Emailed to Members 01/XX/17

Performance Management/Quality Improvement Meeting

Date: December 19, 2016 Time / Location: PH Conference Room 1:30 PM Darlene Smith, , Chris Congdon, Dawn Lindsey, Gail Wechsler, Diane Kiff, Present: Terry Moss Called in: Absent: Vicki Fuerst , Kim Arnold Scribe: Terry Moss Status Agenda Item Discussion Action Items Owner (open/ closed) Approved. Send to Dawn Closed Approval of minutes Minutes of previous meeting were distributed and approved PAC

Policies & Form Updates Following policies/forms updated and reviewed: Polices reviewed and approved. Send to Closed Manual updates: Leave previous years changes in the manual. PAC.

 Communicable & STD Focus Audit Gail (Follow-Up from November)  STD Policy: From June 2016 Gail Hepatitis C added as a reportable disease, we are now testing for this at the jail.  EI Administrative Manual Diane Changed EI audit to: 10 records for twice a yr. instead of 4 times a year.  Ebola Screening Questionnaire/Screening Algorithm updated Gail Removed Guinea from the algorithm, and questionnaire.  Protocol to Ensure Access and Barriers to Care Chris Training completed with staff. Tools to assist are placed with receptionist and available at our clinics. The following audits were reviewed and accepted: Send to PAC and Closed  Preschool Administrative Audit Diane/Chris appropriate PH team QI Audit Reports Working with agencies to inform, educate and support the agencies to meeting. improve results of audit.  LTBI Gail

Audits due for next meeting:

o TB Chart Gail o MCH LHCSA Vicki Audits Next Meeting o EI Diane Open o Preschool Diane o PHCP & SCHCN Chris/Ginny o HIPPA Security Risk Chris/Dawn o B&G Article 28 Checklist Gail

Reviewed and accepted. Send to Biometric Screening-513 total screened and 136 surveys returned. Terry Closed PAC.

Satisfaction Surveys Darlene, Vicki, Open JT to create a Jo-Anne NDPP-Outcomes Follow-Up spreadsheet with results. Surveys Due Next Meeting:

 MCH Home Visit Compile previous quarter breastfeeding Surveys Due Next Meeting  Communicable Disease Terry Open survey in January and  Smart Steuben present in February.

Accidents/Incidents/ o None Dawn Closed Complaints Need to remove STD performance. Remove Immunization survey Change EI to 2x a year Yearly QI Plan Needs to be updated in January 2017 Open and do with a new IPRO audit tool. MSDS Manual update added to plan.

Dental Program- Only 1 dentist in Steuben County willing to participate in the He has not returned program. Dr. O’Connor suggested we contact Mike Slovak on assistance with call. Darlene will ask possible list of dentists that assisted with the rural health program that may be Vicki to contact Mike Darlene/Vicki Open willing to participate. Slovak.

Kris VonHagen reported there was a program in Chemung County that went to the home and helps with the breastfeeding and does routine follow- ups. She Dawn Open PAC Review will report back at our next PAC meeting with more details about this program.

Nicole Walker resigned from PAC. Darlene/Vicki Open PAC – Committee is up for review for required participants. Darlene and Vicki Kimi Archer now will work together and review these requirements. working per diem at Arnot IDMH. Hopefully she will continue as PAC member. Other Outstanding School Surveillance/DISH- Bath and Avoca Schools are willing to participate When this is started, Gail Open need to assign a clerical person to enter data that is sent and will send PH data weekly on Fridays. Data that will be collected is from schools weekly. absenteeism, and type of illnesses.

Gail/Lorelei will send information to schools. Suggest Lorelei/Gail to send educational material to health teachers at schools on HPV sending to Gail/Lorelei or see if there is a health teachers meeting that could be reached out to. administration as Open there is not a county health teachers group.

Lab reporting is at 67% for St. James. St James percentage rate for lab reporting in timely manner. Gail contacted Gail will contact St. James re this: can St. Gail and St. James will contact Uof R. Closed James discuss with U of R lab/Monroe County.

Set up a review meeting to discuss Goal is to start more NDPP classes and we are now able to bill Medicaid. strategy of gathering S2AY has not started a class. statistics on the Darlene/Vicki/ outcomes and success Closed of the NDPP class. Jo-anne

Nothing to report. Looking to possibly start an HPV project at the beginning of next year. Quarterly meetings set up for 2017. Next meeting 1/31/17 neither Email Kim re: conflict Dawn/Kim/ Regional PMQI Committee Ongoing Dawn, nor Darlene can attend. with this date. Darlene

QI Chlamydia Project- Goal of the project is to increase screening and EPT. Kim Ongoing Regional Committee PMQI (More cases equal more screening.) Waiting to check on whether there is Project improvement after the 3 months, from when the last packets were distributed to all healthcare providers. Will check data the beginning of the year 2017. Need to speak with Kim on how to close the HPV project. Next Gail/Kim Open HPV- Gail checked into state rates and found the rates have gone down. HPV meeting Should we continue to work on this or should it be closed out? Check with Kim 12/20/16. on process for the ending of project. SC PMQI Project Schedule training on Chris submitted a project to improve the MSDS Manual. Committee formed the MSDS Manual. 1 Chris Open and had their first meeting 11/17 to actively work on this project. Started with more meeting to set 3 items in manual and are currently up to 88. This will be checked yearly. up procedures.

Review progress quarterly and update. Will meet in December to review the Darlene will update Strategic Plan Darlene Ongoing new CHIP and to close what has been met this year. progress on plan.

Dawn Open PMQI Members- It is documented in the Regional PMQI policy that we rotate SC PMQI Plan This will be put on members annually or add additional members. hold for now.

Will schedule additional meeting in January to focus on Review 4th quarter performance measures next meeting. Update for Year 2017 Performance Measures performance All Open with a 2nd QI meeting in January. measures only. Invite Lorelei, Karen, Jo- Anne. Ethics Committee No issues. Ongoing

Follow-up with Arnot on HIV clinics- Terry will keep in touch with IVY clinic to Terry Ongoing see when there is an opening day for Bath clinic. Currently waiting for Other Business credentialing committee to approve.

NEXT MEETING: January 17, 2017 10:00 AM PH Conference Room

Emailed to members 01/XX/17