December 07, 2019
Each of the committees convened under the broader Quality Improvement umbrella at DBHDS to, primarily, satisfy the requirements of the DOJ Settlement Agreement, has set performance measures which coincide with the DOJ expectations. For example, the Mortality Review Committee has this Performance Measure Indicator:
- Unexpected deaths where the cause of death, or a factor is the death, was potentially preventable and some intervention to remediate was taken. Target = 86%
- Data collected is the number of “unexpected” deaths in a community residential setting deemed “potentially preventable” and some action was taken by the provider within 90 days to remediate (implement training, policies or practices to minimize the possibility of recurrence).
- The good news is that only 21 deaths in FY19 were deemed to be “potentially preventable;” the bad news is 21 deaths were deemed to be potentially preventable. A “potentially preventable death” is one related to a deficit in timeliness or the absence of at least on of the following:
- coordination of care including medication management
- access to care, including delay in seeking treatment
- execution of established protocols
- assessment of the needs or change of status
- These items provide a template for the review of any unexpected death and also provide the obvious link to the memo released this week by the Office of Licensing!