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Advancing Excellence in Nursing Homes Making Nursing Homes Great Places to Live, Visit and Work Chris Condeelis Senior Director of Quality American Health.

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Presentation on theme: "Advancing Excellence in Nursing Homes Making Nursing Homes Great Places to Live, Visit and Work Chris Condeelis Senior Director of Quality American Health."— Presentation transcript:

1 Advancing Excellence in Nursing Homes Making Nursing Homes Great Places to Live, Visit and Work Chris Condeelis Senior Director of Quality American Health Care Association Carol Benner, National Director, Advancing Excellence in Nursing Homes Campaign T ammy Rolfe, LANEs Field Director, Advancing Excellence In Nursing Homes

2 Learning Outcomes 1.Describe the role of Advancing Excellence in Quality First Keeping the Promise. 2.Review the eight goals and targets for improving the performance of nursing homes. 3.Describe the array of comprehensive, customized, evidenced-based resources that are available at no cost. 4.Demonstrate the use of Advancing Excellence website to benchmark and track performance. 2

3  Quality has evolved   7 Principles – no changes  5 – Goals – refined, consensus, measures sources  5 – Tools -- new 3

4 Why Update or Even Keep Quality First? Our goals are more refined. We have targeted 3 rd - party data sources. We can adjust our goals as our environment changes. 4

5 QFKTP Strategic Direction  Self-initiated – voluntary, proactive  Accountability, Transparency  Anchor point – across our membership  Positioning for the Affordable Care Act  Public Reporting  Pay for Performance  Bundling 5

6 “Quality is the combination of care and services that meet or exceed customer needs and expectations.” AHCA/NCAL 6 What is quality ?

7 QFKTP -- 7 Principles Continuous Quality Improvement (CQI) – This principle encourages a collaborative approach to quality management that builds upon traditional quality assurance methods by emphasizing the organization and systems, with a primary focus on process, and utilizes objective data to analyze and improve these processes. In long term care CQI incorporates all the components that are necessary for quality care and services. Public Disclosure and Accountability – This principle seeks to encourage transparency of information that is shared with patients, residents and their families as well as sources of state and federal funding. It also promotes accountability to meeting – and exceeding – patient needs and expectations, while simultaneously exhibiting accountability of government funding for the care provided. Patient/Resident and Family Rights – This principle embodies the critical importance for person-centered care and focus on individual outcomes through services provided. This is exemplified by presenting opportunities to patients and residents to best determine their care and shape the comfort of their environment. 7

8 QFKTP Principles – continued Workforce Excellence – This principle recognizes that a strong organization empowers leaders and develops and supports a stable, qualified and well-trained workforce that is engaged and committed to excellence. Public Input and Community Involvement – This principle recognizes the interconnectedness of long term care facilities and the community. Facilities should strive to achieve positive visibility by promoting themselves as health care providers within the community, becoming involved in issues impacting the community and by sustaining a robust volunteer program that actively engages individuals of all ages. Ethical Practices – This principle embodies the belief that all long term care providers should operate based on a foundation of trust. This includes promoting ethical business standards, corporate integrity and responsible financial stewardship. Financial Stewardship – This principle recognizes that the vast majority of long term care providers rely on government funding (Medicare, Medicaid) to provide quality care and services – and that our profession must operate in a manner that uses these resources responsibly. As a profession, we will endeavor to retain appropriate levels of governmental funding to allow facilities to provide health care and services to those in need. 8

9 QFKTP – 5 Goals Improve and Sustain: 1.Performance in all CMS quality measures 2.Compliance with the federal survey process 3.High rates of resident and family satisfaction 4.High rates staff satisfaction rates 5.Leadership and staff retention, and reduce turnover rates 9

10 QFKTP – Data to Measure Goals Improve and sustain performance in all CMS Quality Measures Source: CMS Nursing Home Compare Update: Quarterly Improve and sustain compliance with the federal survey process Source: CMS OSCAR Data Update: Quarterly Improve and sustain high rates of resident and family satisfaction Source: My InnerView – National Survey of Customer and Workforce Satisfaction in Nursing Homes Report Update : Annual Improve and sustain high staff satisfaction rates Source: My InnerView – National Survey of Customer and Workforce Satisfaction in Nursing Homes Report Update: Annual Improve and sustain leadership and staff retention and turnover rates Source :AHCA 2008 Nursing Vacancy, Turnover, and Retention Report Update: Annual 10

11 CMS Quality Measure Performance (CMS Nursing Home Compare) Quality Measure (QM) % Difference Physical Restraints 3.9%3.1%-.8% High Risk Pressure Ulcer 11.6%10.9%-.7% Pain3.9%3.1%-.8% PAC Pain20.6%19.5%-1.1% PAC Pressure Ulcer 14.2%12.7%-1.5%

12 Federal Survey Process (CMS Nursing Facility OSCAR Standard Health Survey Data) Average CitationsSub Quality Care %2.9% %3.1% %3.4% %4.1%

13 13 Resident and Staff Satisfaction (My InnerView, Inc.2009)  86% of residents rated their nursing home as “good” to “excellent.”  67% of staff rated their home “good” to “excellent” as a place to work. 13

14 14 Retention Rates by Job Category (AHCA, Vacancy and Turnover Study, 2008) CategoryRetention Rate Administrative68% Nursing45% Therapy63% Food Services48% Housekeeping61% Social Activities66% 14

15 Shared Goals Quality First and Advancing Excellence Quality First, Keeping the Promise – Goals Advancing Excellence – Phase II Goals Resident and Family Satisfaction Consistent Assignment Leadership and Staff Retention and Turnover Staff Retention and Turnover Staff Satisfaction CMS Quality Measures Pain, Pressure Ulcers, Advance Care Planning, and Restraints Federal Survey Process All of the Above 15

16 Quality First: Keeping the Promise 5 Tools 1.Advancing Excellence Phase II 2.AHCA/NCAL National Quality Award 3.AHCA LTC Trend Tracker® 4.Resident and Family Satisfaction Assessment 5.Staff Satisfaction Assessment 16

17 Thank-You for What You Do “The leaders who work most effectively, it seems to me, never say “I” They think “we”; they think “team.” “They understand their job to be to make the team function. They accept responsibility and don’t sidestep it, but “we” gets the credit…. This is what creates trust, what enables you to get the task done.” Peter Drucker 17

18 About the Advancing Excellence in America’s Nursing Homes Campaign

19 Campaign Overview Largest national coalition (30 organizations) of nursing home stakeholders Voluntary for nursing homes (43% registered!) Based on measurement of meaningful goals Initially a two-year campaign started in 2006 Just celebrated our 4 th birthday! Incorporated in 2010 And, the data show that it works!!!!

20 Why Join? Participate in a Quality Improvement method that works Advancing Excellence tools are free, evidence-based and user-friendly Up-to-date information on the website to help nursing homes quality of care and life Robust website Periodic newsletters Participation encouraged for consumers and frontline staff in addition to nursing home leaders

21 Campaign Benefits Focuses on meaningful issues Drives nursing homes to a culture of data and QI Increases staff retention and focus Improves customer satisfaction Saves money due to improved quality and staff retention Prepares for Pay-for-Performance Brings stakeholders to the table Complements other initiatives Gets nursing homes ready for QAPI

22 About Quality Improvement

23 Why is Nursing Home QI Important? 1.It’s the right thing to do 1. Affordable Care Act strengthens QA requirements in nursing homes 2. With the shift to MDS 3.0 and the change in quality measures, nursing homes are more accountable than ever for quality.

24 Quality Assurance/Performance Improvement (QA/PI) The Affordable Care Act, Section 6102 requires CMS to strengthen QA requirements in nursing homes CMS must provide technical assistance to nursing homes in order to meet new requirements. Law requires implementation by December 31, 2011 QAPI Plans must be submitted to HHS Secretary one year later

25 QA/PI Meaningful problems or issues Measureable Benchmarks/data-driven Evidence-based interventions Evidence of improvement

26 Reactive Single episode Organizational mistake Prevents something from ever happening again Sometimes anecdotal Retrospective Monitoring based on audit Sometimes punitive Proactive Aggregate Data Organizational process Improves overall performance Always measureable Concurrent Monitoring is continuous Positive change Quality AssuranceQuality Improvement

27 QI Model for Improvement Three Questions and the PDSA Cycle What are we trying to accomplish? How will we know that we have been successful? What changes can we make to achieve our goal?

28 QI Model for Improvement Aims are time-specific and measureable Dependent on change Uses P-D-S-A cycle to test small changes

29 PLAN-DO-STUDY-ACT

30 PDSA

31 PDSA

32 Example 1 What are we trying to accomplish? – I want to lose weight How will we know that we have been successful? – Size 6 dress – Lost 20 pounds What changes can we make to achieve our goal? (First, have to figure out what process I have to change) – Change medicine? Eat less? Eat differently? Exercise?

33 Example 1 AimLose 10 pounds in two months using the bathroom scales to measure PlanRCA: what has caused weight gain? Poor eating practices DoChange eating behavior and start Weight Watchers StudyAfter two weeks, there is a 2-pound weight loss ActKeep doing the same thing and monitor closely

34 Example 2 What are we trying to accomplish? – I want to increase profits in my pizza store How will we know that we have been successful? – 10% $$$ increase at the end of the 2011 What changes can we make to achieve our goal? – First, have to figure out what process I have to change  Better marketing? More cooks? Efficient delivery practices?

35 Example 2 AimIncrease profits by 10% by December 31, 2011 using monthly profit reports to measure PlanRCA: what’s caused the loss of profits? Bad economy DoDistribute coupons in neighborhood newsletters Study After three months, sales are increasing! ActStandardize the new marketing procedure

36 Example 3 What are we trying to accomplish? – Decrease number of in-house acquired pressure ulcers How will we know that we have been successful? – No pressure ulcers and no deficiencies What changes can we make to achieve our goal? – First, have to figure out what process I have to change  Right supplies on hand? Hire wound care nurse?Identification and care of residents at risk for PUs?

37 Example 3 Aim Decrease in-house acquired pressure ulcers from 4% to 2% by December 31, 2011 using AE tool to measure PlanRCA: what’s caused the pressure ulcers? Lack of prevention DoSet up prevention protocol that includes ID, hydration, turning and positioning, use of devices to prevent, etc. StudyNo new pressure ulcers for two weeks ActStandardize the new marketing procedure

38 Campaign Phase 2 Goals 1. Staff Turnover 2. Consistent Assignment 3. Restraints 4. Pressure Ulcers 5. Pain (long and short-stay) 6. Advance Care Planning 7. Resident/Family Satisfaction 8. Staff Satisfaction

39 Quality in Nursing Homes To improve care, we need to stabilize the work force. We need to reduce turnover, improve staff retention. We need to improve relationships between staff and staff, staff and residents.

40 Keep QI Simple Focus on important, meaningful issues. Make sure that your goal is measureable. Figure out what change/process you need to make. Involve the care team Make QI come alive Celebrate your success

41 About the Advancing Excellence QI Tools

42 Advancing Excellence Tools Staff Turnover Calculator Consistent Assignment Calculator Pressure Ulcer Monitoring Tool Restraint Monitoring Tool Pain Monitoring Tool Advance Care Plan Monitoring Tool Suggested tools for measuring Staff Satisfaction and Resident and Family Satisfaction Find these tools at

43 The Campaign Tools Evidence-based, tried and tested…they work! Developed by experts Similar to one another and user-friendly Excel worksheets Simple how-to instructions Macros and formulas built-in Monitoring built-in Downloadable and ready to use Free

44 The Campaign Resources Resources for each Campaign goal include: Implementation Guide Webinar Fact sheet for consumers Fact sheet for CNAs Additional resources include: Videos Research references Resources are regularly updated

45 Using the AE Tools to improve Staff Turnover, Consistent Assignment and Pressure Ulcers

46 A Major Shift In Thinking It’s ALL about STAFF Enough Competent Caring Compassionate Consistent

47 Formula for Success Staff Stability Consistent Assignment + = Happier Staff Better Care and Clinical Outcomes Higher Resident and Family Satisfaction Cost Savings

48 Proving The Link - References A Case For Consistent Assignment: When caregivers get to know their patients more intimately, it opens the way for improved quality and a reduction in staff turnover, Provider Magazine, June 2006 A Keystone For Excellence: Implementing consistent assignment provides a strong foundation for achieving the goals of the Advancing Excellence in America’s Nursing Homes program, Provider Magazine, July, 2007 Predictable scheduling: Nursing homes can boost quality, bottom line with consistent assignment, Modern Healthcare, August 2010 Interventions Table: Staff Retention: An overview of information published between regarding successful or potentially successful interventions to retain staff

49 What is Staff Stability? Low staff turnover High staff retention Low use of agency staff Rare call-outs, absenteeism High staff satisfaction

50 Staff Turnover Staff turnover is one component of staff stability

51 National Nursing Home Turnover Data AHCA’s Staff Vacancy and Turnover Report 2007 CNA65.6% RN41.0% LPN49.9%

52 Staff Turnover – AE Goal Goal 1 - Staff Turnover: Nursing homes will take steps to minimize staff turnover in order to maintain a stable workforce to care for residents. Amazing Resources on the Website: QPRI Staff Stability Toolkit PHI Coaching and Supervision Guide AE Staff Turnover Tracking Tool WEB EX on how to use the tool

53 QI Process for Staff Turnover PLAN Use the AE tool to calculate what the turnover rate is Decide if this is something that needs to change If yes, ask why? Is it low-pay, too much work, geographical area, lack of leadership? Decide on a plan

54 QI Process for Consistent Assignment DO Talk with staff and explain what is going on Implement changes in hiring practices Study After two weeks or so, use the AE Tool and see how you are doing Talk to the staff to see how they are doing

55 QI Process for Consistent Assignment ACT Using the measurement from the AE Tool and the feedback received from the staff, tweak the hiring practices.

56 The Staff Turnover Calculator Tool Only nationally available standardized way to collect turnover data Developed for QIO’s 8 th scope of work and modified to make it better over past 6 years Used to collect and analyze monthly data Provides an Annualized Turnover Rate Monitoring on AE website

57 57 Staff Turnover Calculator

58 58 Instructions TAB

59 59 Common Qs & As TAB

60 60 CNA Calc TAB

61 61 CNA Trending TAB

62 Data Entry on AE Website Enter staff turnover data on AE website at least monthly Print off a copy of the tool for simplicity and as a record Your data are confidential– others cannot see it Use the provided trend graphs for QI meetings Provide feedback to staff and others through data and graphs

63 Consistent Assignment

64 What is Consistent Assignment? The same person takes care of the same resident every time he or she is on duty…

65 The Case for Consistent Assignment How Would You Feel? To never know who your caregiver might be To always have caregivers that don’t know your preferences or routine To know that you may not see the person who cared for you today again There is a possibility that a single resident could have over 20 different caregivers in a week!

66 Consistent Assignment Builds positive relationships Increases resident and family satisfaction Quicker awareness of clinical problems Improves staff accountability Improves communication between shifts and with other disciplines Improves staff satisfaction Improves clinical and quality outcomes!!!

67 A How-To Manual A Step-By-Step Guide to Consistent Assignment Roll-Out This handout is an adaptation from information David Farrell presented during an AHCA webinar held November, 2007 The webinar materials are available for free (See handout for link)

68 Can Any Nursing Home Do This? Yes !! If the Nursing Director and Administrator are on board with PASSION! If the culture is already open for dialogue If the staff feel empowered and not threatened If everyone realizes that consistent assignment is a different way of thinking and behaving If everyone realizes it is best for the resident

69 Consistent Assignment – Goal Definition Goal 2 – Consistent Assignment: Being regularly cared for by the same caregiver is essential to quality of care and quality of life. To maximize quality, as well as resident and staff relationships, the majority of nursing homes will employ “consistent assignment” of CNAs.

70 Consistent Assignment – Objectives The Objectives: The Advancing Excellence Campaign has defined consistent assignment as at least 85% of long stay residents in the nursing home having a maximum of eight CNA caregivers over a four-week period, and at least 85% of short stay residents having a maximum of eight CNA caregivers over a two week period. You may find out that your numbers are higher than 8 and that is OK! If your number is 12, you may want to get it down to 10 Set your goal

71 QI Process for Consistent Assignment PLAN Use the AE tool to calculate how many CNAs are caring for each resident Decide if this is something that needs to change If yes, ask why and how your staffing patterns contribute to the number of different CNAs taking care of residents. Ask the right questions: Is simply a matter of scheduling? High number of “difficult” residents? Too many call-outs? Educate everyone about consistent assignment See the “How-To Manual” slide and handout

72 QI Process for Consistent Assignment DO Talk with staff and get buy-in to change Explain value of consistent assignment Use best practices of others to change scheduling practices Pilot consistent assignment on one unit Provide resources

73 QI Process for Consistent Assignment Study After two weeks or so, use the AE Tool and see how you are doing Talk to the staff to see how they are doing

74 QI Process for Consistent Assignment ACT Using the measurement from the AE Tool and the feedback received from the staff, tweak the scheduling method.

75 Using the Consistent Assignment Tool ONLY national standardized tool that will allow comparisons Download the Excel-based tool on to your computer and save it with a name Set up the tool by adding names of residents and staff The tool is resident-centered not staff-centered and counts the number of caregivers taking care of residents NOT the number of residents being cared for by the caregiver

76 Using the Consistent Assignment Tool The tool is resident-centered not staff-centered and counts the number of caregivers taking care of residents NOT the number of residents being cared for by the caregiver Tool calculates the average number of unique C.N.A.’s per resident for the past 7 days in weekly increments - ready for data entry into the Campaign website Use the tables from the Excel worksheet to brief your QA Committee and provide feedback to the staff

77 77 Consistent Assignment Calculator

78 78 Instructions TAB

79 79 Common Qs & As TAB

80 80 CNA Tab

81 81 Residents TAB

82 82 Week 1 TAB

83 83 Summary TAB

84 Pressure Ulcer Tracking Tool

85 Pressure Ulcers– Goal Definition Goal 4 Pressure Ulcers: Nursing home residents receive appropriate care to prevent and appropriately treat pressure ulcers when they develop

86 QI Process for Pressure Ulcers Define and Measure Pressure Ulcers Determine current pressure ulcer data in your nursing home, state and nation Identify facility information and tracking Investigate Reasons and Sources of Pressure Ulcers Identify current practices and approaches See Pressure Ulcer Care Process Framework

87 QI Process for Pressure Ulcers Identify and Implement Solutions to Improve Pressure Ulcer Rates Use interventions that address the specific problem. Use appropriate resources for solutions that are known to work. Monitor and try different interventions if necessary. Re-evaluate performance practices and results Continue internal data collection on results and processes Provide feedback to staff and others No Data Entry Required – Populated from MDS Use trend graphs from 2007 to 2010

88 National Pressure Ulcer Data Some Key Campaign Objectives: By December 21, 2011 The national average for high risk pressure ulcers will be below 9% 30% of nursing homes will report rates of high risk pressure ulcers at or below 6% 22,500 fewer residents will have pressure ulcers compared to 6/06 Most Current Quarter 2, 2010 high risk pressure ulcer data 10.8 %

89 Knowing Pressure Ulcer Data It is important to know your national, state and facility specific data You can find these on the Campaign website Due to MDS 3.0 the Quality Measures are going dark Last QM data expected to be posted Feb 2011 for Q

90 Using the Pressure UlcerTool Internal QI is essential now in the absence of QM’s Use the AE Pressure Ulcer Tool to collect and analyze monthly data Nationally standardized way to collect this data Amazing graphs and trending Go to website, click on goal and tool, download tool – save to PC with an extension such as date or name

91 Special Tool Features Allows nursing home to monitor in-house acquired and admission acquired by source Shows were pressure ulcers come from Provides multiple graphs for ongoing monitoring There are currently no questions and answers tied to this tool

92 Pressure Ulcer Tool - Data Entry Section

93 Pressure Ulcer Tool - Graphs and Trends

94 Monthly Notes

95 Thank You! Questions?


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