Task 3 ‐ Continuous Improvement Project Rationalization Deliverable 3a ‐ CIP Rationalization Prepared for the Oregon Health Authority / Oregon State Hospital Salem, Oregon in satisfaction of Contract #133459, Oregon State Hospital Excellence Project Prepared by: 14 January 2011 Table of Contents A. Executive Summary……………………………………………………………………………………………………. B. Background ………………………………………………………………………………………………................. C. Scope………..………………………………………………………………………………………………................. D. Approach, Tools and Techniques................................................................................... E. Rapid Improvement Event………………………………………………………………………………………….. F. Preparations for Task 04…………………………………………………………………………………….………. Appendix I ‐ Summary of Disposition of CIP Items Within Category / Impact Area.….… Appendix II ‐ Individual CIP Rankings ……………………………………………………………………….…. Appendix III ‐ CIP Items Prioritized for Chartering………………………………………………………. 1 1 1 2 3 9 A. Executive Summary This document is the Task 3 Deliverable for State of Oregon Personal Services Contract Number 133549. It is a critical review and rationalization of current Continuous Improvement Project (CIP) Items / related initiatives and a determination of their effectiveness and relevance in achieving OSH’s new standards of excellence. B. Background OSH has initiated roughly 200 CIP actions in response to recommendations received from outside sources ‐ e.g., the Department of Justice, various consultants, and internal stakeholders. These items address a variety of organizational and inpatient care issues and were initially being managed by the OSH Office of Strategic Planning. Additionally, the OSH Quality Council is charged with managing a separate inventory of Quality Improvement (QI) actions and there are 28 committees engaged in identifying and managing similar activities. The majority of these actions, collectively referred to as “CIP Items” do not define standard process improvement tools, schedules, timetables, or even what resources and skills are required to move them forward. In fact, many are simply operational issues as opposed to CIP Items and do not require team activities to bring them to conclusion. Completed CIP Items or those identified as redundant are often not removed from the active inventory. Many of the CIP Items are not progressing as originally expected. There are several which have been in process for an extended period of time (years) with little to no progress. OSH seeks to determine whether the current roster of CIP Items are effective in achieving the goals of advancing patient care and performance to new standards of excellence. There is general recognition and acceptance of the need for a robust and predictable process to identify and modify or terminate under / non‐ performing CIPs and to meter new project starts. To ensure this assessment ongoing, OSH desires to implement a process and criteria to rationalize the current CIP inventory and to rank by priority the remaining and future proposed initiatives. C. Scope Task 3 focuses on rationalizing the current inventory of 187 CIP Items, 10 proposed Rapid Process Improvement (RPI) events, and 30 Quality Improvement activities for a total of 227 individual line items. CIP Items are managed in a single database by staff of the Strategic Planning Unit. Quality Improvement and Quality Council items are managed separately by the Quality Improvement Unit. The 10 RPIs are in alignment with items already in the CIP inventory and are essentially a restatement of several priority initiatives. They are also managed by the Strategic Planning Unit, however they are listed separately from the CIPs and tracked manually. Table 1 below highlights the distribution of items by general category and impact area. The complete inventory is collectively referred to as “CIP Items”. Kaufman Global 1 Table 1 ‐ Distribution of CIP Items by Category and Impact Area Category/Impact Area 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Physical Plant and Safety Leadership and Organization Staffing Admissions & Assessments Formulation & Treatment Care Planning Active Care and Treatment Transition, Discharge & Community Service Integrated Physical Health Care Protection from Harm Medical Records, Documentation and Info Mgmnt Quality Assurance & Improvement Staff Education & Development Proposed RPI Events Quality Improvement Items Total CIP Item Count 5 13 4 23 22 43 17 13 18 14 2 13 10 30 227 D. Approach, Tools, and Techniques Kaufman Global applied a specialized project review methodology known as “Initiative Inventory” to identify all CIP Items, Quality Improvement (QI) Items, RPI Events, Projects, Tasks and Activities that actively is being tracked and which are consuming various OSH resources. A primary aim of this methodology is to assess the status of these items and their likelihood of success, and later to help make a determination of their priority ranking. Projects may underperform for a variety of reasons. For example, at an organizational level a project may be hampered by lack of alignment with strategic objectives, unfiltered changing priorities, lack of an effective project champion, or more commonly, from internal competition for limited time and resources. Internal competition may reveal itself through lack of inter‐departmental support, competing priorities, unavailability of critical resources, or, simply too many initiatives being worked on at the same time. At any point in time, a cross‐ section of the projects may be progressing, albeit slowly and ineffectively, but none are getting completed, as illustrated by Figure 1 left. Whatever the circumstances, a standard approach which profiles, rationalizes and ranks both active and proposed CIP Items must be established for OSH. Figure 1 ‐ Complex orgs need ways to both run and change operations Kaufman Global 2 It is vital to have a process which includes Executive Steering Committee (ESC) management of CIP Items through six stages ‐ Qualification, Priority Ranking, Queue Management, Activation, Monitoring and Closing. This work must be done with OSH sponsors, project leaders and functional team members to establish an approach that provides a means to decide which new projects will start and when, as well as a system to evaluate projects in terms of whether to continue investment, modify and re‐charter or eliminate. To accomplish Task 3, Kaufman Global: • • • • • Ensured that we had a clear understanding of the strategic objectives of the organization Researched the historical context and sequence of events leading up to the current state Established a Team Charter and conducted an RPI event with key personnel to develop standard criteria for ranking initiatives Conducted interviews with select CIP Item stakeholders in both the functional areas and support departments within the Strategic Planning Unit Conducted a CIP Rationalization RPI event to: gain agreement on the definition of a CIP, establish criteria for evaluation and ranking of initiatives, determine effectiveness and status of CIPs, assess and make recommendations for continued investment or elimination, and rank CIPs in terms of items to be continued near‐term or in queue pending resource availability Documented the analysis, ranking and recommendations for each CIP Item. Transferred working examples to OSH personnel to enable them to charter, conduct and report out similar events on an ongoing basis Documented and published findings and concerns in support of the Task 3 Deliverables which serve as the basis for Task 04, Model Organization and Work Structure E. Rapid Process Improvement Event • • To gain important input and develop consensus on the deliverables of Task 3, an RPI Event was conducted. Participants in the one and one half day event included a representative cross‐section of OSH leadership. Nena Strickland served as Sponsor and, with Greg Roberts, functioned as the Executive Steering Committee. Working members of the team included: Sue Wimmer, Rick Varnum, Ted Ficken, Mike Duran, Arthur Tolan, Derek Wehr, Nat Thomas, Rebecca Curtis, Barb Pfaltzgraff, and Kathy Deacon. Prior to conducting the event, OSH Leadership confirmed the approach and event deliverables as contained in the Event Charter and finalized the list of key OSH personnel and their participation. Initial barriers, concerns and observations expressed by the team included the following: • • Who is in charge of the CIP process and responsible for the creation of CIP items? The overall direction (at OSH) has been a moving target due to the “revolving door” nature of many positions Kaufman Global 3 • • • • • • • • • • There is a lack of Vision and Aim of the Hospital to guide the development of priorities How do we embody the “recovery philosophy” in the CIP process? Who is in charge of the CIP process and responsible for the creation of CIP items? External forces enter the scene and drive priorities off their path There is a lack of integration of the various “improvement” initiatives… OSH needs a single list of improvement initiatives Are the CIPs currently on the list and being worked having an impact…how do we know? How do we achieve sustainability in this effort? CIPs need to be observable and measureable How can we determine the right balance of CIPs that can be worked on at one time? And, How do we tell people to stop working on a CIP which has a lowered priority as a result of rationalization actions? By working through these issues, the Team concluded that their concerns could be addressed through a CIP Item Initiation, Evaluation and Activation process and a governance structure directed by an Executive Steering Committee. These are part of the Critical Next Steps after Task 3 and are the focus of Task 04. Prior to beginning the actual work of rationalization, some fundamental questions had to be answered that would drive the evaluation and decision‐making process. For example, "What exactly is a CIP Item and how is it different from the other activities people perform as a part of their normal work?” and “What items should be managed at the leadership level and receive priority for resources?” To answer these questions the Team completed a Modified Affinity Process (see Figure 2) to brainstorm the various characteristics of a CIP and arrive at a single, consistent definition. Figure 2 ‐ The RPI Team developed work documents to define and rank characteristics of CIP Items The finalized definition is included below as Figure 3. Development of the definition marked a significant departure from previous processes used to address CIP Items, their origination, resource assignment, management and closure. A key learning in the development of the definition included Kaufman Global 4 recognition that a CIP Item is a manageable, short duration activity focused on specific outcomes vs. statements of issues. A CIP Item is a proposed project which: • Significantly advances the hospital toward its mission and vision Improves patient care and services Promotes patient recovery Improves process to move the patient to the community Integrates the efforts of departments disciplines and programs to work toward a common objective Identifies an executive sponsor / owner and a proposed champion Involves cross‐functional participation and learning Becomes part of a single priority list for the hospital Has a defined outcome which is observable and measurable Provides significant return for effort Outcome can be sustained through owned metrics Has a defined life There is a target start and end date The duration of the project is three months or less May be needed to correct an area of non‐compliance with regulatory standards Figure 3 ‐ Definition of a CIP Item With a clear definition guiding them, the team began the rationalization process by making four passes through the inventory of CIP Items. The first pass assessment involved the identification and separation of CIP Items which had been completed and, therefore, were no longer active and requiring resources. This resulted in the elimination of 76 items. Next, the Team developed and agreed upon reasons for termination of CIP Items (see Figure 4). For example, the item does not meet the definition, it may be a duplication of something else, it is really part of someone’s responsibility and job description, the item has no clear ownership, or no action has been taken toward completion. Using the Termination by Reason criteria, an additional 83 CIPs were eliminated, as outlined in Figure 4 ‐ Using Termination by Reason criteria, 83 additional CIPs Figure 5 below. were eliminated from the total inventory • • • • Kaufman Global 5 Termination Recommendations by Reason Does not meet definition of a CIP, 30 Lack of Ownership, 3 Projects completed/ no longer active, 76 Duplication, 8 No Action, 4 Low Return for Effort, 4 Should be Assigned to an Individual, 31 Low Priority Use of Critical Resources, 3 Figure 5 ‐ Using Termination by Reason criteria, 83 additional CIPs were eliminated from the total inventory After the first two passes the team had eliminated 159 of the original 227 CIP Items, leaving only 68 remaining, as summarized in Table 2. Also see Appendix I: Summary Disposition of CIP Items. Table 2 ‐ Remaining CIP Items by Category / Impact Area Category/Impact Area 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Physical Plant and Safety Leadership and Organization Staffing Admissions & Assessments Formulation & Treatment Care Planning Active Care and Treatment Transition, Discharge & Community Service Integrated Physical Health Care Protection from Harm Medical Records, Documentation and Info Mgmnt Quality Assurance & Improvement Staff Education & Development Proposed RPI Events Quality Improvement Items Total Remaining CIP Items ‐ 5 4 5 10 18 9 4 8 2 ‐ 1 2 ‐ 68 For the final 68 the Team selected 15 criteria to promote thinking and assessment of the relative importance of a CIP Item. The 15 criteria are included below as Figure 6. Kaufman Global 6 CIP Evaluation Criteria Form Scoring: 1 ‐ Low, 5 ‐ High ____ Meets the Definition of a CIP ____ Clear Ownership is Identified ____ Externally Mandated ____ Legal Compliance Requirement ____ Impacts vs. Effort ____ Time to Implement / Benefit Realization ____ Alignment with Strategic Priorities ____ Patient Safety ____ Staff Safety ____ Positive Community Impact ____ Defined Outcome / Measurable ____ Sustainable as Standard Work ____ Resource Availability ____ Skill / Experience Availability ____ Prerequisites / Dependencies Identified ____ Total Figure 6: Form for 15 Point Evaluation Using the form in Figure 6, each of the remaining 68 CIP Items were evaluated against the 15 criteria nodes, each node with a possible scoring scale of one (low) to five (high). A total score for each CIP Item was calculated, ranging from a potential low of “15” to a potential high of “75”. The lowest actual score for any CIP item was 27 and the highest was 74. Appendix II: Individual CIP Rankings, shows the individual rank of each CIP item. Figure 7 ‐ The team completes a 15 Point Evaluation form for each of the remaining 68 CIP Items. The total score of each CIP Item is reflective of its relative importance to resource and complete Kaufman Global 7 With the 15 Point Evaluation complete, the Team then reviewed the 68 remaining CIP Items to determine which had current resource allocations, i.e., specific resources assigned. In most cases there was no obvious linkage between resources assigned, progress or status and the relative priority ranking the Team was willing to assign to any individual CIP. A sort and grouping exercise selected 33 of the CIP items with very high scores and combined them into 5 macro areas: • • • • Active Care and Treatment (9) Discharge Planning and Community Integration (3) Protection from Harm (5) Treatment Care Planning (13) and • “Other” (3) These 33 CIP Items constitute the highest priority items, meaning they are at the top of the list for completion of charters and resourcing. They are the resultant, active CIP Items going forward. The remaining 35 valid CIP Items are in the queue and will be initiated as resources become available to work on them. See Figure 8. Figure 8 ‐ Summary of CIP Item Rationalization The individual CIP Items on the priority list are provided in Appendix III: CIP Item Priorities for Chartering Activity. Kaufman Global 8 Key learning experiences expressed by the Team include the following: • • • • • • Not everything is important Significant interrelationships exist among the CIPs regardless of their prior ranking. This became more and more obvious throughout the ranking and sorting process The remaining CIPs, specifically the 33 highest priority items, must be chartered OSH needs a process to add potential new CIP Items to avoid the need to continuously purge and rationalize the inventory of initiatives There is a high priority need to develop an orientation toward project definition and resourcing Resource assignment and skill planning is a critical step to ensure deliverable attainment F. Preparations for Task 04 The Team recognized and included in their report‐out to the Sponsor and ESC the importance of the following: 1. The chartering of the 33 highest priority CIPs will begin immediately to ensure no learning and forward motion is lost 2. The integrated “one list” concept is integral to development of the ongoing process 3. A needed element of the new process is a mechanism to identify and commit available skills and resources to satisfy the demands placed on the organization by current and future CIP Items 4. Leadership is needed to provide closure on the CIP Items identified in Task 3 as individual responsibilities and hand these off to the appropriate operational resources 5. Thought and direction are required to ensure a positive communication to resources currently working on CIP items which have been terminated Kaufman Global 9 Appendix I - Summary Disposition of CIP Items Summary of Disposition of CIP Items Within Category / Impact Area Terminations Low Does not Should be Priority Low meet Assigned to Lack of No Action Return for Use of Duplication Ownership an definition Critical Effort Individual of a CIP Resources Remaining CIP Items Category/Impact Area CIP Item Count 5 13 4 23 22 43 17 13 18 14 2 13 10 30 227 Completed Priority Queue Remaining CIP Items 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Physical Plant and Safety Leadership and Organization Staffing Admissions & Assessments Formulation & Treatment Care Planning Active Care and Treatment Transition, Discharge & Community Service Integrated Physical Health Care Protection from Harm Medical Records, Documentation and Info Mgmnt Quality Assurance & Improvement Staff Education & Development Proposed RPI Events Quality Improvement Items Total 3 1 1 ‐ 1 2 2 ‐ ‐ ‐ ‐ ‐ 11 ‐ 4 ‐ 9 ‐ 3 ‐ 13 4 4 ‐ 5 ‐ 2 ‐ 4 2 1 ‐ 4 ‐ 2 2 8 2 1 ‐ ‐ ‐ ‐ 1 1 1 10 ‐ ‐ 8 ‐ ‐ 17 10 1 ‐ 76 30 31 3 ‐ ‐ ‐ ‐ 1 ‐ ‐ 2 ‐ ‐ ‐ ‐ 1 1 ‐ 1 ‐ ‐ ‐ ‐ 1 1 2 ‐ ‐ 1 ‐ ‐ ‐ 1 1 ‐ ‐ ‐ ‐ 2 1 ‐ ‐ ‐ ‐ ‐ ‐ 1 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ 2 4 4 3 8 ‐ 2 1 2 8 8 2 6 2 1 1 33 ‐ 3 5 3 4 3 5 2 10 10 18 7 9 4 4 2 8 ‐ 2 ‐ ‐ ‐ 1 1 2 ‐ ‐ 35 68 Appendix II - Individual CIP Rankings Remaining CIPs ‐ Total Count 68 Chapter ‐ CIP Goal/Task 3. Leadership and Organization 3.5.A Review, revise and simplify OSH mission, vision, values, and name of facility 3.4.E Review and implement new patient ward milieu management. 3.4.D Communicate with all Oregon Sate Hospital staff and stakeholders about new structure, function and positions 3.1.A Establish clear lines of responsibility, authority and communication 3.1.B Outline organizational expectations to empower leaders to implement those expectations. 60 51 29 27 26 Evaluation Score 4. Staffing 4.1.A Research and determine necessary numbers, create positions, recruit, hire and retain staff 4.1.B Review and expand current privileging system to enhance staff skill mix for individual patient populations. 4.1.C Identify and obtain advances in technologies and support staff necessary to enhance the effectiveness of direct staff care hours available 4.1.D Increase the number of managers for clinical disciplines to be able to monitor and follow up with clinical issues and quality assurance. 55 49 40 38 5. Admissions & Assessments 5.3.A Research and adopt a level of care instrument for placement decisions. 5.4.H Develop and implement a psychology risk screening process to include suicide/self‐ harm, harm to others, sexual behaviors harmful to self or others, fire setting, substance 5.4.E.a Develop monitoring system to track timeliness and completion of medical records (Qualitative) 5.4.G Research and develop a system for continuous reassessment and monitor the implementation of that system 5.3.C Develop a system to use the level of care instrument on admission for clinical staff to determine hospital placement decisions 60 58 53 52 50 Page 1 of 5 Appendix II - Individual CIP Rankings Remaining CIPs ‐ Total Count 68 Chapter ‐ CIP Goal/Task 6. Formulation & Treatment Care Planning 6.3.C Require core members of the IDT to attend TCP meetings and develop resources and scheduling flexibility that supports this 6.4.D Improve TCP’s to consistently reflect the ultimate goal of discharge and sustained successful community reintegration 6.5.H Establish a system to monitor improvements in structure, content and process of Treatment Care Plans 6.5.I Create process to review complex cases (HAPs and PCMs). 6.4.B Develop case formulation and TCP format including master TCP and revision documents 6.5.B Develop TCP standards to include a minimum of every 30 day review for all patients 6.4.C Improve TCP’s to include focused, pragmatic, individualized goals and interventions that are written in naturalistic language 6.4.E Improve TCP’s specific evidence‐base by utilizing objective, relevant symptom and behavior data incorporating the patients stage of change 6.5.G Set up mentor system to support treatment teams continued growth and improvement 6.5.D Improve TCP’s to reflect achievable treatment goals and interventions mutually developed with the patient with target dates for review and completion 57 55 50 49 45 45 44 44 36 55 Evaluation Score Page 2 of 5 Appendix II - Individual CIP Rankings Remaining CIPs ‐ Total Count 68 Chapter ‐ CIP Goal/Task 7. Active Care and Treatment 7.3.P Revise medication distribution/administration system 7.3.C Establish programming within each mall to meet individual treatment needs of populations and make available at least 20 hours of treatment 7.3.G Develop continuum of care from engagement to transition level group 7.3.H Develop a comprehensive Tx program to address education, self care, vocation, med management, mental illness awareness, psychotherapy (DBT, CBT), CRB, Psycho‐ 7.8.C Incorporate behavioral support plans into the treatment care planning process 7.8.E Establish behavioral support plan review group to review all plans and monitor implementation and effectiveness and develop timeliness for reassessment 7.1.F Develop and monitor individual relapse prevention plans and their use in treatment groups, community integration, work, education and recreational activities 7.1.D.b Develop patient satisfaction survey 7.1.E Develop clinical leadership team to evaluate all program plans for clinical relevancy and monitor implementation of groups 7.4.E Develop comprehensive monitoring and treatment program for metabolic side effects including treatment of diabetes. 7.7.A Implement Co‐Occurring Treatment services for civilly committed patients and expand those services for forensic patients 7.1.A Research and define rehabilitation and recovery guiding principles for the hospital. 7.4.A Research and implement evidence based, best practice prescribing (e.g. APA Practice Guidelines). Educate physicians, pharmacy staff, and nursing on best practices. Educate 7.3.M Develop a plan for delivery of other services offered in mall such as café, store, spiritual services, medical appointments, consumer empowerment 7.8.B Educate staff and treatment teams re: behavioral support plans and implementation. 7.6.A Increase Sex Offender Treatment services in the civil and forensic programs. 7.3.O Develop a plan for coordination of patient services in the treatment malls such as pharmacy, laboratory, medical clinic, etc. 7.1.B Research evidence based and best practices to address rehabilitation and recovery treatment 52 67 67 67 59 55 53 51 51 51 51 47 47 45 45 44 43 42 Evaluation Score Page 3 of 5 Appendix II - Individual CIP Rankings Remaining CIPs ‐ Total Count 68 Chapter ‐ CIP Goal/Task 8. Transition, Discharge & Community Service 8.12.B Research and adopt risk assessment tools to determine safety requirements for discharge 8.1.F Develop documentation toward meeting discharge readiness. 8.3.C Develop distribution system for stakeholders to receive all treatment and discharge meeting schedules 8.1.G Establish and enhance transition teams for civilly committed and forensic patients 8.17.C Develop a reporting system so that updates to the PSRB for forensic patients will be timely and comprehensive 8.3.A Develop new systems of communication with community providers 8.1.D Educate treatment teams regarding discharge planning processes 8.1.B Integrate legal and clinical criteria for discharge into the patient’s treatment care plan 8.16.B Educate staff on Exceptional Barriers. 56 52 52 48 48 48 47 44 37 Evaluation Score 9. Integrated Physical Health Care 9.3.A Expand physical health care capacity by: Efficient use of current staffing, creation of a back‐up coverage list, hiring and privileging of nurse practitioners and PAs for care and 9.1.A Define and support Inter‐Disciplinary Treatment Team psychiatrist responsibility for patient physical health care 9.2.A Organize Inter‐Disciplinary Treatment Team review to include monthly review of physical health care, at minimum 9.4.B Research and develop a comprehensive interdisciplinary patient wellness program with outcome measures 53 50 50 45 Page 4 of 5 Appendix II - Individual CIP Rankings Remaining CIPs ‐ Total Count 68 Chapter ‐ CIP Goal/Task 10. Protection from Harm 10.3.J Incorporate risk assessment data into treatment care planning 10.4.A Reduce seclusion and restraint to an absolute minimum consistent with patient and staff safety 10.4.D Review and revise current treatment care planning to include patient de‐escalation preferences medical and trauma history, and effective patient specific interventions 10.3.D Review, revise and implement Behavioral Precautions Policy 6.010 with special attention to physician and Inter‐Disciplinary Treatment Team roles Create and implement 10.3.B.a Increase capacity to train on interventions for violence and assault. 10.4.C Review and revise all documentation associated with seclusion or restraint 10.4.H Increase patient safety around medications with an Automated Pharmacy and Medication Distribution System 10.3.I Complete risk assessments on admission and when clinically indicated 74 62 62 61 57 52 52 47 Evaluation Score 11. Medical Records, Documentation and Info Mgmnt 11.1.D Develop a process to prioritize clinical direction by use of data (ongoing) 11.9.A Educate staff regarding contemporary standards of documentation including progress notes and treatment care planning with a greater emphasis on formulation; 60 47 13. Staff Education & Development 13.14.A Improve and expand clinical supervision 47 14. Proposed RPI Events RPI ‐ Streamlining risk review ‐ recharter RPI ‐ Discharge process ‐ recharter 53 50 Total Count 68 Page 5 of 5 Appendix III - CIP Items Prioritized for Chartering CIP Item Priorities for Chartering Activity ‐ Total Count 33 Chapter ‐ CIP Goal / Task Active Care and Treatment 3.4.E Review and implement new patient ward milieu management. 5.4.G Research and develop a system for continuous reassessment and monitor the implementation of that system 7.1.E Develop clinical leadership team to evaluate all program plans for clinical relevancy and monitor implementation of groups 7.1.F Develop and monitor individual relapse prevention plans and their use in treatment groups, community integration, work, education and recreational activities 7.3.C Establish programming within each mall to meet individual treatment needs of populations and make available at least 20 hours of treatment 7.3.G Develop continuum of care from engagement to transition level group 7.3.H Develop a comprehensive Tx program to address education, self care, vocation, med management, mental illness awareness, psychotherapy (DBT, CBT), CRB, Psycho‐ d i i i d ll 7.4.E Develop comprehensive monitoring and treatment program for metabolic side effects including treatment of diabetes. 8.1.F Develop documentation toward meeting discharge readiness. 51 52 51 53 67 67 67 51 52 Evaluation Score Discharge Planning and Community Integration 5.3.A Research and adopt a level of care instrument for placement decisions. 8.12.B Research and adopt risk assessment tools to determine safety requirements for discharge RPI ‐ Discharge process ‐ recharter 60 56 50 Protection from Harm 10.3.B.a Increase capacity to train on interventions for violence and assault. 10.3.D Review, revise and implement Behavioral Precautions Policy 6.010 with special attention to physician and Inter‐Disciplinary Treatment Team roles Create and implement b h i l i id li l 10.4.A Reduce seclusion and restraint to an absolute minimum consistent with patient and staff safety 10.4.C Review and revise all documentation associated with seclusion or restraint 11.1.D Develop a process to prioritize clinical direction by use of data (ongoing) 57 61 62 52 60 Page 1 of 2 Appendix III - CIP Items Prioritized for Chartering CIP Item Priorities for Chartering Activity ‐ Total Count 33 Chapter ‐ CIP Goal / Task Treatment Care Planning 6.3.C Require core members of the IDT to attend TCP meetings and develop resources and scheduling flexibility that supports this 6.4.B Develop case formulation and TCP format including master TCP and revision documents 6.4.C Improve TCP’s to include focused, pragmatic, individualized goals and interventions that are written in naturalistic language 6.4.D Improve TCP’s to consistently reflect the ultimate goal of discharge and sustained successful community reintegration 6.4.E Improve TCP’s specific evidence‐base by utilizing objective, relevant symptom and behavior data incorporating the patients stage of change 6.5.B Develop TCP standards to include a minimum of every 30 day review for all patients 6.5.D Improve TCP’s to reflect achievable treatment goals and interventions mutually developed with the patient with target dates for review and completion 6.5.H Establish a system to monitor improvements in structure, content and process of Treatment Care Plans 7.8.C Incorporate behavioral support plans into the treatment care planning process 7.8.E Establish behavioral support plan review group to review all plans and monitor implementation and effectiveness and develop timeliness for reassessment 10.3.J Incorporate risk assessment data into treatment care planning 10.4.D Review and revise current treatment care planning to include patient de‐escalation preferences medical and trauma history, and effective patient specific interventions 11.9.A Educate staff regarding contemporary standards of documentation including progress notes and treatment care planning with a greater emphasis on formulation; h f d di i d l 57 45 44 55 44 45 55 50 59 55 74 62 47 Evaluation Score Other 3.5.A Review, revise and simplify OSH mission, vision, values, and name of facility 4.1.D Increase the number of managers for clinical disciplines to be able to monitor and follow up with clinical issues and quality assurance. 13.14.A Improve and expand clinical supervision 60 38 47 Total Count 33 Page 2 of 2