Enhancement: HCA is dedicated to fostering a culture that supports a patient’s right to be free from restraint. Restraint use will be limited to clinically justified situations, and the least restrictive restraint will be used with the goal of reducing, and ultimately eliminating, the use of restraints or seclusion. Identifying areas of opportunity for improvement through data is important to improve patient outcomes which aligns with delivery of safe patient care.
The following KPI's (Key Process Indicators) will be available to facilities.
Please review to ensure accurate patient care documentation.
KPI: Documentation of Second Tier Review
- A Second Tier Review is required after every Restraint Start Application. A Second Tier Review is not required for Restraint Renewals. Applies to all age groups, locations, and restraint types.
- A Second Tier Review is performed after every Restraint Start Application.
- All 9 questions on the Second Tier Review screen must be answered (not null)
KPI: Timeliness of 2 Hour Nursing Assessments
- A RN Assessment is required every two hours after the start application of a restraint until the restraints are removed. Applies to all age groups, locations, and restraint types.
- The time frame for the two hour check is dependent on the start application timestamp or the timestamp of the last RN Assess documentation.
- If any of the required 2 Hour RN Assessment questions are answered with “No”, the record needs to be flagged as needing review. Except for the following three questions: “Meets criteria for release”, “Response to restraint”, and “Level of consciousness”.
KPI: Patients Restrained
- This metric will be measured at the enterprise, division, market, facility, and department levels.
- Calculation All patients restrained (the distinct count of patients derived from the "Restraints Documentation" screen) divided by total patients (ADT-Admission, discharge, transfers) Exclusions Behavioral health restraints
CHG Bathing – EPIC Data As of Wednesday July 3rd facilities that are on the EPIC EMR will now be able to track their CHG Bathing compliance.
Please comment with questions or concerns.
Thank you for your dedication to Patient Care!
