Transcript Individualized Care: The Key to Quality and Retention

Individualized Care:
The Key to Quality and Retention
Improving the Nursing Home Culture:
A 2004-2005 pilot of QIO work in nursing homes
Funded by CMS
Coordinated by Quality Partners of Rhode Island
OBRA requires that
each facility:
“provide care and services
to attain or maintain
the highest practicable
physical, mental, and
psychosocial well-being
of each resident.”
The Culture Change Journey
Institutionalized Care
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Task oriented
Depersonalized
Fragmented
Schedule driven
One size fits all!
Individualized Care
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Care, delivery systems, daily
routine are focused need, interest, lifestyle, preferences
and choice of the resident
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Focuses on abilities and
strengths
Culture Change Journey
Person-Directed Care
Model
Family
Regulations
Financial Resources
Leadership
Community
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
&
&
co ns uIti ng
Science of Change:
Psychology of Change:
Quality Improvement
Practices
Relationship-Based
Practices
Root-cause analysis
Build on Intrinsic Motivation
Small pilot-tests
Holistic Approach - Personalize
Evaluation and Re-evaluation
Start where people are
Mid-course adjustments
Build capacity for change
Evidence-based solutions
Experiential learning
Collaborative Learning, Spread
Climate Where Truth is Heard
Improving Nursing Home Culture (INHC)
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
What a difference management makes!
Five Management Practices Associated with
Low-Turnover, High Attendance
and High Performance:
High quality
leadership at
all levels of
the
organization
Valuing staff
day-to-day in
policy and
practice, word
and deed
High
performance,
high
commitment
HR policies
Work systems
aligned with
and serving
organizational
goals
Sufficiency
of staff and
resources
to care
humanely
Eaton, 2002
Pilot Testing
Benefits:
• Decrease cynicism
• Predict how much improvement
can be expected
• Learn how to adapt the change
• Evaluate costs and side-effects
• Learn and gain confidence
PDSA
Model for Improvement
What are we trying to
accomplish?
Keys to Success
of the Pilot:
• Collaboration
How will we know that a
change is an improvement?
What changes can we make that
will result in improvement?
• Pilot-testing
• Measurement
Act
Plan
Study
Do
© 2003 Institute for Healthcare Improvement
Measurement Was Key
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Collecting data
Baseline
Evaluate impact of changes
Balancing measures
Correlation to other measures
Creating new measures
Outcomes – WFR Special Study
Results in 9 months from 4 MPQ’s with
a total of 55 SNFs
Nursing Department (RN, LPN, CNA)
turnover rates:
• Relative change = -10%
• Annualized = 196 fewer terminations
• Annualized direct-cost savings =
$490,000
INHC - WFR Collaborative
Results from 95 SNFs
Impact on Quality Measures
Comparing Quarter 1 2004 to Quarter 1 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%
Creative Measures
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
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
Hot off the press – new results
But the work really started
late in Q3 04.
So comparing Q3 04 to Q3 05
we find even better results…
INHC - WFR Collaborative
Results from 95 SNFs - Impact on Quality Measures
Comparing Quarter 3 2004 to Quarter 3 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%
INHC – Person Directed Care
Results from 166 SNFs - Impact on Quality
Measures
Comparing Quarter 3 2004 to Quarter 3 2005:
• Pressure ulcers – high risk population
– Dropped from 11.37% to 11.14%
• Pressure ulcers – low risk population
– Dropped from 2.94% to 2.65%
• Depression
– Dropped from 16.51% to 15.69%
• Greatest impact - Physical Restraints
– Dropped from 6.26% to 4.88%
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