zero-based budget
chaoplay1
EBM_3West2019.xlsxManagementRequirements
| MANAGEMENT REQUIREMENTS |
| 1.EXCEL is to be used for any numeric information – WORD tables are outlawed |
| 2.EMAIL is our official mode of communication – not TEXTING or VERBAL |
| 3. Emails are to be replied to within 1 business day |
| 4. Out-Of-Office-Assistant is to be used when away. |
| 5.DOCUMENTS are to be saved on your hard-drive and/or electronically sent |
| 6.FOLDERS are to be created on your Outlook to archive important emails |
| 7.For non-electronic documents, SCAN them and send via email. |
| 8.DOCUMENTS are to be emailed, not printed, not hand-delivered. |
| 9.JD/PERF-EVAL/COMPETENCY documents are to be completed electronically |
| 10.MEETINGS are scheduled via Outlook calendar – do not request “availability” |
| 11.Your own OUTLOOK PROPERTIES are to be kept current |
| 12.MHMC approved templates are on EBM Workbook – no new templates |
| 13. Your EBM WORKBOOK is to be updated monthly |
| 14. MHMC is Pronoun-and- Acronym-Free-Zone |
| 15. QUALITY, SAFETY and COMPLIANCE are this year's focus. |
Definitions
| STANDARDS | MONITORS | |
| 1 | Dashboard - a glance at dept's performance | Update monthly - this becomes a summary of performance |
| 2 | Overtime monitor | Update each payroll using Financial Report |
| 3 | Volumes | Monitor monthly, by patient class (IP/OP/ER) |
| 4 | Staffing Plan | Staffing plans are DNV-required element for Scope of Service. |
| 5 | Absenteeism | Update each payroll using Financial Report |
| 6 | Tardiness | Update each payroll using Financial Report |
| 7 | Compliance | All department-specific regulations are to be listed here |
| 8 | Quality/Performance Improvement | This is where PI and Quality monitors are detailed. |
| 9 | Meeting Minutes template | Hold 10 staff meetings/year with minutes using this template |
| 10 | Counseling form | Utilize when low performance issues occur |
| 11 | JD-PerfEval-Comps | Maintain one TAB for each JOB/POSITION in your area |
| 12 | CAPRA format | Keep updated for HR compliance |
| 13 | Goals | Annual goals are to be specific and measurable |
| 14 | Customer Satisfaction scores | Now located on MANAGEMENT SHARE drive |
| 15 | Productivity | Not applicable unless this can be captured electronically |
| These are the approved templates for management expectations. | ||
| MHMC uses EBM as our standardized management practice. | ||
| No other templates/forms are to be used. Only EBM is to be used. | ||
| Maintain 2 copies of your EBM Workbook - 1 on your hard drive, | ||
| and 2nd on the Management "SHARE" drive. Others will be utilizing your data. | ||
| Continual EBM educational workshops are provided for you during the year. | ||
| Your Performance Evaluation is linked to your EBM WORKBOOK. |
&"-,Bold"&18Evidence Based Management Program 2015
&"-,Bold"&18Evidence Based Management Program 2015
&"-,Bold"&18Evidence Based Management Program 2015
&"-,Bold"&18Evidence Based Management Program 2015
&"-,Bold"&18Evidence Based Management Program 2015
&"-,Bold"&18Evidence Based Management Program 2015
&"-,Bold"&18Evidence Based Management Program 2015
Dashboard
| Insert dept. name | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | 2017AVG | 2016 AVG | 2015 AVG | 2014 AVG | 2013 AVG |
| Salary Expenses | ERROR:#DIV/0! | $13,320 | $16,650 | $18,500 | |||||||||||||
| Non-Salary Exp. | ERROR:#DIV/0! | $2,160 | $2,700 | $3,000 | |||||||||||||
| TOTAL Exp/Costs | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ERROR:#DIV/0! | $15,480 | $19,350 | $21,500 | |
| Gross Charges | ERROR:#DIV/0! | $2,540,615 | 2,286,562 | 1,890,265 | |||||||||||||
| Collections (15%) | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ERROR:#DIV/0! | $381,092 | 342,984 | 283,540 | |
| Profit/Loss | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | ERROR:#DIV/0! | $365,612 | 323,634 | 262,040 | |
| Volume IP | ERROR:#DIV/0! | 1266 | 1,140 | 912 | |||||||||||||
| Volume OP | ERROR:#DIV/0! | 1133 | 1,020 | 816 | |||||||||||||
| Volume ER | ERROR:#DIV/0! | 254 | 229 | 183 | |||||||||||||
| Volume TOTAL | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ERROR:#DIV/0! | 2,653 | 2,388 | 1,911 | |
| $ Supply/Unit | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | $0.81 | $1.13 | $1.57 | |
| $ Salary/Unit | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | $5.02 | $6.97 | $9.68 | |
| $ Cost/Unit | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | $5.83 | $8.10 | $11.25 | |
| $ Revenue/Unit | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | $137.81 | $135.52 | $137.12 | |
| $ Profit/Loss/Unit | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | $131.98 | $127.41 | $125.87 | |
| AVERAGE OT % | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | 3.0% | 5.3% | 5.92% | |
| Absenteeism # | ERROR:#DIV/0! | 23.0 | 18 | 22 | |||||||||||||
| Tardiness # | ERROR:#DIV/0! | 22.0 | 2 | 2 | |||||||||||||
| Staff Meeting dates | ERROR:#DIV/0! | 1.0 | 2.0 | 2.0 | |||||||||||||
| (PG)satisfaction % | ERROR:#DIV/0! | 85.0% | 82.50% | 80.46% | |||||||||||||
| Quality/PI data | ERROR:#DIV/0! | 24.0 | 26.0 | 27.0 | |||||||||||||
| Quality/PI data | ERROR:#DIV/0! | 1.0 | 0.0 | 1.0 | |||||||||||||
| Quality/PI data | ERROR:#DIV/0! | 45.0% | 45.0% | 52.0% | |||||||||||||
| Quality/PI data | ERROR:#DIV/0! | 2.0 | 2.0 | 3.0 | |||||||||||||
| Quality/PI data | ERROR:#DIV/0! | 1.0% | 3.0% | 5.0% | |||||||||||||
| Specify your PI/ | Only white cells are to be populated. | ||||||||||||||||
| Quality indicators | Blue cells will auto-populate. |
&"-,Bold"&14Dashboard Monitor
&"-,Bold"&14Dashboard Monitor
&"-,Bold"&14Dashboard Monitor
&"-,Bold"&14Dashboard Monitor
&"-,Bold"&14Dashboard Monitor
&"-,Bold"&14Dashboard Monitor
&"-,Bold"&14Dashboard Monitor
OvertimeMonitor
| 3 payrolls/mth. | Cost Center # | <2% | Cost Center # | Cost Center # | Avg. OT | |||||||||||
| PP | Total Hrs. | OT Hrs. | Total $$$ | % OT | Total Hrs. | OT Hrs. | Total $$$ | % OT | Total Hrs. | OT Hrs. | Total $$$ | % OT | ||||
| 1 | 3026 | 55 | 1678 | 1.82% | ERROR:#DIV/0! | ERROR:#DIV/0! | ||||||||||
| 2 | 3031 | 115 | 3775 | 3.79% | ERROR:#DIV/0! | ERROR:#DIV/0! | ||||||||||
| 3 | 3446 | 232 | 9567 | 6.73% | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | Jan | ||||||||
| 4 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | |||||||||||||
| 5 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | Feb | |||||||||||
| 6 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | |||||||||||||
| 7 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | Mar | |||||||||||
| 8 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | |||||||||||||
| 9 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | Apr | |||||||||||
| 10 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | |||||||||||||
| 11 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | May | |||||||||||
| 12 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | |||||||||||||
| 13 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | June | |||||||||||
| 14 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | |||||||||||||
| 15 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | |||||||||||||
| 16 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | July | |||||||||||
| 17 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | |||||||||||||
| 18 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | Aug | |||||||||||
| 19 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | |||||||||||||
| 20 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | Sept | |||||||||||
| 21 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | |||||||||||||
| 22 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | Oct | |||||||||||
| 23 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | |||||||||||||
| 24 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | Nov | |||||||||||
| 25 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | |||||||||||||
| 26 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | |||||||||||||
| 27 | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | ERROR:#DIV/0! | Dec |
&"-,Bold"&14OVERTIME
&"-,Bold"&14OVERTIME
&"-,Bold"&14OVERTIME
&"-,Bold"&14OVERTIME
&"-,Bold"&14OVERTIME
&"-,Bold"&14OVERTIME
&"-,Bold"&14OVERTIME
Volume
| Volume | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | AVG |
| Admissions | 400 | 400 | |||||||||||
| Tests | 300 | 300 | |||||||||||
| Exams | 600 | 600 | |||||||||||
| Births | 50 | 50 | |||||||||||
| Surgeries | 100 | 100 | |||||||||||
| Pt. Days | 500 | 500 | |||||||||||
| Tests/Tx. | 703 | 703 | |||||||||||
| TOTAL A | 2653 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 2653 |
| IP | 1266 | 1266 | |||||||||||
| OP | 1133 | 1133 | |||||||||||
| ER | 254 | 254 | |||||||||||
| TOTAL B | 2653 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 2653 |
| Whatever you count, list it here. | |||||||||||||
| Customize as necessary. | |||||||||||||
| TOTAL A should equal TOTAL B |
&"-,Bold"&18VOLUME
&"-,Bold"&18VOLUME
&"-,Bold"&18VOLUME
&"-,Bold"&18VOLUME
&"-,Bold"&18VOLUME
&"-,Bold"&18VOLUME
&"-,Bold"&18VOLUME
StaffingPlan
| SUN | MON | TUES | WED | THU | FRI | SAT | SUN | MON | TUES | WED | THU | FRI | SAT | FTEs | SUN | MON | TUES | WED | THU | FRI | SAT | SUN | MON | TUES | WED | THU | FRI | SAT | FTEs | |||
| Dept. Name 3 West | 22.0 | 27.0 | 25.0 | 27.0 | 25.0 | 21.0 | 22.0 | 18.0 | 27.0 | 27.0 | 21.0 | 25.0 | 27.0 | 22.0 | 18.30 | Dept. Name 3 West | 16.0 | 18.0 | 20.0 | 18.0 | 16.0 | 18.0 | 16.0 | 18.0 | 14.0 | 14.0 | 16.0 | 16.0 | 16.0 | 16.0 | 16.80 | |
| Manager | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | |||||||||||||||||||||
| ANM | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | |||||||||||||||||||||
| Nursing Assistant | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | RN | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | |||||||||||||
| Nursing Assistant | 1.00 | RN | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | |||||||||||||||||||||||
| Nursing Assistant | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | RN | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | |||||||||||||
| Nursing Assistant | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | RN | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | |||||||||||||
| Nursing Assistant | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | RN | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | |||||||||||||
| Nursing Assistant | 1 | 1 | 1 | 1 | 1 | 1 | 0.60 | RN | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | |||||||||||||||||
| Nursing Assistant PD | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0.70 | RN | 1 | 1 | 1 | 1 | 1.00 | ||||||||||||||||||
| Totals | 4 | 4 | 4 | 4 | 4 | 3 | 4 | 3 | 4 | 4 | 3 | 4 | 4 | 4 | RN | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | ||||||||||
| Nursing Assistant | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | RNPD | 1 | 1 | 1 | 1 | 1 | 0.40 | ||||||||||||||
| Nursing Assistant | 0.00 | RNPD | 1 | 1 | 1 | 1 | 0.40 | |||||||||||||||||||||||||
| Nursing Assistant | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | RNPD | 1 | 1 | 0.20 | |||||||||||||||||
| Nursing Assistant | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | RNPD | 1 | 1 | 1 | 1 | 0.40 | |||||||||||||||
| Nursing Assistant | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | 0.00 | ||||||||||||||||||||
| Nursing Assistant PT | 1 | 1 | 1 | 1 | 1 | 1 | 0.60 | Totals | 4 | 5 | 5 | 5 | 4 | 5 | 4 | 5 | 4 | 4 | 4 | 4 | 4 | 4 | ||||||||||
| Nursing Assistant PD | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0.70 | RN | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | ||||||||||||||||
| Totals | 4 | 4 | 4 | 4 | 4 | 3 | 4 | 3 | 4 | 4 | 3 | 4 | 4 | 4 | RN | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | ||||||||||
| Nursing Assistant | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | RN | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | ||||||||||||
| Nursing Assistant | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | RN | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | |||||||||||||||
| Nursing Assistant | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | RN | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | |||||||||||||
| Nursing Assistant | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0.70 | RN | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | ||||||||||||||||
| Nursing Assistant PT | 1 | 1 | 1 | 1 | 1 | 1 | 0.60 | RN | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0.40 | ||||||||||||||||
| Nursong Assistant PT | 1 | 1 | 1 | 1 | 0.40 | RN PT | 1 | 1 | 1 | 1 | 1 | 0.40 | ||||||||||||||||||||
| 0.00 | RN PD | 1 | 1 | 1 | 0.30 | |||||||||||||||||||||||||||
| Totals | 3 | 4 | 3 | 4 | 3 | 3 | 3 | 3 | 4 | 4 | 3 | 3 | 4 | 3 | RN PD | 1 | 1 | 1 | 1 | 0.30 | ||||||||||||
| Transporter | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | Totals | 4 | 4 | 5 | 4 | 4 | 4 | 4 | 4 | 3 | 3 | 4 | 4 | 4 | 4 | ||||||
| 1 | Days | This is to demonstrate how many | 1 | 7am-7pm | ||||||||||||||||||||||||||||
| 1 | Eves | FTEs are staffed on a daily basis | 1 | 7pm-7am | ||||||||||||||||||||||||||||
| 1 | Nites | Staff as if nobody is on vacation/sick. | ||||||||||||||||||||||||||||||
| SUN | MON | TUES | WED | THU | FRI | SAT | SUN | MON | TUES | WED | THU | FRI | SAT | FTEs | ||||||||||||||||||
| Dept. Name 3 West | 6.0 | 6.0 | 6.0 | 6.0 | 6.0 | 6.0 | 6.0 | 6.0 | 6.0 | 6.0 | 6.0 | 6.0 | 6.0 | 6.0 | 5.20 | |||||||||||||||||
| 0.00 | ||||||||||||||||||||||||||||||||
| 1.00 | ||||||||||||||||||||||||||||||||
| Telemetry tech FT | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | |||||||||||||||||||||
| Telemetry tech PT | 1 | 1 | 1 | 1 | 1 | 1 | 0.60 | |||||||||||||||||||||||||
| Telemetry tech PT | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0.80 | |||||||||||||||||||||||
| Telemetry tech PD | 1 | 1 | 1 | 1 | 0.40 | |||||||||||||||||||||||||||
| Telemetry tech PD | 1 | 1 | 1 | 1 | 0.40 | |||||||||||||||||||||||||||
| Telemetry tech FT | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1.00 | |||||||||||||||||||||
| 0.00 | ||||||||||||||||||||||||||||||||
| Totals | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | ||||||||||||||||||
&"-,Bold"&14Staffing Plan&"-,Regular"&11
&"-,Bold"&14Staffing Plan&"-,Regular"&11
&"-,Bold"&14Staffing Plan&"-,Regular"&11
&"-,Bold"&14Staffing Plan&"-,Regular"&11
&"-,Bold"&14Staffing Plan&"-,Regular"&11
&"-,Bold"&14Staffing Plan&"-,Regular"&11
&"-,Bold"&14Staffing Plan&"-,Regular"&11
CAPRA
| Name | Job Title | FTEs | Date of Hire | ACLS | BLS | NIH | PALS | CEU credits |
| ACOSTA, RAINY | TT FT | 1 | 3/17/15 | N/A | N/A | N/A | N/A | |
| ARZADON, ARMILYN | RN PT | 0.5 | 8/17/15 | Jun-19 | Jun-19 | Jun-18 | ||
| BENDAS, LYUDMYLA | RN PD | 0.1 | 7/11/11 | Aug-18 | Sep-18 | N/A | ||
| BOLANOS, JENNY | NA FT | 1 | 12/7/10 | N/A | Dec-17 | N/A | N/A | |
| BRADFORD, LEAH | RN PT | 0.5 | 10/7/15 | Sep-18 | Jul-17 | N/A | ||
| BRAVENBOER, AMY | RN PD | 0.1 | 2/19/15 | Jul-18 | Aug-18 | Feb-18 | ||
| CHOI, VANE | RN FT | 1 | 12/7/10 | Jan-18 | Jan-18 | N/A | ||
| Carter, Idelle | NA FT | |||||||
| Carter, Nicole | NA FT | Jun-19 | ||||||
| CAMPOS,MAYRA | TT PD | |||||||
| CRUZ, IVETTE | TT FT | 1 | 5/10/14 | N/A | Aug-17 | N/A | N/A | |
| DEERING, DEBORAH | RN FT | 1 | 12/7/10 | Jan-18 | Jul-19 | N/A | ||
| FLEITES-GUERRA, CLARA | RN FT | 1 | 12/7/10 | Jan-18 | Feb-17 | N/A | ||
| GILGALLON, MARY | RN FT | 1 | 12/7/10 | Jan-20 | Jan-18 | N/A | ||
| GOMEZ, AMELIA | NA FT | 1 | 12/7/10 | N/A | Aug-17 | N/A | N/A | |
| GROSS, KELLY | RN PT | 0.4 | 7/21/14 | Jul-18 | Sep-17 | N/A | ||
| GRUBYAK, NADIYA | RN PD | 0.1 | 12/30/13 | Dec-17 | Dec-17 | Dec-17 | ||
| HAYWOOD, LORI | RN FT | 1 | 12/7/10 | Jan-18 | Oct-17 | N/A | ||
| IOUDINA, KSENIA | RN FT | 1 |
Angely Lopez: Angely Lopez: emailed about certs. 11/30/16 | Aug-18 | N/A | |||
| JAGGESSAR, PEGGY | RN PT | 0.5 | 12/7/10 | Jan-18 | Apr-19 | N/A | ||
| LALUZ, YVONNE | NA PT | 0.5 | 12/7/10 | N/A | Nov-17 | N/A | N/A | |
| LAMPANO, RENATO | NA FT | 1 | 12/7/10 | N/A | Feb-17 | N/A | N/A | |
| LICHTENBERGER, RACHEL | RN FT | 1 | 12/7/10 | Jan-18 | Jul-17 | N/A | ||
| LOPEZ, DELFI | NA PT | 0.5 | 8/31/15 | N/A | Sep-18 | N/A | N/A | |
| MACALUSO, CLAUDE | RN FT | 1 | 12/7/10 | Sep-17 | Sep-18 | N/A | ||
| MAINGI, BERNADETTE | RN PT | 0.6 | 12/7/10 | Sep-18 | Sep-18 | N/A | ||
| MARTINEZ, WANDA | TT PD | 0.1 | 6/24/15 | N/A | N/A | N/A | N/A | |
| MATEIRO, STEPHANIE | RN PT | 0.5 | 8/17/15 | Apr-18 | Feb-18 | N/A | ||
| NUNEZ, KELLY | RN PT | 0.6 | 10/7/15 | Aug-18 | Aug-18 | N/A | ||
| PETROWSKY, SUSAN | NA FT | 1 | 10/10/12 | N/A | Aug-17 | N/A | N/A | |
| POLANCO, CARLOS | TT PD | 0.1 | 9/10/15 | N/A | N/A | N/A | N/A | |
| RESLEN, NATHALIE | RN FT | 1 | 6/5/14 | Apr-18 | N/A | N/A | ||
| ROSA, MARIA | RN PD | 0.1 | 5/24/13 | Mar-17 | Oct-18 | N/A | ||
| ROTH, RACHEL | RN PD | 0.1 | 1/27/14 | Jul-17 | Jul-17 | N/A | ||
| SEVILLES, DEXTER | RN FT | 1 | 8/17/15 | Nov-17 | Nov-17 | N/A | ||
| SIERRA, FRANGY | TT PD | 0.1 | 9/23/15 | N/A | N/A | N/A | N/A | |
| STONE, STEPHANIE | NA FT | 1 | N/A | Apr-17 | N/A | |||
| VIELMAN, HEATHER | RN PT | 0.5 | 8/17/15 |
Angely Lopez: Angely Lopez: send email 11/30/16 regarding ACLS | May-17 | N/A | ||
| WRIGHT,SIMEON | Sep-18 | |||||||
| YARMULNIK, ANNA | RN PD | 0.1 | 11/8/12 | Oct-17 | Oct-17 | N/A | ||
| YAROTSKA, MARYNA | TT PD | 0.1 | 10/25/13 | N/A | N/A | N/A | N/A | |
| ZONGWE, MANDA | NA PT | 0.6 | 12/7/10 | N/A | Nov-17 | N/A | N/A |
&"-,Bold"&14CAPRA
&"-,Bold"&14CAPRA
&"-,Bold"&14CAPRA
&"-,Bold"&14CAPRA
&"-,Bold"&14CAPRA
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&"-,Bold"&14CAPRA
Absenteeism
| Dept. | 2012 Total | 2013 Total | 2014 Total | 2015 Total | 2016 Total | 2017 Total | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| Annie | 2 | 1 | 2 | 2 | 0 | |||||||||||||
| Bonnie | 2 | 0 | 2 | 2 | 0 | |||||||||||||
| Charlie | 3 | 0 | 3 | 3 | 0 | |||||||||||||
| David | 1 | 1 | 1 | 1 | 0 | |||||||||||||
| Elaine | 5 | 1 | 1 | 1 | 0 | |||||||||||||
| Francie | 1 | 2 | 1 | 1 | 0 | |||||||||||||
| George | 2 | 3 | 2 | 2 | 0 | |||||||||||||
| Helen | 0 | 1 | 0 | 0 | 0 | |||||||||||||
| Irene | 4 | 5 | 2 | 2 | 0 | |||||||||||||
| Johnny | 2 | 0 | 2 | 2 | 0 | |||||||||||||
| Killian | 3 | 4 | 3 | 3 | 0 | |||||||||||||
| Lynn | 1 | 2 | 1 | 1 | 0 | |||||||||||||
| Mary | 4 | 2 | 1 | 1 | 0 | |||||||||||||
| Nancy | 3 | 3 | 1 | 1 | 0 | |||||||||||||
| Ophelia | 2 | 1 | 0 | 0 | 0 | |||||||||||||
| Queenie | 0 | 1 | 0 | 0 | 0 | |||||||||||||
| Ralph | 1 | 1 | 0 | 0 | 0 | |||||||||||||
| Sally | 1 | 2 | 1 | 1 | 0 | |||||||||||||
| Tommy | 1 | 0 | 1 | 1 | 0 | |||||||||||||
| Victor | 2 | 2 | 1 | 1 | 0 | |||||||||||||
| Wally | 0 | 2 | 0 | 0 | 0 | |||||||||||||
| Xavier | 2 | 4 | 2 | 2 | 0 | |||||||||||||
| Yana | 2 | 4 | 2 | 2 | 0 | |||||||||||||
| Zachary | 3 | 0 | 2 | 2 | 0 | |||||||||||||
| Total Sick Days 2012 | 47 | 42 | 31 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| More than 3 absences/qtr = Excessive | ||||||||||||||||||
&"-,Bold"&14ABSENTEEISM MONITOR
&"-,Bold"&14ABSENTEEISM MONITOR
&"-,Bold"&14ABSENTEEISM MONITOR
&"-,Bold"&14ABSENTEEISM MONITOR
&"-,Bold"&14ABSENTEEISM MONITOR
&"-,Bold"&14ABSENTEEISM MONITOR
&"-,Bold"&14ABSENTEEISM MONITOR
Tardiness
| Dept. | 2012 Total | 2013 Total | 2014 Total | 2015 Total | 2016 Total | 2017 Total | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| Annie | 3 | 0 | 0 | 0 | 0 | |||||||||||||
| Bonnie | 1 | 0 | 0 | 0 | 0 | |||||||||||||
| Charlie | 1 | 0 | 1 | 1 | 0 | |||||||||||||
| David | 1 | 0 | 0 | 0 | 0 | |||||||||||||
| Elaine | 2 | 0 | 1 | 1 | 0 | |||||||||||||
| Francie | 0 | 1 | 0 | 0 | 0 | |||||||||||||
| George | 2 | 2 | 1 | 1 | 0 | |||||||||||||
| Helen | 3 | 1 | 1 | 1 | 0 | |||||||||||||
| Johnny | 1 | 2 | 1 | 1 | 0 | |||||||||||||
| Killian | 1 | 1 | 0 | 0 | 0 | |||||||||||||
| Mary | 2 | 1 | 0 | 0 | 0 | |||||||||||||
| Nancy | 0 | 1 | 1 | 1 | 0 | |||||||||||||
| Ophelia | 1 | 1 | 0 | 0 | 0 | |||||||||||||
| Queenie | 1 | 0 | 0 | 0 | 0 | |||||||||||||
| Ralph | 2 | 0 | 0 | 0 | 0 | |||||||||||||
| Sally | 0 | 3 | 2 | 2 | 0 | |||||||||||||
| Victor | 2 | 3 | 2 | 2 | 0 | |||||||||||||
| Wally | 2 | 2 | 0 | 0 | 0 | |||||||||||||
| Xavier | 3 | 1 | 0 | 0 | 0 | |||||||||||||
| Yana | 0 | 2 | 1 | 1 | 0 | |||||||||||||
| Zachary | 0 | 1 | 0 | 0 | 0 | |||||||||||||
| Total Tardiness | 28 | 22 | 11 | 11 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
| COUNSELINGS = | More than 3 tardy incidents/qtr = Excessive | |||||||||||||||||
| Eg. = Charlie was counseled 3/15 | Update the 2012 Total column | |||||||||||||||||
| George counseled 7/25 | ||||||||||||||||||
&"-,Bold"&14TARDINESS MONITOR
&"-,Bold"&14TARDINESS MONITOR
&"-,Bold"&14TARDINESS MONITOR
&"-,Bold"&14TARDINESS MONITOR
&"-,Bold"&14TARDINESS MONITOR
&"-,Bold"&14TARDINESS MONITOR
&"-,Bold"&14TARDINESS MONITOR
Compliance
| REG # | EXAMPLE - DNV, DOH and dept-specific REGULATIONS | Y/N | If YES, state where the policy is found (policy number) as per P&P. If No, what needs to be addressed in a future policy? (the action plan) |
| SS.8 = NC1 | SR.1 An operative report describing techniques, findings, and tissues removed or altered shall be written or dictated and signed by the surgeon immediately following surgery. SR.2 The operative report shall be dictated or written in its entirety before the patient is transferred to the next level of care (e.g. before the patient leaves the post anesthesia care area). | N | During review of 2 charts, Post-Op note did not contain Estimated Blood Loss, Complications or Grafts/implants section in Chart 2. Immediate Post-Op template was not the updated form. In Chart 3, Grafts/implant section of Immediate post-Op note dated 1-29-13 was blank. In Endoscopy charts (4,5,6) Post-Procedure Notes did not contain Estimated Blood Loss or Anesthesia Type. |
| PR. 4 = NC1 | PR.4 = organization shall obtain an informed written consent from each patient for the provision of medical and/or surgical care except in emergencies. Consent shall include explanation of risks, benefits, aletrnatives for high-risk procedures, sedation and participation inresearch projects as defined by medical staff and State law. | N | In 4 of 5 charts, no Anesthesiologist name was provided. Name of surgeon was missing. |
| QM.2 | Organization to initiate a process of conducting internal reviews of P&Ps and prepare corrective action plans and a means to verify compliance. | N | Need Quality Plan to include audit process. |
| QM.2 | Organization to implement ISO 9001 methodology - at a minimum Control of Documents | N | Need Document Control P&P and process |
| QM.5 | Failure, Mode, Effect Analysis and Root cause Analysis, Performance Report and Non-Conformity Report missing | N | Quality Committee has not encompassed all inputs and outputs as required. |
| QM.6 | Quality policy statement of commitment | N | Missing a quality policy |
| SS.4 | Downgraded to NC-2 | N | Still needs better compliance |
| MM.1 | Control of nonconformance | N | Medications expired in Women's Health Center and PACU Crash cart |
| SM.5 | Control of documents | N | Departmental defined certifications were missing - need to be dept. specific |
| SM.7 | Compliance not being met due to backlog of paperwork | N | 2012 HR files not addressed at all; 2011 completed. |
| PE.2 | Must provide infrastructure of safety in building and workspaces | N | Fire alarms need to be installed in every sleeping room. EXIT signs blocked by hanging signs. |
| PE.4 | Workplace Violence P&P needed, Hazard assessment, training and education, Incident reporting, Follow-up and Recordkeeping | N | No Work Place Violence program in place. |
| 2 | Total of Non-compliant regulations | 0% | Inspection-readiness |
| List all dept. specific regulatory agency's standards above. |
&"-,Bold"&18COMPLIANCE GRID
&"-,Bold"&18COMPLIANCE GRID
&"-,Bold"&18COMPLIANCE GRID
&"-,Bold"&18COMPLIANCE GRID
&"-,Bold"&18COMPLIANCE GRID
&"-,Bold"&18COMPLIANCE GRID
&"-,Bold"&18COMPLIANCE GRID
MeetingMinutes
| Date: January 18,2018 | Meeting Name and Organizer: 3W staff meeting. K. Fonti RN | Attendees: D.Deering,I. Struminsky,M.Gillgallon, V. Choi, M.McGroarty,K.Kabigting |
| Start time:3pm | End time:4:30pm | |
| TOPIC | DISCUSSION | FOLLOW-UP |
| Patient pagers | Pagers have to be worn wir nursing assistants and nurses at all times | |
| TOPIC | DISCUSSION | FOLLOW-UP |
| Patient Care Plans | New care plans to address comorbidity. Committee to start to develop platfrm for new emr | |
| TOPIC | DISCUSSION | FOLLOW-UP |
| Patient education | Staff need to document education for coumadin, Hep C and Diabetes in your education notes | |
| TOPIC | DISCUSSION | FOLLOW-UP |
| Hudson Regional Forms | Only forms with Hudon Regional Hospital can be used. Look at the Intranet for forms that you need. | |
| TOPIC | DISCUSSION | FOLLOW-UP |
| Evaluations | All evals need to be signed | |
| TOPIC | DISCUSSION | FOLLOW-UP |
| Patient Care-Getting patients out of bed | More has to be done to make sure patients are getting oob daily including ICU. | |
| TOPIC | DISCUSSION | FOLLOW-UP |
| New Ownership | The hospital has been sold to a new owner. The new name is Hudson Regional Hospital | |
| TOPIC | DISCUSSION | FOLLOW-UP |
| 2018 Goals | Increased patient satisfaction | |
| Continue hourly rounding | ||
| Medication awareness (patients know what medcations they are taking and why) | ||
| Open Questions | Pharmacy problems on weekends,3-11 and night shift | |
| Recovery Room Supervisor to call in staff when there is an OR not a procedure | ||
| Signature and Date: | ||
| Use this format for all meetings. | ||
&"-,Bold"&14STAFF MEETING (10/year) MINUTES
&"-,Bold"&14STAFF MEETING (10/year) MINUTES
&"-,Bold"&14STAFF MEETING (10/year) MINUTES
&"-,Bold"&14STAFF MEETING (10/year) MINUTES
&"-,Bold"&14STAFF MEETING (10/year) MINUTES
&"-,Bold"&14STAFF MEETING (10/year) MINUTES
&"-,Bold"&14STAFF MEETING (10/year) MINUTES
CounselingForm
| Disciplinary Action Form |
| Employee Name: Job Title: |
| Department: Date of Hire: |
| Date of Infraction: |
| Meeting Date: |
| Disciplinary History (last 12 months): □ N/A Date: Level: Infraction: |
| Date: Level: Infraction: |
| Date: Level: Infraction: |
| DISPOSITION: (check level of discipline) |
| 1. □Verbal (kept by manager) 2. □Documentation of Counseling (signed & filed in HR Dept.) |
| 3.□ Written Warning 4. □Final Written Warning (in lieu of suspension) |
| 5. □ Discharge: Effective date: ________ |
| INFRACTION: (give complete details) Specify action/remedy required: (not applicable in discharge case) |
| □ Investigatory Suspension □ with pay □ without pay (5 days only) |
| Notice to Employee: Repeat infraction will result in the following disciplinary action: |
| □Written Warning |
| □Final Written Warning |
| □Discharge |
| EMPLOYEE’S EXPLANATION /DEFENSE: |
| The employee’s signature below does not necessarily imply agreement with this notice; it means only that the supervisor has discussed it with the employee and the employee has received a copy. |
| Signature of Employee: |
| Signature of Supervisor/Manager: |
| Signature of Union Representative (if applicable): |
| Signature of Human Resources Director: |
| PRESENT AT DISCIPLINARY ACTION MEETING (Please print names) |
| 1. ________________________________________________4. __________________________________________________ |
| 2. ________________________________________________ 5. _________________________________________________ |
| 3. ________________________________________________ 6. _________________________________________________ |
| □ Copy sent to union if applicable rev.12/13/12 |
JDperfEval
| 1. Performance Evaluation | ||
| 2. Job Description | ||
| 3. 90- Day Evaluation | ||
| 4. Annual Competency | ||
| NAME | ||
| POSITION TITLE | ||
| REPORTS TO: | ||
| EMPLOYMENT DATE OF HIRE | ||
| DEPARTMENT | ||
| EVALUATION PERIOD COVERED - Select one below | ||
| 1. INTRODUCTORY PERIOD - DUE @ 90 DAYS | ||
| 2. PERFORMANCE/COMPETENCIES - DUE ANNUALLY | ||
| DATE LICENSE WAS VERIFIED AS VALID | ||
| # DAYS ABSENT | ||
| # TARDY INCIDENTS | ||
| # MINUTES UNAUTHORIZED OT | ||
| JOB DESCRIPTION | ||
| Job Specific Competencies: | ||
| 1= Does NOT Meet Expectations 2=MEETS Expectations 3= EXCEEDS Expectations | ||
| Job Specific Competencies: | Rate 1, 2, or 3 | |
| 1 | ||
| 2 | ||
| 3 | ||
| 4 | ||
| 5 | ||
| 6 | ||
| 7 | ||
| 8 | ||
| 9 | ||
| 10 | ||
| 11 | ||
| 12 | ||
| 13 | ||
| 14 | ||
| 15 | ||
| 16 | ||
| 17 | ||
| 18 | ||
| 19 | ||
| 20 | ||
| 21 | ||
| 22 | ||
| JOB SPECIFIC AVERAGE SCORE | ||
| PERFORMANCE STANDARDS | ||
| 1= Does NOT Meet Expectations 2=MEETS Expectations 3= EXCEEDS Expectations | ||
| Service Excellence Indicators | Rate 1, 2, or 3 | |
| 1 | Offers assistance to anyone who appears lost or in need of help | |
| 2 | Allows visitors and patients to step onto elevator prior to themselves | |
| 3 | Maintains confidentiality of all written and electronic information | |
| 4 | Keeps voice low and refrains from social conversations in public | |
| 5 | Appropriately introduces self to customers with a smile and eye contact | |
| 6 | Displays I.D. appropriately 100% of the time | |
| 7 | Responds pleasantly when customers ask for assistance | |
| 8 | Answers the telephone within three rings and identifies their name | |
| 9 | Keeps patients, visitors and physicians informed of potential & actual wait time | |
| 10 | Complies with dress code policy | |
| 11 | Maintains the dignity and confidentiality of the customer | |
| 12 | Respects the rights, property, and privacy of others | |
| SERVICE EXCELLENCE AVERAGE SCORE | ERROR:#DIV/0! | |
| Comments: | ||
| Teamwork Indicators: | ||
| 1= Does NOT Meet Expectations 2=MEETS Expectations 3= EXCEEDS Expectations | Rate 1, 2, or 3 | |
| 1 | Is flexible and committed to department/unit team and other co-workers | |
| 2 | Never has inappropriate discussions in front of any customers | |
| 3 | Assists co-workers whenever asked – crosses over to other departments to help | |
| 4 | Positive work approach - increases overall department morale with optimism | |
| 5 | Prepared to begin work at start of shift | |
| 6 | Provides guidance and support to new employees, students, all others. | |
| 7 | Offers help to co-workers whenever their tasks are completed | |
| TEAMWORK AVERAGE SCORE | ERROR:#DIV/0! | |
| Comments: | ||
| Behavioral Expectations Indicators: | ||
| 1= Does NOT Meet Expectations 2=MEETS Expectations 3= EXCEEDS Expectations | Rate 1, 2, or 3 | |
| 1 | Exercises proper judgment – makes exceptions when needed | |
| 2 | Is proactive - makes recommendations for improvement | |
| 3 | Takes the initiative to avoid problems | |
| 4 | Accepts responsibility and follows-through | |
| 5 | Executes results – completes all tasks | |
| 6 | Demonstrates good utilization of time – increases activity when census spikes | |
| 7 | Accommodates patient to avoid customer dissatisfaction | |
| BEHAVIORAL AVERAGE SCORE | ERROR:#DIV/0! | |
| Comments: | ||
| Flexibility Indicators: | ||
| 1= Does NOT Meet Expectations 2=MEETS Expectations 3= EXCEEDS Expectations | Rate 1, 2, or 3 | |
| 1 | Reacts positively and quickly to change | |
| 2 | Handles stressful situations professionally and calmly | |
| 3 | When problems occur, discusses constructively rather than confrontationally | |
| FLEXIBILITY AVERAGE SCORE | ERROR:#DIV/0! | |
| Comments: | ||
| Professional Development/Competency: Indicators: | ||
| 1= Does NOT Meet Expectations 2=MEETS Expectations 3= EXCEEDS Expectations | Rate 1, 2, or 3 | |
| 1 | The licensed healthcare professional maintains current + valid credentials with relevant regulatory body | |
| 2 | Completes required department and system wide competencies | |
| 3 | Attends educational seminars, workshops and staff meetings to stay informed about relevant areas of clinical or managerial skills. | |
| 4 | Actively participates in Performance Improvement (PI) projects | |
| 5 | Exercises tact, sensitivity, sound judgment and professionalism when relating to patients/visitors and employees | |
| PROFESSIONAL AVERAGE SCORE | ERROR:#DIV/0! | |
| Comments: | ||
| Regulatory Agency Compliance Indicators: | ||
| 1= Does NOT Meet Expectations 2=MEETS Expectations 3= EXCEEDS Expectations | Rate 1, 2, or 3 | |
| 1 | Adheres to the current national patient safety regulations | |
| 2 | Provides for HIPAA patient privacy and safeguards the patients medical information | |
| 3 | Documentation is legible, complete, accurate and in accordance with policies and procedures | |
| 4 | Reports and documents potential adverse occurrences and communicates to manager | |
| 5 | Communicates promptly with physicians and healthcare providers regarding changes in patient conditions and/or responses to treatment | |
| 6 | Familiar with and adheres to all regulatory requirements | |
| REGULATORY AVERAGE SCORE | ERROR:#DIV/0! | |
| Comments: | ||
| Safety Indicators: | ||
| 1= Does NOT Meet Expectations 2=MEETS Expectations 3= EXCEEDS Expectations | Rate 1, 2, or 3 | |
| 1 | Practices safety by observing established hospital policies and procedures. | |
| 2 | Assures the safety and security of customers and staff at all times | |
| 3 | Demonstrates the safe use of equipment. Reports any equipment malfunctions or environmental hazards promptly and arranges for repair or correction | |
| 4 | Follows hospital guidelines for medication safety and accountability | |
| 5 | Transcribes and countersigns physicians orders accurately and in a timely manner | |
| 6 | Properly identifies patients prior to treatment or test according to hospital policy and procedure | |
| SAFETY AVERAGE SCORE | ERROR:#DIV/0! | |
| Comments: | ||
| Leadership Indicators: | ||
| 1= Does NOT Meet Expectations 2=MEETS Expectations 3= EXCEEDS Expectations | Rate 1, 2, or 3 | |
| 1 | Provides directions and supervision to other health care members to ensure proper implementation of plan of care | |
| 2 | Abides by all hospital policies and procedures and reports any non-compliance | |
| 3 | Is financially responsible regarding expenses and prevents waste of resources | |
| 4 | Contributes to proper, accurate and compliant billing | |
| 5 | Is a role model of service excellence | |
| LEADERSHIP AVERAGE SCORE | ERROR:#DIV/0! | |
| Comments: | ||
| Service Excellence Rating: | ERROR:#DIV/0! | |
| Team Work Rating: | ERROR:#DIV/0! | |
| Behavioral Expectation Ratings: | ERROR:#DIV/0! | |
| Flexibility Rating: | ERROR:#DIV/0! | |
| Professional Development/Competency Rating | ERROR:#DIV/0! | |
| Regulatory Agency Compliance Rating | ERROR:#DIV/0! | |
| Safety Rating: | ERROR:#DIV/0! | |
| Leadership Rating: | ERROR:#DIV/0! | |
| Job Specific Rating | 0.00 | |
| OVERALL PERFORMANCE AVERAGE SCORE | ERROR:#DIV/0! | |
| Working Conditions: | ||
| 1 | An employee may be exposed to a variety of activities and conditions that place him/her at risk to exposure to certain diseases | |
| 2 | May be exposed to blood borne pathogens and bodily fluids | |
| 3 | May be exposed to a variety of electro-mechanical hazards and radiation | |
| 4 | May be exposed to hazards of flammable, and/or explosive gases | |
| 5 | May be exposed to outside elements (accidents, injuries, illness, death) | |
| 6 | May be exposed to varying and unpredictable situations | |
| 7 | May be exposed to stress due to multiple tasks & demands for time | |
| 8 | Able to walk, stand, sit, lift, push, pull, carry, stoop, kneel + climb without restriction | |
| 9 | May be exposed to extreme weather changes - hot, cold, wet. | |
| 10 | May be exposed to dust, vapors, fumes | |
| 11 | Other if needed | |
| Physical Demands of this position = indicate all that apply; e.g. 1,4,5 | ||
| EDUCATION + EXPERIENCE REQUIREMENTS: | ||
| CREDENTIALS + QUALIFICATIONS: | ||
| MANAGER'S COMMENTS: (include goals for employee) | ||
| EMPLOYEE COMMENTS: | ||
| SIGNATURES and DATES | ||
| EMPLOYEE | ||
| MANAGER | ||
| ADMINISTRATOR | ||
| HR REPRESENTATIVE | ||
Q1 PLAN OF CARE
| Performance Improvement Findings | ||||||||||||||
| Department: | ||||||||||||||
| Date Initiated: | Date discontinued | |||||||||||||
| Performance Measure, Reason for Measuring and External Benchmark (Regulation): | ||||||||||||||
| PLAN OF CARE (Revised) | ||||||||||||||
| Outcome Measure (Is what is being measured an outcome of a process?) | ||||||||||||||
| Method of Data Collection: | ||||||||||||||
| Compliance Rate = the measured numerator/denominator | ||||||||||||||
| PI measures: | January | February | March | April | May | June | July | August | September | October | November | December | 2018 Average | 2017Average |
| POC initiated within 24 hrs | 5 | 5 | 5 | 5 | ||||||||||
| POC includes co-morbid conditions | 3 | 2 | 3 | 4 | ||||||||||
| POC updated daily | 5 | 5 | 5 | 5 | ||||||||||
| Compliance | 87% | 80% | 87% | 93% | ||||||||||
| January Narrative: | February Narrative: | |||||||||||||
| In progress | ||||||||||||||
| March Narrative: | April Narrative: | |||||||||||||
| May Narrative: | June Narrative: | |||||||||||||
| July Narrative: | August Narrative: | |||||||||||||
| POC data collection completed retrospectively for June and July. A total of 10 charts were audited. H&P reviewed for co-morbid conditions as well as current admitting diagnosis and problems identified during the in-patient stay. Hypothyroidism not reflected in POC. Eduation provided to nursing staff. | ||||||||||||||
| September Narrative: | October Narrative: | |||||||||||||
| 10 charts reviewed for August and September: Improvement noted in identification of co-morbid conditions and inclusion in the nursing plan of care. Three patients were post operative and did not have wound care reflected in the POC. Nursing notes reflected wound care. "Other" category added to the POC note with free text capability. Education to be provided to nursing staff. | ||||||||||||||
| November Narrative: | December Narrative: | |||||||||||||
&"-,Bold"&14QUALITY/PERFORMANCE IMPROVEMENT INDICATORS
&"-,Bold"&14QUALITY/PERFORMANCE IMPROVEMENT INDICATORS
&"-,Bold"&14QUALITY/PERFORMANCE IMPROVEMENT INDICATORS
&"-,Bold"&14QUALITY/PERFORMANCE IMPROVEMENT INDICATORS
&"-,Bold"&14QUALITY/PERFORMANCE IMPROVEMENT INDICATORS
&"-,Bold"&14QUALITY/PERFORMANCE IMPROVEMENT INDICATORS
&"-,Bold"&14QUALITY/PERFORMANCE IMPROVEMENT INDICATORS
StaffingPlan
| SUN | MON | TUES | WED | THU | FRI | SAT | SUN | MON | TUES | WED | THU | FRI | SAT | FTEs | Total FTEs | |||
| Dept. Name | 50.2 | |||||||||||||||||
| Debbie D. (AsstMgr) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | |||||||
| RNFull time Days | ||||||||||||||||||
| Rennals, B | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| Gilgallon,M | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| Lichetenberger,R | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| Macaluso,C | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| Risquet, C | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| Maingi,B | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| Sturminsky,I | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| Slipets, J | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| vacant | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| Vacant | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| Vacant | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| Part-time | ||||||||||||||||||
| Choi, V | 1 | 1 | 1 | 1 | 0.6 | |||||||||||||
| RN Per Diem | ||||||||||||||||||
| Bendas,L | 0.32 | |||||||||||||||||
| Grubyak,N | 0.32 | |||||||||||||||||
| Rosa,M | 0.3 | |||||||||||||||||
| Quick, Chris | 0.3 | |||||||||||||||||
| Total DAYS | 5 | 5 | 5 | 5 | 6 | 5 | 4 | 5 | 6 | 5 | 4 | 5 | 6 | 4 | 13.4 | |||
| RN Full Time Nights | ||||||||||||||||||
| Fleitas-Guerra,C | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| Mateiro, Stephanie | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| David | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| Barbara | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| Przyb,Christa | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| Samara | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| Manisha | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| Faith | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| KC | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| Agnes | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| vacant | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| Anthony | 1 | 1 | 1 | 1 | 1 | 1 | 0.96 | |||||||||||
| Dungo, M (PT) | 1 | 1 | 1 | 1 | 0.96 | |||||||||||||
| Jaggesar,Peggy (PT) | 1 | 1 | 1 | 1 | 0.6 | |||||||||||||
| RN PerDiem NIGHTS | 0 | |||||||||||||||||
| Wright,Simeon | 0.32 | |||||||||||||||||
| Johnson, Kayla | 0.3 | |||||||||||||||||
| Shulun,W | 0.3 | |||||||||||||||||
| Yarmulnik,A | 0.3 | |||||||||||||||||
| Tifarah | 0.3 | |||||||||||||||||
| Heather | 0.3 | |||||||||||||||||
| Giselle | 0.3 | |||||||||||||||||
| Total NIGHTS | 5 | 6 | 6 | 6 | 6 | 6 | 6 | 6 | 6 | 6 | 6 | 6 | 5 | 4 | 15.2 | |||
| NURSING AIDES | ||||||||||||||||||
| Full time days | ||||||||||||||||||
| Barerra Ana | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | |||||||
| vacant | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | |||||||
| Renato Lampano | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | |||||||
| Part Time | ||||||||||||||||||
| Yvonne Laluz | 1 | 1 | 1 | 1 | 1 | 1 | 0.6 | |||||||||||
| Latifa | 1 | 1 | 1 | 1 | 1 | 1 | 0.6 | |||||||||||
| Per Diem | ||||||||||||||||||
| Kara Carson | 0.3 | |||||||||||||||||
| Zachary | 0.3 | |||||||||||||||||
| Renae | 0.3 | |||||||||||||||||
| Francisco Medina | 0.3 | |||||||||||||||||
| NA TOTAL DAYS | 3 | 3 | 4 | 3 | 3 | 3 | 2 | 2 | 3 | 3 | 4 | 3 | 3 | 3 | 5.4 | |||
| NA Evenings FT | ||||||||||||||||||
| Thomas Melendez | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | |||||||
| Susan Petrowski | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | |||||||
| Sindy Vespa | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | |||||||
| NA per diem | ||||||||||||||||||
| vacant | 0.3 | |||||||||||||||||
| Philomena (PT) | 1 | 1 | 1 | 1 | 1 | 1 | 0.6 | |||||||||||
| Argelia (PT) | 1 | 1 | 1 | 1 | 1 | 1 | 0.6 | |||||||||||
| Anelle (PT) | 1 | 1 | 1 | 1 | 1 | 1 | 0.6 | |||||||||||
| TOTAL EVENINGS | 4 | 4 | 3 | 3 | 4 | 3 | 4 | 3 | 3 | 4 | 3 | 4 | 3 | 3 | 5.1 | |||
| NA Nights FT | ||||||||||||||||||
| Nicole Carter | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | |||||||
| Dimarie Jaquez | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | |||||||
| Claribel Matos | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | |||||||
| Arlene Siman | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | |||||||
| 1 | ||||||||||||||||||
| NA Part Time | 1 | |||||||||||||||||
| Frederick Viado | 1 | 1 | 1 | 1 | 1 | 1 | 0.6 | |||||||||||
| NA TOTAL NIGHTS | 3 | 3 | 4 | 4 | 4 | 3 | 2 | 2 | 3 | 3 | 4 | 4 | 4 | 3 | 6.6 | |||
| Telemetry Tech | ||||||||||||||||||
| Rainy Acosta (days) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | |||||||
| Ivette Cruz(PD) | 0.3 | |||||||||||||||||
| Wanda Martinez (PD) | 0.3 | |||||||||||||||||
| Jamel Parillon (FT Eve) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | |||||||
| Melanie PT | 1 | 1 | 1 | 1 | 1 | 1 | 0.6 | |||||||||||
| vacant PT | 1 | 1 | 1 | 1 | 1 | 1 | ||||||||||||
| Jane FT | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | |||||||
| Imran (PD) | 0.3 | |||||||||||||||||
| Total Tele | 3 | 3 | 3 | 4 | 3 | 3 | 3 | 2 | 3 | 3 | 3 | 3 | 3 | 3 | 4.5 | |||
| RN | NA | Tele tech | total | total | ||||||||||||||
| # SHIFTS NEEDED | SHIFTS | 138 + | 12 | 100 + 36 | 30 + 12 | 433 | 433 | |||||||||||
| X | 72 | HRS | 72 + 48 | 37.5 + 22.5 | 37.5 + 22.5 | 240 | 240 | |||||||||||
| TOTAL HRS NEEDED TO FILL ALL | 9936 + 576 | 3750 + 810 | 1125 + 270 | 24184.5 | 24184.5 | |||||||||||||
| TOTAL FTES NEEDED | 28.6 | 17.1 | 4.5 | 50.1 | 50.1 | |||||||||||||
| CURRENT #FTES | 114 + 12 | 90 + 36 | 30 + 6 | 40.9 | 40.9 | |||||||||||||
| X | 72 | HRS | 72 + 48 | 37.5 + 22.5 | 1125 + 135 | 240 | 240 | |||||||||||
| HOURS CURRENTLY FILLED | HRS | 8202 + 576 | 3375 + 810 | 1260 | 14223 | 14223 | ||||||||||||
| HOURS SHORT/OVER | HRS | 1734 | 375 | 135 | 9961.5 | 9961.5 | ||||||||||||
| FTES NEEDED/ OVER | FTES | 4 | 1 | 0.6 | 5.6 | 5.6 | ||||||||||||
| ADD TIME OFF COVERAGE |
Q2 DC INSTRUCTIONS
| Performance Improvement Findings | ||||||||||||||
| Department: 3west /ICU | ||||||||||||||
| Date Initiated: 1/1/2018 | Date discontinued ongoing | |||||||||||||
| Performance Measure, Reason for Measuring and External Benchmark (Regulation): | ||||||||||||||
| DISCHARGE INSTRUCTIONS | ||||||||||||||
| Outcome Measure (Is what is being measured an outcome of a process?) Outcome | ||||||||||||||
| Method of Data Collection: Chart review | ||||||||||||||
| Compliance Rate = the measured numerator/denominator | ||||||||||||||
| PI measures: | January | February | March | April | May | June | July | August | September | October | November | December | 2018 Average | 2017Average |
| DC instructions completed by RN or MD | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | ||||||
| DC instructions reviewed with patient/family | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | ||||||
| Documented follow up with MD | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | ||||||
| Patient/family signature | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | ||||||
| Copy given to patient/family | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | ||||||
| January Narrative: | February Narrative: | |||||||||||||
| Discharge instructions have been complete. Looking for next 2 months for complete evaluation to continue audit | did well this month | |||||||||||||
| March Narrative: | ||||||||||||||
| continue to evaluate | april -- discharge instructions are complete | |||||||||||||
| May Narrative: | June Narrative: | |||||||||||||
| Doing well will coninue to evaluate | will continue audit | |||||||||||||
| July Narrative: | August Narrative: | |||||||||||||
| will continue to evaluate | continue | |||||||||||||
| September Narrative: | October Narrative: | |||||||||||||
| November Narrative: | December Narrative: | |||||||||||||
Q3 IMM COMPLIANCE
| Performance Improvement Findings | ||||||||||||||
| Department: ICU/3 west | ||||||||||||||
| Date Initiated: 1/1/2018 | Date discontinued ongoing | |||||||||||||
| Performance Measure, Reason for Measuring and External Benchmark (Regulation): | ||||||||||||||
| IMMUNIZATION COMPLIANCE | ||||||||||||||
| Outcome Measure (Is what is being measured an outcome of a process?) Outcome | ||||||||||||||
| Method of Data Collection: Audits/chart review | ||||||||||||||
| Compliance Rate = the measured numerator/denominator | ||||||||||||||
| PI measures: | January | February | March | April | May | June | July | August | September | October | November | December | 2018 Average | 2017Average |
| Consent to Share is complete | 100% | 100% | 60% | 100% | 100% | |||||||||
| Immunization data is accurate and complete | 100% | 100% | 100% | 100% | 100% | |||||||||
| Case Data is complete | 100% | 100% | 100% | 100% | 100% | |||||||||
| January Narrative: | February Narrative: | |||||||||||||
| Because of the change in ownership, the IT department has to re -register the Hospital under the new name and start the process of electronic submission from the beginning. There is no way to monitor the process or outcome of the new entity | Did a spot check of Jan and Feb to measure compliance even though we have no data from the State. Charts reviewed passed. | |||||||||||||
| March Narrative: | April Narrative: | |||||||||||||
| May Narrative: | June Narrative: | |||||||||||||
| July Narrative: | August Narrative: | |||||||||||||
| September Narrative: | October Narrative: | |||||||||||||
| November Narrative: | December Narrative: | |||||||||||||
Sheet1
| discharge data | ||||||||
| Jan-18 | feb | march | april | may | june | july | aug | |
| 1100042686 | 1100124623 | 1100125149 | 1100126137 | 1100086370 | 1100127845 | 1100128440 | 1100126665 | |
| 1100123550 | 1100124627 | 1100125389 | 1100126138 | 1100126917 | 1100127666 | 1100128487 | 1100128828 | |
| 1100040455 | 1100124321 | 1100125036 | 1100126133 | 1100126636 | 1100127634 | 1100128480 | 1100079391 | |
| 1100047994 | 1100003104 | 1100125681 | 1100126128 | 1100021315 | 1100128256 | 1100128488 | 1100106291 | |
| 1100117182 | 11001248869 | 1100125086 | 1100126142 | 1100126920 | 1100127652 | 1100128329 | 1100129248 | |
| 1100124327 | 1100125049 | 1100103463 | 1100118728 | 1100065987 | 110081658 | 1100129306 | ||
| med req. | ||||||||
| jan. 2018 | feb. | march | april | may | june | july | aug. | |
| 110042686 | 1100124623 | 1100125680 | 1100125885 | 1100126917 | 1100127382 | 100128444 | 1100126665 | |
| 1100123550 | 1100124347 | 1100125490 | 1100125894 | 1100086370 | 1100127336 | 1100128440 | 1100128828 | |
| 1100040455 | 1100124627 | 1100125507 | 1100000366 | 1100126636 | 1100025120 | 1100128487 | 1100130129 | |
| 1100082202 | 1100124321 | 1100125319 | 1100049520 | 1100021315 | 1100127358 | 1100128488 | 1100106291 | |
| 1100047994 | 1100003104 | 1100125086 | 1100126447 | 1100126920 | 1100127368 | 1100128329 | 1100130339 | |
| 1100117182 | 1100124869 | 1100125089 | 1100044529 | 1100118728 | 1100127341 | 1100081658 | 1100129248 | |
| immunizations | ||||||||
| jan.2018 | feb. | march | april | may | ------------- | -------------- | ------------ | |
| 1100124626 | 110047994 | 1100126138 | 10012607 | |||||
| 1100124623 | 1100125110 | 1100126133 | 1100127121 | |||||
| 1100124347 | 1100125490 | 1100126142 | 100127199 | |||||
| 1100124627 | 1100125507 | 1100126285 | 100126805 | |||||
| 1100124321 | 1100125319 | 1100103463 | 100127197 | |||||
| 1100003104 | 1100124917 | 100125325 | ||||||
| adv. Dir | ||||||||
| Jan-18 | feb. | april | may | june | july | aug. | ||
| 110042686 | 1100124626 | 1100125885 | 1100086370 | 1100127595 | 100128444 | 1100126665 | ||
| 1100123550 | 1100124623 | 1100125725 | 1100126917 | 1100127782 | 1100128440 | 1100128828 | ||
| 1100040455 | 1100124347 | 1100014028 | 1100126636 | 1100126819 | 1100128487 | 1100130129 | ||
| 110082202 | 1100124627 | 1100125894 | 1100021315 | 1100127419 | 1100128488 | 1100106291 | ||
| 1100117745 | 1100124321 | 1100123428 | 1100126920 | 1100127526 | 1100068011 | 1100130339 |
DISCHARGE MED REC
| Performance Improvement Findings | ||||||||||||||||||
| Department: 3 WEST | ||||||||||||||||||
| Date Initiated: 1/1/2018 | Date discontinued: Ongoing | |||||||||||||||||
| Performance Measure, Reason for Measuring and External Benchmark (Regulation): | ||||||||||||||||||
| DISCHARGE MED REC | ||||||||||||||||||
| Outcome Measure (Is what is being measured an outcome of a process?) | ||||||||||||||||||
| Medication Reconciliation on discharge | ||||||||||||||||||
| Compliance Rate = the measured numerator/denominator | ||||||||||||||||||
| PI measures: | January | February | March | April | May | June | July | August | September | October | November | December | 2018 Average | 2017Average | ||||
| Inpatient medication is reconciled with discharge medication | 100% | 80% | 100% | 100% | 100% | 100% | 100% | 100% | ||||||||||
| Time next dose is to be administered is clearly documented | 83% | 80% | 83% | 100% | 83% | 100% | 100% | 100% | ||||||||||
| E scribe | 67% | n/a | 17% | n/a | 32% | 17% | ||||||||||||
| Rx given to patient | 100% | 100% | 100% | 100% | 67% | 100% | 100% | 83% | ||||||||||
| January Narrative: | February Narrative: | |||||||||||||||||
| Next dose medication needs to be addressed. One outlier identified and will be spoken to. | Still working on clearly defining next dose to be given | 1 | ||||||||||||||||
| March Narrative: | April Narrative: | |||||||||||||||||
| Working slowly but better. MDs not using e-scribe | much better this month | |||||||||||||||||
| May Narrative: | June Narrative: | |||||||||||||||||
| prescriptions were given to 4 out of the 6 patients and 1 patient had an e scribe | no e-scribe used | |||||||||||||||||
| July Narrative: | August Narrative: | |||||||||||||||||
| still need to encourage doctors to e-scribe. 2 out of 6 med rx was e-scribed. | not every patient was given a prescription for home, and only one was e-scribed out of 6 patients. | |||||||||||||||||
| September Narrative: | October Narrative: | |||||||||||||||||
| November Narrative: | December Narrative: | |||||||||||||||||
