Transcript The National CMS Pilot Study: INHC Improving Nursing Home

The National CMS Pilot Study:
Improving Nursing Home Culture
(INHC)
This material was designed by Quality Partners, the Medicare Quality Improvement Organization for Rhode Island, under contract with the Centers for Medicare & Medicaid
Services (CMS), an agency of the US Department of Health and Human Services. Contents do not necessarily represent CMS policy. 8SOW-RI-NHQIOSC-082006-2
Improving Nursing Home Culture
What we did . . .
• Pilot tested a model and methodology to
transform nursing homes into a better place
to live and work
• Integrated quality improvement practices with
person directed care and workforce retention
practices-drawing on both the science and
psychology of change
Improving Nursing Home Culture
Who was involved . . .
• We worked with 21 QIOs /168 nursing
homes
• 7 MPQs (corporations or QIOs serving
with trade associations /86 nursing
homes
IMPROVING NURSING HOME CULTURE
Special Study
Person Directed Care
21 QIOs
23
recruit
5-10 Nursing Homes from their
state
Workforce Retention
58 Corporations
& 2 State Triads (QIO, State
AASHA & AHCA)
recruit
10-12 nursing homes
11year
year
August
2004-October
2005
September 2004– August
2005
Training
QIO 4 Sessions
Corps 4 Sessions
Nursing Home Sessions
168 NH Participants
Training
N H Sessions
Outcomes Congress
86 NH Participants
Improving Nursing Home Culture
The design . . . .
Five Key Pieces:
1. The Framework
2. The Way of Inquiry
3. The Tools
4. Adult Learning Design
5. Measurement
1. The Framework
Holistic Approach to Transformational Change
HATCh
Government & Regulations
Family
Leadership
Community
2. The Way Of Inquiry
Person Directed Care
Way of Inquiry
Phase 1
Phase 2
Phase 3
Irritant
Catalyst
Awakening
-Live with it
-Can’t quite put my finger on it
-outside influence
-internal influence
-tipping point
-become aware that there is the
necessity or possibility of something
different (dawn of hope)
Prompts us to begin to ask questions
Can’t any longer ignore it
Internalize the “no” (rationalize the
reasons it can’t change)
Accept the “no”
Impose the “no”
Hope
Choosing hope:
-Gives rise to growth
and our greatest
humanity
vs.
Despair
Choosing despair:
-Produces resignation
and surrender
Phase 4
Immobilization
Action Step
Absence of Growth or action
-now ready to ask the questions that
have been suppressed
-continue the current process
3. The Tools: Domain of Workplace
Practice
• Susan Eaton’s: What A Difference
Management Makes
– 5 key practices between high & low turnover
homes
– The Grid
• Jim Collins -Good to Great
– Small steady changes no fanfare or
pronouncements
Exercises
• The “Drill down”
3. The Tools: Domain of Workplace
Practice (cont’d)
Homework Assignments-Explored the Common
Irritants
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Homework 1. What is your cycle of turnover?
Homework 2. What is your cycle of understaffing?
Homework 3. Where is your money going?
Homework 4. What are your financial incentives?
Homework 5. High-Turnover/Low-Turnover -Looking At Your Facility’s Landscape
3. The Tools: Domain of Workplace
Practice (cont’d)
Homework Assignments-Explored the Common
Irritants
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Homework 6.What Do Employees Want in Their Job?
Homework 7.Management Practices That Support Retention
Homework 8.Building on Intrinsic Motivation
Homework: Mystery Shopper
Homework: Exploring Our Worlds
Cost of Turnover Nationwide
• $2,500 per employee
• $2.5 billion nationwide
• Direct costs
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Advertisement costs
Staff time to interview, check references, etc.
Drug screen, pre-employment physical
Classroom orientation
Unit orientation
Cost of coverage of the vacant position
• Indirect costs
– Vacant shifts, lower quality, slower service, lost new
admissions, workers compensation, lost revenue,
stress leading to errors
Seavey, D., “The Cost of Frontline Turnover in LTC.” 2004
Turnover Rates
• Drill Down
• In one Corporation:
• 37% of their turnover occurred in the first 90
days
• 53% in the first 6 months
• In another:
• 200% turnover rate of CNA class participants
• In one individual facility:
• 50% of new hires left within the first 7 days
Cycle of Understaffing
• What they found when they asked how it felt
to work short:
– “Unsafe.”
– “Hectic-fingernails don’t get cut, people
don’t get changed.”
– “Stressful.”
– “Can’t give residents emotional support.”
– “Can’t do little things like give a hug.”
Cycle of Understaffing (cont’d)
• What does it feel like when you have enough
staff?
– “Relief – feel you accomplished
something.”
– “Can do little things for the residents like
give them a hug.”
– “Can give them a back rub, talk to them,
you can take the time to be more human.”
Cycle of Understaffing (cont’d)
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What they found:
Avg. call-outs per month was 45
Highest in September, October, November
One unit of one facility was down one CNA
every day for 30 consecutive days
Financial Incentives
• What they did:
• Find out what incentives exist (bonuses,shift
differentials,two 12 hour shifts-paid for 36,
extra per hour pay for working per diem)
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Sign-on bonuses
Recruitment bonuses
Longevity bonuses
Completing a class
• Find out the outcomes of the bonuses
Financial Incentives (cont’d)
• What they found out:
– $3 per hour extra to work an unscheduled shift awarded the bonus 27 times per month
– Offered a $4K sign-on bonus - 3 RN’s were
eligible only one remained after 3 months
• When staff were asked what incentives they
wanted:
– Snow removal from their cars
– Paid CEUs
– Gift cards
Practices that Support Retention
• What they found:
• On-being a new staff member
– “Terrified.”
– “People did not seem happy to see me.”
– “I did not receive instruction on proper transferring
techniques until three weeks after I started.”
• What they observed in the break room:
• Needed paint, gloomy
• Bare windows, dirty refrigerators
Practices that Support Retention
• What they found regarding staff education:
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Offered only those topics required by law
One person teaches all
“Repetitive and boring.”
“Needs a more open forum for dialogue and
questions.”
– “When training is scheduled during work, I get
stressed out and I fall behind in my work.”
Attendance Issues
• What happens that leads your co-workers to
call-off?
– “Just tired mentally. Overwhelmed and can’t overcome
it.”
– “Burn out if you worked 7 - 11 am.”
– “Stress – someone is always asking you to stay late.”
• Top reasons for call-offs:
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Sickness of self
Sick family member
Baby sitter problem
Car problem
Domestic crises
The “Stop Doing” List
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Incentives to waive benefits
Bonuses for working short
Scheduling overtime and double-time
Rotating staff
Sick pay – use it or lose it
No sick pay until second day of absence
No incentives or disincentives
What Employees Want
What they did:
• Asked – “What brought you into care giving?”
• Asked - “What keeps you here?’
• What they found out:
• “I like to care for people.”
• “I enjoy older people.”
• Why they stay:
• “RESIDENTS!”
• “Administration is fair.”
• “It is like family here.”
• “I make a difference in someone’s life.”
Results: Domain of Workplace Practice
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Consistent assignment
Peer mentoring
Self governed work teams
Self scheduling
Cross training
Communities / neighborhoods
Opportunities for leadership development
On-going & Consistent recognition
3. The Tools: Domain of Environment
• Judith Carboni - Homelessness among the
institutionalized elderly. J Gerontol Nurs 1990
Jul; 16 (7): 32-7.
– Home vs. Homelessness
• Exercise: What is home? INHC teams were
asked-”How close is this facility to home”
Results: Domain of Environment
• De-institutionalize the common rooms
(bathrooms, living areas)
• Design for accessibility
• Diminish barriers
• The creation of sanctuary, shelter and peace
that provides a sense of community, safety
and free of unwanted intrusions
• The creation of beauty and comfort
3. The Tools: Domain of Care Practices
• “Bathing Without A Battle” - Joanne
Rader
• “Look at Me” - Veterans Administration
• Exercises
– McNally Exercise
– Change Ideas Sheet
Results: Domain of Care Practices
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Waking and Sleeping
Meals-Service, Delivery, variety
Food Preferences
Daily routine
Bathing-frequency, time, method
ADL’s
Activities
Innovative, creative care solutions
“I” format care plans
Community mourning
3. The Tools: Domain of Leadership
• Kouzes and Posner -The Leadership
Challenge
– 5 principles
• Connie McDonald, Administrator,Maine
General Rehabilitation and Nursing
Care at Glenridge
• Exercises
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Stand Up and Tell Them (BJBC)
Power Island
Privilege Walk
People of Color/What hue are you?
Results: Domain of Leadership
• Support the full empowerment of workers
allowing them to grow, direct, and affect the
care of elders
• Create a climate in which compassion and
common sense can flourish
• Became visible leaders-managing by walking
around
• Recognize the value of all staff
3. The Tools: Domain of Family and
Community
• Lori Todd and her staff from Loomis
House
• Carolyn Blanks from the Mass
Extended Care Federation provided
powerful examples to support efforts
in this domain
3. The Tools: Domain of Regulatory/
Government
• Karen Schoeneman, Senior
Policy Analyst, Centers for
Medicare & Medicaid Services
• Creating inclusion with surveyorsprocess for getting answers when
attempting change
Exercise:
• “Think like a surveyor”
Results: Regulatory & Government
• Opportunities to direct questions about
changes to CMS
• Created a relationship with surveyors
4. Educational Design
• Experiential Learning Design
• Susan Aylward, PhD-Effectiveness of
Continuing Education in Long Term Care.
The Gerontologist 2003; Vol. 43, No 2, 2003
Measurement is Key
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Collecting data
Baseline
Evaluate impact of changes
Balancing measures
Correlation to other measures
Creating new measures
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What changes can we make that
will result in improvement?
Act
Plan
Study
Do
© 2003 Institute for Healthcare Improvement
Creative Measures – Quality of Life
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Individual facility’s measures and results:
Room tray requests – reduced from 15 per day to 6
Plate waste – reduced by 75%
Resident socialization - increased
Staff stress levels - decreased
Resident behaviors - declined
Focus group responses – from negative to positive
Staff time with residents - increased
Peanut butter sandwiches – declined from 6 to 0
Other Key Measures
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Individual facility’s results:
Falls – dropped 8.9%
Antipsychotic medications – decreased by 50%
Resident satisfaction – 100% said staff listen to me
Staff satisfaction – from 60% to 80%
Worker’s Compensation claims – dropped from 44 to 7
Weight loss – reduced to 0
Survey results – from 13 deficiencies to 3
Pressure ulcers – from 4.9% to .7%
Suppositories – reduced from 9 to 0
INHC - WFR Collaborative
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Results from 95 SNFs
Impact on Quality Measures
Comparing Q1 2004 to Q1 2005:
Pain – chronic care population
– Dropped from 6.32 to 5.44
• Greatest impact – Physical Restraints
– Dropped from 6.51 to 5.94
– 66% of all SNFs had a decline
– 4 dropped to 0%
INHC Special Study Outcomes –
WFR
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Results from 4 MPQ’s representing 55 SNFs
Nursing Department (RN, LPN, CNA):
Relative change = -10%
Annualized = 196 fewer terminations
Annualized direct-cost savings = $490,000
Outcomes – CMS Special Study (cont’d)
• Across all job categories
• Annualized latest re-measurement period in 2005
compared to baseline:
• MPQ #1 Apr/May/Jun = 15.2% turnover decline
• MPQ #2 Apr/May/Jun = .8% turnover decline
• MPQ #3 Apr/May/Jun = 1.2% turnover increase
• MPQ #4 Jun/Jul/Aug = 20.4% turnover decline
• MPQ#5 Jun/Jul/Aug = 6.8% turnover decline
Percentages to People
As a result of the pilot study:
• 245 people were set free from physical
restraints
• 143 people were relieved of moderate to
severe pain
Hot Off The Press: New Results
• But the work really started late in Q3
2004.
• So comparing Q3 2004 to Q3 2005 we
find even better results…
INHC - WFR Collaborative
• Results from 95 SNFs Impact on Quality Measures
• Comparing Q3 2004 to Q3
2005:
• Pain – Chronic care
population
– Dropped from 5.81% to
5.41%
• Pressure ulcers – high risk
population
– Dropped from 12.87% to
11.69%
• ADL decline
– Dropped from 18.53%
to 17.00%
• Locomotion worsening
– Dropped from 14.89%
to 14.09%
• Greatest impact – Physical
Restraints
– Dropped from 6.61% to
5.12%
– 66% of all SNFs had a
decline
– 4 dropped to 0%
Percentages to People
• As a result of the CMS special study:
• 345 people were set free from physical
restraints
• 191 fewer people are depressed
• 128 fewer people experienced an ADL
decline
• 78 fewer people have a pressure ulcer
It Makes Good $ense
Staff Stability
and
Empowerment
Individualized
Care
Increased
Census
Better
Retention
Better
Quality
Better Bottom
Line