized at time of visit.- Staff Compliance with the dress code has improved in recent months.
Needs Improvement:- Ongoing Issues: Not enough detail or description provided in most logs - This includes Unit Condition
Reports, Shift Summaries & Client Daily Data Sheets. At times, logs/reports include contradictory data. Furthermore, the handwriting is often illegible. Staff at Sargent are in need of a Report Writing refresher
training.- Cleanliness of client bathrooms is often an issue.
- Incidents documented in the Communication Log do not always have corresponding Incident Reports. This was especially a problem in April and May 2011. On the same note, there were some instances in which not all staff member involved in the incident submitted their own report, or multiple staff members completed one
report together.
Data obtained from SQA Monitoring Visits
YOUTH SATISFACTION SURVEYS
Results taken from survey conducted in November 2011Data obtained from Youth Satisfaction Surveys
Some-what
Prepared83%
Very Prepared
17%
How prepared are you to move to your next placement or to go
home?
The Best Thing About This Program So Far Is:
- “The Support.” - “I am doing better than when I first
came here.” - “ I like the privileges and all the
staff and almost all the clients!”
Some Things I Would Change About This
Program Are:- “The rules.”
- “The way people treat each other.” - “Clients threatening, stealing,
instigating each other and to do what their (sic) told when they know
better and for me to actually learn how to cook.”
Other- “I like the staff.”
YOUTH SATISFACTION SURVEYS
Data obtained from Youth Satisfaction Surveys
Results taken from survey conducted November 2011
0
1
2
3
4
5
6 Clinical Services Never
Sometimes
Most Times
Always
No Answer/Not Appli-cable
I am treated with re-
spect by staff.
Staff are friendly
and easy to talk to.
Staff lis-tens to
everyone in the
program.
Staff are very clear
about what the program rules are and what
is ex-pected of
me.
Staff are able to
calm me down
when my emotions get a little
out of control.
Staff are good role models.
Staff use respectful language (i.e., they
never swear or
yell).
Staff use restraints appropri-
ately (i.e., only when
neces-sary).
The way staff
treats me encour-ages me
to im-prove my behavior.
0123456 About the Staff Never
Sometimes
Most Times
Always
No Answer/Not Appli-cable