1. Health Facility Evaluation and Quality Improvement September 21, 2010 “The Indiana State Department of Health supports Indiana’s economic prosperity and quality of life by promoting, protecting, and providing for the health of Hoosiers in their community.”

2. NextPrevious Outline Nursing Home Evaluation Process and Quality Measures Healthcare Quality Improvement Initiatives and Their Outcomes

3. NextPrevious Indiana Nursing Home Evaluation Process and Quality Measures

4. NextPrevious Overview of Long Term Care Facilities

5. NextPrevious Overview of Indiana Long Term Care Facilities Long Term Care Facility Types Comprehensive care facility – nursing home –Skilled nursing facility (SNF) –Nursing facility (NF) –Non-certified comprehensive care (State only) –Residential care beds Residential care facility Assisted living facility Intermediate care facility for the developmentally disabled (ICFDD) – group home

6. NextPrevious Overview of Indiana Long Term Care Facilities Number of Indiana Long Term Care Facilities Certified comprehensive care facilities (nursing homes) – 502 facilities Non-certified comprehensive care facilities - 3 Comprehensive care facilities with residential care beds – 110 Freestanding residential care facilities – 109 Source: ISDH Data September 2010

7. NextPrevious Overview of Indiana Long Term Care Facilities Indiana Long Term Care Beds Certified comprehensive care facilities (nursing homes) – 48,636 comprehensive care beds Certified comprehensive care facilities with residential care beds – 8,256 residential care beds Non-certified comprehensive care – 1165 comprehensive beds Non-certified with residential beds – 304 residential care beds Freestanding residential care facilities – 8,861 residential beds Total residential beds: 17,421 beds Source: ISDH Data September 2010

8. NextPrevious Survey Process and Findings

9. NextPrevious Overview of Nursing Home Survey Process Survey Frequency State licensing and federal certification surveys conducted every 9-15 months –Indiana has met that standard State and federal complaint survey conducted for all complaints based on a priority tier –Indiana has met that standard

10. NextPrevious Overview of Nursing Home Survey Process Number of Nursing Home Surveys Completed (2009) Number of Annual Licensing / Certification Surveys (2009) – 533 Number of Complaint Surveys (2009) – 1,459 Number of Annual Life Safety Code Surveys (2009) – 533 Source: CMS Casper Report

11. NextPrevious Indiana Nursing Home Survey Findings Most Cited Deficiencies (2010) F282: Services provided by qualified persons in accordance with care plan – 43% of providers F323: Facility is free of accident hazards – 33% F272: Comprehensive assessments – 33% F514: Clinical records – 29% F157: Inform of significant changes – 28% F441: Infection control – 25% Source: CMS Casper System

12. NextPrevious Indiana Nursing Home Survey Findings Most Cited Immediate Jeopardies (2010) F323: Facility is free of accident hazards – 5 F224: Facility prohibits abuse, neglect – 3 F441: Infection control – 2 F225: Facility does not employ persons guilty of abuse – 2 F314: Pressure ulcers – 2 F223: Residents right to be free from abuse – 2 Source: CMS Casper System

13. NextPrevious Indiana Nursing Home Survey Findings Outcomes: Deficiency free surveys 2005: 47 facilities 2006: 47 facilities 2007: 51 facilities 2008: 59 facilities 2009: 57 facilities 2010: 66 facilities (through Sept. 13) Source: CMS OSCAR quarterly reports

14. NextPrevious Indiana Nursing Home Survey Findings Outcomes: Deficiency free surveys (% of facilities with no deficiencies) Indiana Region V National Q4 2006: 10.60% n/a 8.20% Q4 2007: 11.70% 10.41% 8.30% Q4 2008: 10.78% 9.09% 7.60% Q2 2009: 12.25% 8.77% 7.83% Source: OSCAR quarterly reports

15. NextPrevious Indiana Nursing Home Survey Findings Outcomes: Immediate jeopardy findings 2006: 91 – Indiana 3 rd highest 2007: 106 – Indiana 5 th highest 2008: 76 - Indiana 13 th highest (68 surveys) 2009: 46 – Indiana 17 th highest (35 surveys) 2010: 25 (through September 13) Source: CMS CASPER data

16. NextPrevious Indiana Nursing Home Survey Findings Outcomes: Immediate jeopardy findings (% of facilities with IJ) Indiana Region V National Q4 2006: 4.50% n/a 2.20% Q3 2007: 5.64% 3.36% 2.17% Q2 2008: 5.08% 3.75% 2.58% Q2 2009: 2.77% 3.23% 2.89% Source: OSCAR quarterly reports

17. NextPrevious Indiana Nursing Home Survey Findings Average Number of Deficiencies Per Survey Indiana Region V National 2006: 1.7 1.5 1.5 2007: 2.7 2.4 2.0 2008: 3.0 2.5 2.1 2009: 2.7 2.52.1 2010: 2.5 2.2 2.0 Source: OSCAR quarterly reports through Sept 13, 2010

18. NextPrevious Indiana Nursing Home Survey Findings Data Variability Between States Percent of surveys timely completed Whether state citing all deficiencies Whether citing associated tags

19. NextPrevious Indiana Nursing Home Survey Findings Differences in Surveys Between Provider Types Acute Care –Compliance based on status at time of survey –Regulations based on facility policy Long Term Care –Compliance determination goes back to previous annual survey –Regulations based on descriptive requirements

20. NextPrevious Indiana Nursing Home Survey Findings Reporting of Survey Findings ISDH Nursing Home Consumer Report –All survey reports and plan of corrections will be added in 2010 to Consumer Report CMS Nursing Home Compare

21. NextPrevious Healthcare Quality Issues Identified Through the Survey Process Common Root Causes Appropriate admissions / placement Timely and accurate assessments Care transition and coordination Staff education, training, & sufficiency Negative health care culture

22. NextPrevious Healthcare Quality Issues Identified Through the Survey Process Quality of Care Issues Pressure ulcers Healthcare associated infections Medication errors / patient safety Falls / wandering Behavior management Abuse and neglect

23. NextPrevious Health Care Staffing

24. NextPrevious Staffing Staffing Initiatives Leadership Conference Staffing Strategies September 17, 2009 (funded by Civil Money Penalty Fund) Staffing Study of Long Term Care Facilities (funded by the ISDH Civil Money Penalty Fund)

25. NextPrevious Staffing 2009 Long Term Care Staffing Study Number of administrator changes per facility over past three years – 2.5 Number of director of nursing changes per facility over past three years – 2.8

26. NextPrevious Staffing 2009 Long Term Care Staffing Study Turnover rate for Registered Nurses (RN) – 74.1% (46% nationally) Turnover rate for LPN – 67% (43% nationally) Turnover rate for certified nurse aides (CNA) – 98.1% (64% nationally)

27. NextPrevious Staffing ISDH Senior Staffing for Survey Program Three Division Directors (Acute Care, Health Care Education, Long Term Care) and all seven long term care area supervisors are new within the past three years

28. NextPrevious CMS Quality Indicator Survey System

29. NextPrevious Health Care Survey System Survey Program Quality Improvement Implement CMS Quality Indicator Survey (QIS) system –Kick-off for QIS system occurred in August 2010 –Training of surveyors for QIS surveys to begin in January 2011

30. NextPrevious ISDH Healthcare Quality Improvement Initiatives

31. NextPrevious Goals Promote health care quality and health literacy through educational initiatives Increase public awareness and focus on a state health issues Protect the public through oversight of quality of care provided by health care facilities

32. NextPrevious Healthcare Quality Improvement Principles Principles for Improvement Summarize evidence into checklists Identify and mitigate local barriers to implementation Measure performance Ensure all patients reliably receive the intervention

33. NextPrevious Healthcare Quality Competing Interests OUTCOMES Scientific Foundation Regulatory Feasibility Health Care Culture

34. NextPrevious SUCCESSFUL AGING Rowe & Kahn, 1998 AVOIDING DISEASE & DISABILITY MAINTAINING HIGH COGNITIVE & PHYSICAL FUNCTIONING ENGAGEMENT WITH LIFE

35. NextPrevious Quality Improvement Themes Evidence-based System-based Incorporate care coordination principles Incorporate assessment tools Incorporate culture change principles Include patient and family centered care principles Measurable outcomes Plan for continuity after the initiative

36. Indiana Health Care Quality Improvement Initiatives Survey-based Initiatives

37. NextPrevious Survey-based Initiatives CMS Special Focus Facility Program –Adding a facility in October 2010 –Will be five special focus facilities –Funded by CMS and state funds ISDH Consultant Program –Offered to facilities with substandard quality of care findings –Funded through ISDH Civil Money Penalty Fund CMS Critical Need Nursing Home Project (Through Quality Improvement Organization – Health Care Excel) –Pilot program for 4-5 facilities in northwest Indiana –Funded by CMS grant to Health Care Excel

38. Indiana Health Care Quality Improvement Initiatives Addressing Immediate Jeopardy Level Deficiencies

39. NextPrevious Improving Survey Findings The Challenge In 2007, Indiana had the 5 th highest number of immediate jeopardy findings on nursing homes surveys

40. NextPrevious Improving Survey Findings Quality Improvement Activities Monthly meetings with provider associations to review findings Quarterly meetings with advocate organizations to discuss quality of care concerns Collaborative quality improvement initiatives with healthcare organizations

41. NextPrevious Improving Survey Findings Quality Improvement Activities: CMS and ISDH consistency workgroups Review of all immediate jeopardy findings by provider associations ISDH implemented a biweekly long term care newsletter in January 2008 (funded through ISDH Civil Money Penalty Fund) Implemented collaborative healthcare quality improvement initiatives

42. NextPrevious Indiana Nursing Home Survey Findings Outcomes: Immediate jeopardy findings 2006: 91 – Indiana 3 rd highest 2007: 106 – Indiana 5 th highest 2008: 76 - Indiana 13 th highest (68 surveys) 2009: 46 – Indiana 17 th highest (35 surveys) 2010: 25 - Through September 13 Source: CMS CASPER data

43. NextPrevious Indiana Nursing Home Survey Findings Outcomes: Immediate jeopardy findings (% of facilities with IJ) Indiana Region V National Q4 2006: 4.50% n/a 2.20% Q3 2007: 5.64% 3.36% 2.17% Q2 2008: 5.08% 3.75% 2.58% Q2 2009: 2.77% 3.23% 2.89% Source: OSCAR quarterly reports

44. Indiana Health Care Quality Improvement Initiatives Indiana Healthcare Leadership Conferences

45. NextPrevious Healthcare Quality Leadership Conferences Joint conferences for long term care providers, organizations, associations, and surveyors Two conferences per year Each conference covers one topic Conferences serve as kick-off for quality improvement initiatives Funded through the ISDH Civil Money Penalty Fund

46. NextPrevious Healthcare Quality Leadership Conferences Previous Conferences June 2007: Falls October 2007: Pressure ulcers March 2008: Restraints and behavior management September 2008: Emergency preparedness March 2009: Incontinence September 2009: Staffing March 2010: Healthcare Associated Infections

47. NextPrevious Healthcare Quality Leadership Conferences Planned Conferences Alzheimer’s and Dementia Care – October 14, 2010 Nutrition and Hydration – March 31, 2011 Abuse and Neglect – Fall 2011 Patient Safety / Medical Errors – Spring 2012

48. NextPrevious Healthcare Quality Leadership Conferences Conference Checklist Attend conferences Use information and resources to develop education and training program in facility Implement quality improvement project in facility Celebrate quality accomplishments

49. Indiana Health Care Quality Improvement Initiatives Indiana Pressure Ulcer Initiative

50. NextPrevious Indiana Pressure Ulcer Initiative Participating Facility and Agencies Phase 1 Phase 2 Total Home Health / Hospice 27 13 40 Hospitals 417 48 Nursing Homes 94 62 156 Totals 162 82 244 Funded through ISDH Civil Money Penalty Fund

51. NextPrevious Indiana Pressure Ulcer Initiative Indiana incidence of pressure ulcers in long term care facilities –Q4 2003 – 9.5% (Ranked 36 th in US) –Q4 2004 – 9.2% –Q4 2005 – 8.6% –Q4 2006 – 8.4% –Q4 2007 – 8.1% –Q4 2008 – 8.3% (Ranked 36 th in US) Source: CMS GPRA Data

52. NextPrevious Indiana Pressure Ulcer Initiative Initiative Components Three In-person Learning Sessions Toolkits Six Online education modules – www.in.gov/isdh/24558.htm Consumer brochure

53. NextPrevious Indiana Pressure Ulcer Initiative Initiative Outcomes: Pressure Ulcer Rates for all Indiana Nursing Homes Q1 2008: 8.5% (34 th ) Q4 2008: 8.3% (36 th ) Q1 2009: 8.0% (29 th ) Q2 2009: 7.6% (28 th ) Q3 2009: 7.3% (26 th ) Source: CMS GPRA Data

54. NextPrevious Indiana Pressure Ulcer Initiative Initiative Outcomes: Number of Nursing Home Residents with a Pressure Ulcer Q1 2008: 2992 Q3 2008: 2867 Q4 2008: 2899 Q2 2009: 2618 Q3 2009: 2506 Q4 2009: 2664 Q1 2010: 2574 - 14% Statewide Decrease from Q1 2008 Source: CMS GPRA Data

55. NextPrevious Indiana Pressure Ulcer Initiative Initiative Outcomes: One Year Cost Savings for Indiana Nursing Homes 300-400 fewer pressure ulcers per quarter Average cost of over $10,000 per pressure ulcer to heal For 300 residents, savings of over $12 million in one year Source: CMS GPRA Data

56. NextPrevious Indiana Pressure Ulcer Initiative Initiative Outcomes: One Year Cost Savings for One Unit of One Hospital 2008: 14 pressure ulcers with some stage 3 or 4 2009: 0 pressure ulcers Average cost of over $30,000 per pressure ulcer to heal For 14 patients at one hospital, savings of over $420,000 over one year Source: CMS GPRA Data

57. NextPrevious Indiana Pressure Ulcer Initiative Pressure Ulcer Deficiencies YearDeficienciesImmediate Jeopardies 2007 19518 2008 186 5 2009 157 4 2010 96 2 (to Sept. 13) Source: CMS CASPER Data

58. Indiana Health Care Quality Improvement Initiatives Indiana Healthcare Associated Infection Initiative

59. NextPrevious Indiana Healthcare Associated Infection Initiative Infection Control Deficiencies YearDeficienciesImmediate Jeopardies 2009 170 0 2010 137 2 (to Sept. 13) Source: CMS CASPER Data

60. NextPrevious Indiana Healthcare Associated Infection Initiative Healthcare Associated Infections Catheter associated bloodstream Catheter associated urinary tract Clostridium difficile Methicillin-resistant Staphylococcus aureus (MRSA) Surgical site Ventilator associated pneumonia

61. NextPrevious Indiana Healthcare Associated Infection Initiative Indiana will focus on two infections Catheter associated urinary tract infections Clostridium difficile infections

62. NextPrevious Indiana Healthcare Associated Infection Initiative Goals of Initiative Develop a state infection plan Develop and implement an infection surveillance system Implement a prevention initiative focusing on two of the infections

63. NextPrevious Indiana Healthcare Associated Infection Initiative Participating Facilities Ambulatory Surgery Centers - 3 Dialysis (ESRD) Clinics- 2 Home Health and Hospice Agencies- 13 Hospitals- 48 Nursing Homes- 134

64. NextPrevious Indiana Healthcare Associated Infection Initiative Initiative Funding Centers for Disease Control and Prevention (CDC) Grant ISDH Civil Money Penalty Fund

65. Indiana Health Care Quality Improvement Initiatives Reducing Restraints CMS GPRA Target

66. NextPrevious Restraint Reduction in Nursing Homes CMS GPRA Restraint Data Q4 2003: 6.2% (27 th rank) Q4 2004: 5.8% (26 th ) Q4 2005: 5.8% (30 th ) Q4 2006: 5.4% (30 th ) Q4 2007: 4.4% (32 nd ) Source: CMS GPRA Data

67. NextPrevious Restraint Reduction in Nursing Homes Quality Improvement Activities ISDH Leadership Conference on Restraint Reduction in March 2008 (funded by ISDH Civil Money Penalty Fund) Quality Improvement Organization (QIO) focus on restraint reduction (funded by CMS)

68. NextPrevious Restraint Reduction in Nursing Homes CMS GPRA Restraint Data Q1 2008: 4.0% (32 nd rank) Q2 2008: 3.6% Q4 2008: 3.1% (27 th ) Q1 2009: 2.8% Q4 2009: 2.3% (22 nd ) Q1 2010: 2.2% Source: CMS GPRA Data

69. NextPrevious Other Civil Money Penalty Fund Quality Improvement Initiatives Alzheimer’s and Dementia Care Initiative –Development of 10 education modules –Creation of Alzheimer’s and Dementia Certification Program –Provided scholarships Bladder Scanner Study for Incontinence Care

70. NextPrevious Quality Improvement Initiatives in Progress Aide Curriculum Review Project Healthcare Quality Resource Center Implementation of New Regulations –Life safety code –Infection control – Sept 2009 Implementation of MDS 3.0 Care Transition and Coordination

71. Indiana Health Care Quality Improvement Initiatives Medical Error Reporting System

72. NextPrevious Indiana Medical Error Reporting System Based on National Quality Forum’s 27 (now 28) reportable events In 2002 NQF identified 27 events that are serious, largely preventable, and of concern to the public and providers Indiana was the second state to use these reporting standards

73. NextPrevious Indiana Medical Error Reporting System Most Reported Events Stage 3 or 4 pressure ulcers acquired after admission Retention of a foreign object in patient after surgery Surgery performed on the wrong body part Death or serious disability associated with a medication error

74. NextPrevious Indiana Medical Error Reporting System Outcomes Pressure ulcer data as top reportable event resulted in Indiana Pressure Ulcer Initiative and decrease in pressure ulcers Increased awareness of medical errors Allocation of resources to patient safety Increase in number and activity of state and regional patient safety coalitions

75. Indiana Health Care Quality Improvement Initiatives Patient Protection and Affordable Care Act - Long Term Care Initiatives

76. NextPrevious Affordable Care Act Initiatives Affordable Care Act Includes Nursing Home Quality Improvement Activities Facilities required to implement a Quality Assurance & Performance Improvement Program (QAPI) Posting of survey reports and plan of corrections on consumer-oriented Website Disclosure of ownership

77. NextPrevious Affordable Care Act Initiatives Affordable Care Act Includes Nursing Home Quality Improvement Activities CMS Nursing Home Compare to include criminal violations Improved reporting of staffing Sanctions for inadequate notice of facility closure Reduced civil money penalties for some self- reported deficiencies