OATdb Archive

2014 - 2015

Health Services

Goal
Quality Health Services
The Health Center will provide quality health care services.

Objective
Isolation Room Identification For Tuberculosis
Evaluate and identify an area of the new Student Health Center that will serve as an isolation room in the case a patient presents with active TB.


KPI
Identify Clearance Room Within Health Center
Locate a room or area within the SHC that has exhaust airflow leading to the exterior of the building.

Result
Room Analysis
Engineers analyzed through apparatus to measure the exhaust air volume of 2 areas within the clinic that could be identified as an isolation area. Technicians observed the CFM of the exhaust fan to identify targeted rooms to be used for isolation. Room 166 was in compliance with the requirements for an isolation room.


KPI
Complete Room Clearance Time Calculation Worksheet
Per the Center for Disease Control and Prevention, the clinic needs to identify the room volume, air changed per hour, calculate room clearance time.


Result
Calculated Room Clearance Time Based On 99.9% Removal Efficiency
The following was identified:

  1. Room Volume: 854.25 ft3
  2. 2a. Measured exhaust airflow rate: 85 CFM
    2b. = 2a x 60 minutes: 5,100 ft3 per hour
    2c. = 2b / 1d: 6 ACH
  3. Calculated Room Clearance Time based on 99.9% removal efficiency: 69 minutes

Action
Creation Of Policy
A policy was created to notify clinical and nursing staff that Room 166 is the isolation room in the instance of a suspected TB case or any suspicious airborne infectious disease.

Objective
Dental Clinic - Procedural Consent Forms And Patient Education
Evaluate the frequency that dental patients are given procedural consent forms.


KPI
Frequency Of Patients Receiving Procedural Education
Measure the compliance of documented education (risks and benefits) given to patients that receive a procedure. A Daily Journal Report was run for the date range 01/01/15 to 03/31/15 that included all services, excluding all payments and adjustments. The resulting data was further refined to exclude all procedures codes that fell outside of the range D2000-D8999. The specificity of this range was intended to capture only procedures that require consent forms to be signed. Filtering the patient names along this procedure code range produced a list of unique patient visits (unique patient names per date). The presence of a signed consent form and patient education was checked by examining each of the resulting patients' notes sections, which is typically where consent forms are stored.


Result
Result Findings
69 charts were reviewed and 34 charts were non-compliant with the expectations of education and signatures. 51% of patients that received a clinical dental procedure were given a procedural consent form and were educated about the risks and benefits. The clinic did not achieve the established goals to achieve 100% compliance in both procedural consent forms and patient education.


KPI
Frequency Of Patients Signing Consent Forms
Evaluate the frequency that a dental patient signs a procedural consent form. A Daily Journal Report was run for the date range 01/01/15 to 03/31/15 that included all services, excluding all payments and adjustments. The resulting data was further refined to exclude all procedures codes that fell outside of the range D2000-D8999. The specificity of this range was intended to capture only procedures that require consent forms to be signed. Filtering the patient names along this procedure code range produced a list of unique patient visits (unique patient names per date). The presence of a signed consent form and patient education was checked by examining each of the resulting patients' notes sections, which is typically where consent forms are stored.

Result
Result Findings
69 charts were reviewed and 34 charts were non-compliant with the expectations of education and signatures. 51% of patients that received a clinical dental procedure were given a procedural consent form and were educated about the risks and benefits. The clinic did not achieve the established goals to achieve 100% compliance in both procedural consent forms and patient education.

Action
Proficiency Training
The dental clinic's staff recieved training for the following:

  1. Understand the importance of completing education and obtaining a signature.
  2. Staff are to demonstrate proficiency in obtaining the consent form and education.
  3. Demonstrate where to document in the EHR that the information was obtained.
  4. Locate the policy and procedure.

Goal
Peer Review
The Health Center will achieve re-accreditation through AAAHC Peer Review.

Objective
Completion Of Survey
The clinic will be evaluated by peers through the AAAHC to evaluate how the clinic ranks against a set of established 2015 clinical standards.  


KPI
Number Of Standards Are Compliant And Non-Compliant
Measure the number of standards held in a status of non-compliance. These measures are evaluated post-survey and a follow-up report was given to the clinic to discuss the reasons why the clinic was non-compliant. These non-compliant measures are graded and the award outcome is based on what standards are met against what standards are not met.

KPI
Site Visit Evaluation
Accreditation Association of America for Ambulatory Health Care (AAAHC) evaluates programs via  thorough criteria rubric encompassed in a survey report.  The following areas (Chapters) of practice are extensively evaluated: Rights of Patients, Governance, Administration, Quality of Care Provided,  Quality Management and Improvement, Clinical Records and Health Information, Infection Prevention, Facilities and Environment, Anesthesia Services, Surgical and Related Services, Pharmaceutical Services, Pathology and Medical Lab Services, Diagnostic and Other Imaging Services, Dental Services, Other Professional and Technical Services, Health Education and Promotion, Behavioral Health, and Teaching and Publication Activities.  Possible outcomes of clinical practice evaluations are Substantial Compliance (SC), Partial Compliance (PC), Non-Compliance (NC), and Non-Applicable (NA).  The Student Health Center (SHC) will achieve no less than 95% for SC across all chapters comprehensively.  SHC will not have any NC ratings, but does have some NA marks as the measures do not apply to the SHC’s practices.

Result
Site Visit Outcomes
The SHC received marks of substantial compliance (SC) in all (100%) Chapters measured.  With that said, there were some partial compliance (PC) marks in Patient Rights and Responsibilities and in the Governance Chapters respectively, but not enough (

Action
Planning For Future Accreditation
The Health Center staff is in the process of addressing the identified Partial Compliance issues in order to bring them up to Full Compliance level. Feedback from the AAAHC site visit will be incorporated into the Health Center's strategic planning process, which will take place during the fall semester of '15.

Update to previous cycle's plan for continuous improvement

CBC Analysis:

The clinic did implement a CBC machine to assist in making better clinical decisions. Although the machine was somewhat helpful, we quickly realized that the type of machine was not producing the outcome that the clinic had hoped and proved to be more of a hassle than a benefit. Based on the clinic's specific type of lighting in the lab, the machine's baseline was thrown off on a number of instances, making the patient's blood work non-specific. Additionally, the 3-part differential machine lacked information that could accurately describe the patients' potential diagnosis. Due to these stated issues, the governing body decided that for the purpose of fiscal responsibility and efficiency, the clinic will discontinue the use of the CBC machine and transfer it to the Agriculture Department. CBC send outs are still available to the clinicians and is the test most often utilized for diagnostics.

Allergy Injections:

The clinic has achieved 100% compliance on documenting the post injection assessments. This has been demonstrated through peer review. The nurse clinic that is run by Registered Nurses are the only employees that administer allergy injections. Each month they review the expiration of the allergy serum and document on a designated form. Additionally, the EHR schedule was opened to allow students to schedule their allergy appointments online. This has exceeded expectations and has improved the efficiency regarding scheduling errors. Due to patient privacy, these documents cannot be uploaded. We do have them available upon request.

Health Promotion:

The Health Promotions department held an on campus free STI outreach program. 301 student participated in the event.

Plan for continuous improvement Quality Health Services will be continually provided through  the identified isolation room for TB positive patients that will remain in standard use as needed.  The Dental clinic staff received training and were assessed  via the AAAHC accreditation process.  There were no concerns found throughout the process with regards to dental practices and education, indicating that no further action is required.  Follow up to ensure future compliance will take place as continued preparation and participation in future AAAHC accreditation surveys are performed over the next three years.  Any partial compliance (PC) measurements highlighted during the AAAHC accreditation process will be addressed  and ameliorated before the next accreditation process in the 2018-2019 school year.

Sam Houston State University | A Member of The Texas State University System