Performance Improvement Indicator EFFICIENCY: Risk Management 2019
Since risk management at Whitemarsh House is a generalized procedure with overall facility goals, it is not necessary to incorporate separate plans for the Residential cluster and the Home and Community cluster. These standards and procedures continue to apply equally to all residents, staff and visitors to the facility nd to the overall sound fiscal planning necessary to support operations.
Risk Management activities at Whitemarsh House are documented in the policy and procedure and the quality assurance meeting agendas as recorded by the Executive Director who chairs these meetings. These reports are provided under separate cover. Risk management activities may also be ascertained through interviews with the Executive Director, Controller, Clinical Director, Personal Care Home Administrator, Nurse Manager and Associate Program Director.
This report serves as a supplement to those activities as a general overview of the efficiency of the risk management process.
Goals Achieved from Prior Plan (2018) and from Relevant CARF Recommendations.
1. Risk Management Plans were assessed at least annually by facility Administration: Achieved Winter 2018 and Ongoing
2. Assured that Executive Director convened and documented the Quality Assurance Reviews and that this was attended by facility management personnel. Also reviewed documentation of the agenda regarding these meetings. Achieved Winter 2018 and Ongoing
3. Management continued to assess implementation of risk management measures described in first paragraph above. Achieved January 1, 2018 and Ongoing
4. Input on risk management was solicited from families and other stakeholders as well as various team meetings and administrative contacts. Achieved through revised Satisfaction Surveys (See Satisfaction Performance Improvement Report) Achieved 2018 and Ongoing
5. Obtained input on risk management activities from residents. Achieved 2018 and Ongoing
6. Educated staff and obtained input from staff on risk management. Achieved: Ongoing and was the topic of one additional staff meeting prior to April 2018
Performance Improvement Targets 2020
1. A full risk management plan will only be implemented after consideration of input from residents, families, stakeholders and staff, update current risk management procedures. Target Date: April 1, 2020
2. Share the new risk management plan with residents, families, stakeholders and staff. This will be accomplished via the web site and through the other means described above. Target Date: April 22, 2020
3. Be prepared for further revision of this “final” set of procedure in the event that this publishing of the procedure provokes further suggestions for revision. Target Date: April 22, 2019
4. Continue with all risk management activities as described in #1-6 above. Target Date: April 22, 2020
5. Continue to implement revised feedback loop from line staff on critical resident incidents. Target Date: Ongoing