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Quality 2017-08-14T12:15:46+00:00

To better ensure the safety of our clients and achieve greater effectiveness and efficiency in our use of resources in a client-centered environment, Crotched Mountain has adopted a program of quality improvement and quality assurance through DNV Healthcare, Inc. This is an organization-wide effort that involves every employee.

We have created a series of quality committees, each with its own charter of responsibilities, so that every aspect of the services and care that our patients, students, residents and consumers receive are subject to close review and opportunities for improvement. We have adopted a quality policy that is far reaching and aspirational. We are using new tools of performance review and quality improvement every day. We have set objectives that are measurable and that guide our work. We seek the input of our “customers” including our patients and clients, but also the organizations that fund our work and the suppliers of our materials and services.

Quality is never achieved, it is something that we are always striving to improve. As we continue to improve, we will better ensure that Crotched Mountain will remain a beacon of hope for the individuals and families that have depended on us.

Learn More About Quality at Crotched Mountain


Quality Policy

Adopted by Board of Directors on Dec. 3, 2010
Through the dedicated efforts of our professional and direct support staff and in partnership with clients, families and communities, Crotched Mountain will be the region’s most effective, accomplished and safe provider of health, therapy, education, assistive technology and residential support services to people with disabilities and other needs.

To achieve this goal we are committed to quality improvement through an organization-wide culture that includes all programs, departments, disciplines and services, with the active involvement of all staff, and with the oversight of our governing Board of Directors. As an indicator of our commitment to quality improvement and client safety, we have achieved and will maintain accreditation for the hospital, school and rehabilitation center by meeting and exceeding the standards established by DNV Healthcare, Inc. and other accrediting bodies. Within three years after achieving hospital accreditation we will achieve ISO9001 compliance and certification for the hospital, school and other programs and services of Crotched Mountain.


Quality Committees

Crotched Mountain organizes its quality improvement and assurance program through committees with functional responsibilities for specific areas of focus. The charters of these committees are drawn from the NIAHO® standards of DNV for the hospital and from other accrediting bodies for other programs of Crotched Mountain. These committees report to a Quality Council which itself reports to a Quality Improvement Committee of the Board of Directors. This system ensures that all levels of the organization – from every employee to the governing body – are involved in the quality improvement. The committees are:

  • Client and Patient Safety
  • Physical Environment of Care
  • Infection Control
  • Document Control
  • Utilization Review and Discharge Planning
  • Nursing Leadership
  • Physician Leadership
  • Emergency Preparedness and Response
  • Client Rights and Ethics
  • Corporate Compliance

The Tools of Quality Improvement

Root Cause Analysis (RCA)
When standards are not met, or an adverse event has occurred, it is necessary to conduct a root cause analysis, which means taking a look back at the sequence of events that led to the discrepancy error. The steps include:

Identify the processes involved and keep asking the question, “Why did this happen?” (5 times)
Analyze each step in the process using a process map or flow chart to show what happened and compare that to the established protocol or policy then keep asking why the protocol was not followed.

Once problem-solving has taken place, make the necessary change in the system using a Plan-Do-Study-Act (PDCA methodology) or similar methodology.

Failure Mode Effects Analysis (FMEA)
FEMA is a risk management technique that looks at current systems to identify an area/process that could potentially cause an adverse event. It is a proactive risk management activity that works by involving all stakeholders to:

  • Identify the patient care processes that make up the system
  • Identify the risk in each process
  • Ask, “What are we doing to reduce the risk?” and take action when gaps are identified.

Proactive Interaction (RADAR)
RADAR defines ways to interact with people so interactions remain interactions and do not escalate into incidents. We strive to be conscious about the process of threat assessment so we can maintain our safety and the safety of others and to be aware of how we may appear to be threatening to others. RADAR stands for:

  • Recognize: Use all of your senses. RADAR works by being aware of your surroundings.
  • Assess: Assess what is happening to everyone, starting with yourself and the environment.
  • Decide: Decide what to do after you have recognized and assessed.
  • Action: The decision comes to life.
  • Results: Evaluate the results. Did you achieve the goals of your action(s)?

Plan-Do-Check-Act Cycle (PDCA)
PCDA is a dynamic cycle that could be implemented for any process within the organization. It combines planning, implementing, controlling and continual improvement within the realization processes.

  • Plan: Recognize an opportunity and plan a change.
  • Do: (select an option for improvement, initiate improvement, and establish success measurements)Test the change. Carry out a small-scale study.
  • Check: (measure performance)Study. Review the test, analyze the results and identify what you’ve learned.
  • Act: (modify plan for improvement as necessary to meet established success measurements) Take action based on what you learned in the Check Step: If the change did not work, then go through the cycle again with a different plan.  If you were successful, incorporate what you learned from the test into wider changes. Use what you’ve learned to plan new improvements, beginning the cycle again.

Community Benefits

Introduction
Pursuant to RSA 7:32-e, Crotched Mountain Rehabilitation Center (CMRC), is pleased to post its Community Benefits Report for the Fiscal Year Beginning July 1, 2015. We welcome public review and commentary. Your thoughts and questions may be directed to communitybenefits@crotchedmountain.org. Further information concerning the details and background of this statue is available through the State of New Hampshire, Office of the Attorney General,Charitable Trusts Unit. Crotched Mountain’s community benefits plan is based, in part, upon a collaborative needs assessment which was conducted by a committee representing several healthcare charitable trusts throughout the Monadnock region of New Hampshire. A summary of the collaborative needs assessment is posted on the Monadnock Community Hospital web site. Additionally, we conducted a series of disability-related needs assessments associated with CMRC’s key operations (as listed below).

Our Communities
As a specialty hospital and rehabilitation center for children and adults with disabilities, we recognize two distinct communities of need and service. First, CMRC serves the community of people with disabilities and their families throughout New Hampshire and other states through two key operations, the Crotched Mountain School and the Crotched Mountain Specialty Hospital. Crotched Mountain School, a residential and day school, serves students with disabilities from New England and the northeastern states. Children enrolled in the School have significant health impairments due to genetic and neurological conditions and trauma experienced in their lifetimes. The largest single diagnosis is autism. Some students have medical conditions that require skilled nursing level of care so they reside in a pediatric unit of the Specialty Hospital. The skills of our staff and resources of the School allow them to have access to an educational program that is rich in content and that otherwise could not occur. The Crotched Mountain Specialty Hospital serves children and adults with brain injuries, strokes, complex medical conditions, respiratory needs including vent management and weaning, spinal cord injuries and other neurological impairments and injuries. Our patients are from New Hampshire and other states including Massachusetts, Vermont, Maine, Connecticut and New York.

The second major service population resides in the local Monadnock community. We operate selected outpatient clinics that focus on people with disabilities. The services of the clinic inlcude audiology, developmental pediatrics and pediatric physical therapy. We also serve the Monadnock community through outdoor recreation programs that focus on health and well being that are inclusive of everyone.

Benefits Provided   
The “Actual Benefit Value” of the activities outlined in our Community Benefits Report 7/01/15-6/30/16, totals $3,507,298. The “Estimated Benefit Value” of the 10 consolidated activities outlined in our Community Benefits Plan 7/01/16 – 6/30/17, totals $2,871,293. Our plan continues to address a number of identified needs relative to our communities, including access to specialty rehabilitation services in an inpatient setting, specialty medical services (such as physical and occupational therapy, speech/hearing, and assistive technology); professional and community education; and internships that provide exposure to clinical and educational occupations. Crotched Mountain Foundation also makes small grants to community organizations for underwriting and sponsorship. Through a related corporation of Crotched Mountain, the Harry Gregg Foundation, we make over $150,000 in small grants to low income individuals with disabilities and chronic health conditions to support their needs and aspirations.

In the Crotched Mountain Specialty Hospital we provide multiple benefits for the community. Over 75% of our patients rely on Medicaid which only covers a fraction of the cost of their care and rehabilitation. Crotched Mountain accepts patients who have yet to establish their Medicaid eligibility which moves them more quickly to a rehabilitation program, saves the State of New Hampshire and the health care system millions of dollars in health care expenses at tertiary hospitals and frees up beds in those facilities so that more acute patients can be served. The Hospital continues to serve a population with neuro-rehabilitation needs as well as ventilator management for medically stable adult patients and patients requiring vent weaning. Over 60% of our patients have neuro-psychological diagnoses or co-morbidities or require 1:1 staffing for behavioral management support.

Moving outside the Hospital, Crotched Mountain provides benefits to the wider community by providing access to recreation for everyone, including people with mobility and other disabilities. Our accessible trails, which attract visitors from across the country, provide the opportunity for everyone to experience the outdoors in ways not usually possible for people with mobility impairments. In addition to quality of life, this promotes health and well being. The Crotched Mountain Accessible Recreation and Sports (CMARS) program has staff and more than 60 volunteers who support skiing and snowboarding, kayaking, hiking, shooting and other sports for hundreds of people who otherwise would be denied these opportunities.

While this Community Benefits legislation requires this type of community benefits accounting, we feel it is important to recognize that CMRC has provided benefits to the disability community in New Hampshire and other states through budgeted subsidies from the Crotched Mountain Foundation (CMF) for fifty years. Millions of dollars provided by CMF to CMRC have improved services, provided additional services, and increased the number of people served. Crotched Mountain is committed to ensuring that needed services are provided to people with disabilities whether or not a source of reimbursement exists.

Through affiliated corporations, Crotched Mountain also serves New Hampshire communities in Portsmouth, Derry, Manchester, and Whitefield by providing housing, care management and direct services for people with disabilities, the elderly and low-income populations. These programs also receive planned operating subsidies from CMF.

Conclusion 
We look forward to receiving public commentary on our community benefits plan and welcome the opportunity to engage in new collaborations with other local and disability-related organizations. We continually explore ways in which Crotched Mountain will expand its community education and outreach programs in order to extend the resources of CMRC from “the mountain” into communities throughout the state and beyond.

Click here to view our Community Benefits Reports archive. (PDF)

To better ensure the safety of our clients and achieve greater effectiveness and efficiency in our use of resources in a client-centered environment, Crotched Mountain has adopted a program of quality improvement and quality assurance through DNV Healthcare, Inc. This is an organization-wide effort that involves every employee.

We have created a series of quality committees, each with its own charter of responsibilities, so that every aspect of the services and care that our patients, students, residents and consumers receive are subject to close review and opportunities for improvement. We have adopted a quality policy that is far reaching and aspirational. We are using new tools of performance review and quality improvement every day. We have set objectives that are measurable and that guide our work. We seek the input of our “customers” including our patients and clients, but also the organizations that fund our work and the suppliers of our materials and services.

Quality is never achieved, it is something that we are always striving to improve. As we continue to improve, we will better ensure that Crotched Mountain will remain a beacon of hope for the individuals and families that have depended on us.

Learn More About Quality at Crotched Mountain


Quality Policy

Adopted by Board of Directors on Dec. 3, 2010
Through the dedicated efforts of our professional and direct support staff and in partnership with clients, families and communities, Crotched Mountain will be the region’s most effective, accomplished and safe provider of health, therapy, education, assistive technology and residential support services to people with disabilities and other needs.

To achieve this goal we are committed to quality improvement through an organization-wide culture that includes all programs, departments, disciplines and services, with the active involvement of all staff, and with the oversight of our governing Board of Directors. As an indicator of our commitment to quality improvement and client safety, we have achieved and will maintain accreditation for the hospital, school and rehabilitation center by meeting and exceeding the standards established by DNV Healthcare, Inc. and other accrediting bodies. Within three years after achieving hospital accreditation we will achieve ISO9001 compliance and certification for the hospital, school and other programs and services of Crotched Mountain.


Quality Committees

Crotched Mountain organizes its quality improvement and assurance program through committees with functional responsibilities for specific areas of focus. The charters of these committees are drawn from the NIAHO® standards of DNV for the hospital and from other accrediting bodies for other programs of Crotched Mountain. These committees report to a Quality Council which itself reports to a Quality Improvement Committee of the Board of Directors. This system ensures that all levels of the organization – from every employee to the governing body – are involved in the quality improvement. The committees are:

  • Client and Patient Safety
  • Physical Environment of Care
  • Infection Control
  • Document Control
  • Utilization Review and Discharge Planning
  • Nursing Leadership
  • Physician Leadership
  • Emergency Preparedness and Response
  • Client Rights and Ethics
  • Corporate Compliance

The Tools of Quality Improvement

Root Cause Analysis (RCA)
When standards are not met, or an adverse event has occurred, it is necessary to conduct a root cause analysis, which means taking a look back at the sequence of events that led to the discrepancy error. The steps include:

Identify the processes involved and keep asking the question, “Why did this happen?” (5 times)
Analyze each step in the process using a process map or flow chart to show what happened and compare that to the established protocol or policy then keep asking why the protocol was not followed.

Once problem-solving has taken place, make the necessary change in the system using a Plan-Do-Study-Act (PDCA methodology) or similar methodology.

Failure Mode Effects Analysis (FMEA)
FEMA is a risk management technique that looks at current systems to identify an area/process that could potentially cause an adverse event. It is a proactive risk management activity that works by involving all stakeholders to:

  • Identify the patient care processes that make up the system
  • Identify the risk in each process
  • Ask, “What are we doing to reduce the risk?” and take action when gaps are identified.

Proactive Interaction (RADAR)
RADAR defines ways to interact with people so interactions remain interactions and do not escalate into incidents. We strive to be conscious about the process of threat assessment so we can maintain our safety and the safety of others and to be aware of how we may appear to be threatening to others. RADAR stands for:

  • Recognize: Use all of your senses. RADAR works by being aware of your surroundings.
  • Assess: Assess what is happening to everyone, starting with yourself and the environment.
  • Decide: Decide what to do after you have recognized and assessed.
  • Action: The decision comes to life.
  • Results: Evaluate the results. Did you achieve the goals of your action(s)?

Plan-Do-Check-Act Cycle (PDCA)
PCDA is a dynamic cycle that could be implemented for any process within the organization. It combines planning, implementing, controlling and continual improvement within the realization processes.

  • Plan: Recognize an opportunity and plan a change.
  • Do: (select an option for improvement, initiate improvement, and establish success measurements)Test the change. Carry out a small-scale study.
  • Check: (measure performance)Study. Review the test, analyze the results and identify what you’ve learned.
  • Act: (modify plan for improvement as necessary to meet established success measurements) Take action based on what you learned in the Check Step: If the change did not work, then go through the cycle again with a different plan.  If you were successful, incorporate what you learned from the test into wider changes. Use what you’ve learned to plan new improvements, beginning the cycle again.

Community Benefits

Introduction
Pursuant to RSA 7:32-e, Crotched Mountain Rehabilitation Center (CMRC), is pleased to post its Community Benefits Report for the Fiscal Year Beginning July 1, 2015. We welcome public review and commentary. Your thoughts and questions may be directed to communitybenefits@crotchedmountain.org. Further information concerning the details and background of this statue is available through the State of New Hampshire, Office of the Attorney General,Charitable Trusts Unit. Crotched Mountain’s community benefits plan is based, in part, upon a collaborative needs assessment which was conducted by a committee representing several healthcare charitable trusts throughout the Monadnock region of New Hampshire. A summary of the collaborative needs assessment is posted on the Monadnock Community Hospital web site. Additionally, we conducted a series of disability-related needs assessments associated with CMRC’s key operations (as listed below).

Our Communities
As a specialty hospital and rehabilitation center for children and adults with disabilities, we recognize two distinct communities of need and service. First, CMRC serves the community of people with disabilities and their families throughout New Hampshire and other states through two key operations, the Crotched Mountain School and the Crotched Mountain Specialty Hospital. Crotched Mountain School, a residential and day school, serves students with disabilities from New England and the northeastern states. Children enrolled in the School have significant health impairments due to genetic and neurological conditions and trauma experienced in their lifetimes. The largest single diagnosis is autism. Some students have medical conditions that require skilled nursing level of care so they reside in a pediatric unit of the Specialty Hospital. The skills of our staff and resources of the School allow them to have access to an educational program that is rich in content and that otherwise could not occur. The Crotched Mountain Specialty Hospital serves children and adults with brain injuries, strokes, complex medical conditions, respiratory needs including vent management and weaning, spinal cord injuries and other neurological impairments and injuries. Our patients are from New Hampshire and other states including Massachusetts, Vermont, Maine, Connecticut and New York.

The second major service population resides in the local Monadnock community. We operate selected outpatient clinics that focus on people with disabilities. The services of the clinic inlcude audiology, developmental pediatrics and pediatric physical therapy. We also serve the Monadnock community through outdoor recreation programs that focus on health and well being that are inclusive of everyone.

Benefits Provided   
The “Actual Benefit Value” of the activities outlined in our Community Benefits Report 7/01/15-6/30/16, totals $3,507,298. The “Estimated Benefit Value” of the 10 consolidated activities outlined in our Community Benefits Plan 7/01/16 – 6/30/17, totals $2,871,293. Our plan continues to address a number of identified needs relative to our communities, including access to specialty rehabilitation services in an inpatient setting, specialty medical services (such as physical and occupational therapy, speech/hearing, and assistive technology); professional and community education; and internships that provide exposure to clinical and educational occupations. Crotched Mountain Foundation also makes small grants to community organizations for underwriting and sponsorship. Through a related corporation of Crotched Mountain, the Harry Gregg Foundation, we make over $150,000 in small grants to low income individuals with disabilities and chronic health conditions to support their needs and aspirations.

In the Crotched Mountain Specialty Hospital we provide multiple benefits for the community. Over 75% of our patients rely on Medicaid which only covers a fraction of the cost of their care and rehabilitation. Crotched Mountain accepts patients who have yet to establish their Medicaid eligibility which moves them more quickly to a rehabilitation program, saves the State of New Hampshire and the health care system millions of dollars in health care expenses at tertiary hospitals and frees up beds in those facilities so that more acute patients can be served. The Hospital continues to serve a population with neuro-rehabilitation needs as well as ventilator management for medically stable adult patients and patients requiring vent weaning. Over 60% of our patients have neuro-psychological diagnoses or co-morbidities or require 1:1 staffing for behavioral management support.

Moving outside the Hospital, Crotched Mountain provides benefits to the wider community by providing access to recreation for everyone, including people with mobility and other disabilities. Our accessible trails, which attract visitors from across the country, provide the opportunity for everyone to experience the outdoors in ways not usually possible for people with mobility impairments. In addition to quality of life, this promotes health and well being. The Crotched Mountain Accessible Recreation and Sports (CMARS) program has staff and more than 60 volunteers who support skiing and snowboarding, kayaking, hiking, shooting and other sports for hundreds of people who otherwise would be denied these opportunities.

While this Community Benefits legislation requires this type of community benefits accounting, we feel it is important to recognize that CMRC has provided benefits to the disability community in New Hampshire and other states through budgeted subsidies from the Crotched Mountain Foundation (CMF) for fifty years. Millions of dollars provided by CMF to CMRC have improved services, provided additional services, and increased the number of people served. Crotched Mountain is committed to ensuring that needed services are provided to people with disabilities whether or not a source of reimbursement exists.

Through affiliated corporations, Crotched Mountain also serves New Hampshire communities in Portsmouth, Derry, Manchester, and Whitefield by providing housing, care management and direct services for people with disabilities, the elderly and low-income populations. These programs also receive planned operating subsidies from CMF.

Conclusion 
We look forward to receiving public commentary on our community benefits plan and welcome the opportunity to engage in new collaborations with other local and disability-related organizations. We continually explore ways in which Crotched Mountain will expand its community education and outreach programs in order to extend the resources of CMRC from “the mountain” into communities throughout the state and beyond.

Click here to view our Community Benefits Reports archive. (PDF)

 

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