01_04_2017 BOH Minutes1
Joshua Swift
Deputy Health Director
Health Department
New Hanover County
•Performance Standards
•Customer Satisfaction
•Audit Findings
Health Department
New Hanover County
The annual Quality Assurance Report is produced by the Quality Assurance Committee and the
Quality Assurance Officer each year.
The report is a combination of the findings of three performance indicators for the department:
•Performance Standards –Created by using the agreement addenda, grant objectives and pertinent
Information from the individual programs in the health department.
•Customer Satisfaction ‐Representative sampling of 5‐10% of those utilizing the services for 17 different
areas of the department.
•Medical Records Audit Committee Findings ‐This committee is responsible for performing medical record
audits for all programs that utilize medical records within the department.
Joshua Swift
Deputy Health Director
2
Health Department
New Hanover County
•To develop quantifiable standards and measure our department against
those standards and compare trends over time such as audit findings.
•This report will enable us to gauge the departments performance overall,
and at the program level.
•This process has enhanced our reporting capability, increased
accountability, and refocused our staff on the main objectives of our
programs.
Joshua Swift
Deputy Health Director
Health Department
New Hanover County
Joshua Swift
Deputy Health Director
3
Children’s Environmental Health, Institution & Public Swimming Pool Programs4/4100.00%
Food Safety Program4/4100.00%
Onsite Water Protection Program2/2100.00%
Vector Control4/4100.00%
Division Percentage13/13100.00%
Program Standards
Met/Total
Percent
Met Corrective Actions/Comments
Health Department
New Hanover County
Joshua Swift
Deputy Health Director
Health Promotion3/3100.00%
Injury Prevention/SAFE KIDS7/7100.00%
Non‐Traditional Testing5/683.33%
BT –Communication3/475.00%Missed one month of radio checks due to staff turnover.
BT –Preparedness8/8100.00%
Division Percentage26/2892.85%
Program Standards
Met/Total
Percent
Met Corrective Actions/Comments
Health Department
New Hanover County
Joshua Swift
Deputy Health Director
4
Health Department
New Hanover County
Program Standards
Met/Total
Percent
Met Corrective Actions/Comments
BCCCP5/683.33%
Care Coordination for Children (CC4C) 4/4100.00%
Communicable Disease (CD) 3/3100.00%
Child Fatality Prevention Team 3/3100.00%
Child Health 3/3100.00%
Childhood Lead Poisoning Prevention Program 2/2100.00%
Good Shepherd Homeless Medical Clinic 0/10.00%
The clinic served 270 new unduplicated clients in FY 2015‐
2016(goal 300). Census was down for the shelter for FY
2015‐2016.Served 241 new unduplicated clients in FY
2014‐2015.
Family Counseling 3/3100.00%
Health and Behavioral Intervention (HBI) Service1/1100.00%
Joshua Swift
Deputy Health Director
Health Department
New Hanover County
Program Standards
Met/Total
Percent
Met Corrective Actions/Comments
Immunizations 3/3100.00%
Laboratory 9/9100.00%
Maternal Health 5/5100.00%
Mobile Dental Unit 2/2100.00%
Pregnancy Care Management 5/5100.00%
School Health 3/475.00%
Severeallergies met at 80%, School Nurses will continue to
intensively case manage students with Diabetes, Epilepsy
and Severe Allergies
School Mental Health8/8100.00%
STD‐HIV 8/988.89%
The 2015‐2016 STD Agreement Addendum changedfrom
fiscal year to calendar year. STD Program Coordinator saw
166 patients from Jan 1, 2016 to Oct 31, 2016 and received
13.3 hours of continuing education credits.
Joshua Swift
Deputy Health Director
5
TB25/25100.00%
WIC Breastfeeding Peer Counselor Program3/3100.00%
WIC General18/1994.74%
Averaged 96% of WIC caseloadfor the year (goal 97%). Will
continue to use missed appointment and missed pick up
reports to call participants and encourage them to return to
WIC.
WIC Lactation Training Center 5/5100.00%
Wise Woman4/4100.00%
Women's Preventive Health 5/683.33%Clinic hada provider vacancy for 2 ½ months and provider
had to complete a 6‐month probation period.
Division Percentage127/13395.48%
Program Standards
Met/Total
Percent
Met Corrective Actions/Comments
Health Department
New Hanover County
Joshua Swift
Deputy Health Director
Program Standards
Met/Total
Percent
Met
Corrective Actions/Comments
Customer Care3/3 100.00%
Fiscal Support3/3100.00%
Program Support1/1 100.00%
Division Percentage7/7100.00%
Health Department
New Hanover County
Joshua Swift
Deputy Health Director
6
Health Department
New Hanover County
Joshua Swift
Deputy Health Director
Health Department
New Hanover County
Overall
Health Department
Satisfaction
Excellent + Good = Overall
88.51% + 4.75% = 93.27%
FY 2015‐2016 Satisfaction Survey Results
Program Survey
Month ExcellentGoodAverage
N/A
or
Blank
Below
Average Poor
Overall
Program
Satisfaction
Care Coordination ‐CSCJuly97.14%2.86%0.00%0.00%0.00%0.00%100.00%
Care Coordination ‐PCMJuly97.14%2.86%0.00%0.00%0.00%0.00%100.00%
Environmental HealthAugust88.00%8.00%2.00%2.00%0.00%0.00%96.00%
Health PromotionSeptember92.50%3.33%3.33%0.00%0.00%0.83%95.83%
Clinic ServicesNovember80.95%11.19%3.10%1.19%1.67%1.67%92.14%
LaboratoryNovember98.18%0.00%0.00%1.82%0.00%0.00%98.18%
School HealthNovember96.36%3.64%0.00%0.00%0.00%0.00%100.00%
School Mental HealthDecember94.09%5.91%0.00%0.00%0.00%0.00%100.00%
WIC/NutritionDecember90.99%6.92%1.65%0.11%0.11%0.22%97.91%
Care Coordination ‐CSCJanuary100.00%0.00%0.00%0.00%0.00%0.00%100.00%
Care Coordination ‐PCMJanuary100.00%0.00%0.00%0.00%0.00%0.00%100.00%
Environmental HealthFebruary93.00%7.00%0.00%0.00%0.00%0.00%100.00%
Health PromotionMarch97.42%2.58%0.00%0.00%0.00%0.00%100.00%
School HealthMarch97.49%1.46%0.13%0.93%0.00%0.00%98.95%
School Mental HealthApril85.74%11.30%2.96%0.00%0.00%0.00%97.04%
Clinic ServicesMay91.34%7.54%0.56%0.00%0.28%0.00%98.88%
LaboratoryMay91.52%7.37%51.00%0.00%0.30%0.30%98.89%
WIC/NutritionJune89.87%8.37%1.21%0.11%0.33%0.11%98.24%
Total Satisfaction 88.51%4.75%3.47%0.32%0.14%0.16%93.27%
Joshua Swift
Deputy Health Director
7
Health Department
New Hanover County
Joshua Swift
Deputy Health Director
Health Department
New Hanover County
TheNewHanoverCountyHealthDepartmenthascompleteditseleventhyearofinternal
programandmedicalrecordsaudits.The MedicalRecordAuditCommitteeisamulti‐
disciplinaryteamcomposedofmembersfromthePersonalHealthServicesandSupport
ServicesDivisions.
Forthisfiscalyear,the17programaudits averageda100%compliancescoreontheir
programauditsand19programsaverageda98%compliancescoreforBestPractice
ChartingStandards.Theconsistencyinourscoresshowsthecommitmentouragencyhas
forhighservicestandardsandcontinuousqualityimprovement.
TheAuditCommitteecontinuesworkingwiththe transitiontoelectronicmedicalrecords
andconductedan“electronic”medicalrecord auditontheGoodShepherdMedicalClinic,
ChildhoodLeadPreventionProgram,WICandtheMobileDentalUnitprograminthis
fiscalyear.
.
Fiscal Year 2015-2016
Joshua Swift
Deputy Health Director
8
Health Department
New Hanover County
Joshua Swift
Deputy Health Director