The URL can be used to link to this page

Home My WebLink About01_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