Date: / July 26, 2016
Time / Location: / PH Conference Room 10:00 AM
Present: / Darlene Smith, Vicki Fuerst, Chris Congdon, Dawn Lindsay, Diane Kiff, Gail Wechsler, Karen Travis, Terry Moss
Called in:
Absent: / Kim Arnold, Lorelei Wagner
Scribe: / Terry Moss
Agenda Item / Discussion / Action Items / Owner / Status (open/ closed)
Approval of minutes / Minutes of previous meeting were distributed and approved / Approved / Dawn / Closed
Performance Measures / Reviewed and discussed 2nd quarter performance. Areas in need of improvement are as follows:
Ø Emergency preparedness:
Presentations -2 per year. Need of 1 more this year.
Percent of staff responding to notification’s within 60 minutes, needs improvement. Some issues with notification system.
Ø Lead
5-9.9 lead levels being retested within 6 mos., percentage low due to not responding to reminder calls
Number of 2 year olds retested, low for this quarter. Not comparable to last year. Baseline needs to reflect previous year.
Ø PH Goals
Smart Steuben website designed goal was not met- It was decided that a website would not be created, but that a Facebook page would be more appropriate at this time.
Not all of the documents submitted to S2AY by deadline for domains was not turned in timely –
For 2nd quarter, 3 out of 73 documents did not get turned in on time. 2 of the docs originally were marked as MJD but we found out after the due date they were no longer MJD. One doc we are waiting on S2AY to provide policy in order to submit as a complete example.
Ø Chronic Disease
Tobacco- Number of participants “0” due to not enough participants interested in a class.
Ø Immunization
Falling short for reaching goal of total TDAP’s given. Percentage down slightly on HIV/STD starting Hep A/B series.
Ø Rabies- Should we run a PSA article on what to do when bitten by a dog.
Ø HIV/STD- Number of inmates at the jail that are tested for HIV/STD are slightly down to meet target. This may increase when Hep C is available to test. / Karen to send email to staff re: performance measure and importance to respond within 1 hour.
Document explanation on last drill response d/t issues with NYS notification system.
Terry to try texting when no response through voicemail.
Karen to document the issues with the response.
Gail to send brochures to Catholic Charities.
Gail to draft a PSA on: What to do when bitten by a domestic animal. / Closed
Closed
Closed
Closed
Open
Policies & Form Updates / Following policies updated and reviewed and were accepted:
· Dish Protocol
· Zika Policy
· Lead Manual
O:\Policies\Lead Policies (SAY)\Current Policies\Policy Review Sheet 05.16.docx
· Workforce Development
· Lead Audit Tools / Take lead manual and Workforce Development to PAC and appropriate PH team meeting. / Gail
Gail
Gail
Chris
Gail/Dawn / Closed
QI Audit Reports / Following was reviewed and accepted:
· TB chart review-no pt. Gail
· MCH LHCSA -no pt. Vicki
· B&G Article 28 Gail
· Early Intervention Diane
· Preschool Billing Diane
· HIPPA Security Risk Assessment / Send to PAC except for B&G Article 28, and appropriate PH team meeting.
Was completed but needs summary. / Dawn/Chris / Closed
Open
Audits Next Meeting / · Lead
· Lead LHCSA
· Immunization
· CD
· STD
· Preschool Agency
· PHCP & CSHCN / Brittney to do immunization audit. / Karen
Karen
Gail
Gail
Gail
Chris
Ginny/Chris / Open
Satisfaction Surveys / · MCH Home Visits
· Communicable Disease
· Breastfeeding / Be sure to document an action on survey if client contact, so it can be put into action at review time. (DK Breastfeeding, GW communicable) / Terry / Closed
Surveys Due Next Meeting / · EI / Focus on #1 (The providers are helping my child) as the satisfaction key. / Terry / Open
Accidents/Incidents / None this month.
Dog Control Officer – had concerns on our procedures. / Wrote up concerns from the phone call documenting the explanation in our procedures. / Dawn / Closed
Other Outstanding Polices / STD- Baseline rates of Gonorrhea cases with adequate treatment is lower than 2015 due to a change by the state: Adequate treatment in 2015 was 2 days, now the state says 1 day. Send letter to MDs regarding change, this will be included in letter about all STD reporting requirement. We will send separate one on CD reporting.
DISH
Early Intervention- Advanced Service Coordination Working with families & Transition within 1 year
Core Competency Review/Training during evaluation. / New letter to be completed with updated requirements for STD reporting by end of June.
Bring numbers to next meeting.
Send 2015 NY State Health Profile with communication letter to every healthcare provider.
All service coordinators to take this course.
Create template for narratives at evaluation time. / Gail
Gail
Diane / Open
Open
Open
Open
Regional PMQI Committee / Each member to do a self- assessment survey. Awaiting survey. / Meet August 24th
. / Dawn/Kim / Open
DISH / CD and Emergency Preparedness reps to work on DISH due to inconsistency.
Update in September to see if improvements / Gail/Karen / Open
Regional Chlamydia Project – QI Project-Goals is for increased screening and EPT. (More cases equals more screening.) / Add target and add % of treatment.
Update in September any improvements.
Packets being distributed to providers. / Kim / Open
SC PMQI Project / HPV- Have sent information out. Will check NYSISS to see if an increase in HPV vaccine has been given. / Gail / Open
Strategic Plan / Review progress quarterly and update. Due in July / Darlene needs to update the plan to make sure progress is being made. / Darlene / Open
SC PMQI Plan / Under Appendix D on plan: Add QI goals and objectives and training projects to dash board as this is a requirement for accreditation.
Will ask Lorelei to train staff on QI Project proposed form Appendix F tool for project request.
HPV- HPV education for 6th-12th to school nurses. May letter went out to providers. / September check rates. / Dawn/Chris / Closed
Open
Other Business / Breastfeeding Survey- What to do with results.
Jo-Anne to send contact information for Christie Richards in Ontario County to Terry to send results to regional coalition.
School Surveillance/DISH
EI Surveys-What number should we focus on for satisfaction? Focus on #1 (The providers are helping my child) as the satisfaction key.
Follow-up with Arnot on HIV clinics
New nurses MCH- Focus Audit
Fax machine/BT fax for preschool clients. / Terry got the contact information and emailed the survey to Christie Richards.
Gail to get samples forms and tracking from area counties on what using for surveillance.
Discuss more in detail about surveillance for the schools to possibly begin in the fall to track trends.
Gail to work on letter to schools with a proposal in the fall to participate in a tracking of trends.
Change performance measures to reflect this number.
Terry to call Arnot HIV clinic to find out any details on the clinic for Bath
Do focus audit on the new nurses documentation
Special Children’s to use BT fax when large document’s faxed. Confirmation print has been stopped. / Terry
Gail
All
Terry
Dawn/Vicki
Terry / Closed
Open
Closed
Open
Open
Closed
NEXT MEETING: / August 15, 2016 / 10:00 AM / PH Conference Room
Emailed to members 08/10/2016
O:\QI\Minutes\2016\PMQI Meeting July 26 2016.docx