Transcript www.ahcancal.org

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
[email protected]
Carol Benner,
National Director,
Advancing
Excellence in
Nursing Homes
Campaign
[email protected]
Tammy Rolfe,
LANEs Field Director,
Advancing Excellence In
Nursing Homes
[email protected]
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.
3
Quality has evolved
7-5-5
7 Principles – no changes
5 – Goals – refined, consensus,
measures sources
5 – Tools -- new
4
Why Update or Even Keep Quality
First?
• Our goals are more refined.
• We have targeted 3rd- party data sources.
• We can adjust our goals as our environment
changes.
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
6
What is quality ?
“Quality is the combination of care and services
that meet or exceed customer needs and
expectations.”
AHCA/NCAL
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.
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.
9
QFKTP –
5 Goals
Improve and Sustain:
1.
2.
3.
4.
5.
Performance in all CMS quality measures
Compliance with the federal survey process
High rates of resident and family satisfaction
High rates staff satisfaction rates
Leadership and staff retention, and reduce
turnover rates
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
CMS Quality Measure Performance
(CMS Nursing Home Compare)
Quality
Measure (QM)
2008
2009
% Difference
Physical
Restraints
3.9%
3.1%
-.8%
High Risk
Pressure Ulcer
11.6%
10.9%
-.7%
Pain
3.9%
3.1%
-.8%
PAC Pain
20.6%
19.5%
-1.1%
PAC Pressure
Ulcer
14.2%
12.7%
-1.5%
Federal Survey Process
(CMS Nursing Facility OSCAR Standard Health Survey Data)
Average Citations
Sub Quality Care
2006
6.4%
2.9%
2007
6.8%
3.1%
2008
7.0%
3.4%
2009
7.0%
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.
14
Retention Rates by Job Category
(AHCA, Vacancy and Turnover Study, 2008)
Category
Retention Rate
Administrative
68%
Nursing
45%
Therapy
63%
Food Services
48%
Housekeeping
61%
Social Activities
66%
15
Shared Goals
Quality First and Advancing Excellence
Quality First, Keeping the
Promise – Goals
Advancing Excellence – Phase II
Goals
Resident and Family Satisfaction
•Resident and Family Satisfaction
•Consistent Assignment
Leadership and Staff Retention and
Turnover
•Staff Retention and Turnover
Staff Satisfaction
•Staff Satisfaction
CMS Quality Measures
•Pain, Pressure Ulcers, Advance Care
Planning, and Restraints
Federal Survey Process
All of the Above
16
Quality First: Keeping the Promise
5 Tools
1.
2.
3.
4.
5.
Advancing Excellence Phase II
AHCA/NCAL National Quality Award
AHCA LTC Trend Tracker®
Resident and Family Satisfaction Assessment
Staff Satisfaction Assessment
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
About the
Advancing Excellence
in
America’s Nursing Homes Campaign
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 4th birthday!
• Incorporated in 2010
• And, the data show that it works!!!!
www.nhqualitycampaign.org
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
www.nhqualitycampaign.org
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
www.nhqualitycampaign.org
About Quality Improvement
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.
www.nhqualitycampaign.org
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
www.nhqualitycampaign.org
QA/PI
• Meaningful problems or issues
• Measureable
• Benchmarks/data-driven
• Evidence-based interventions
• Evidence of improvement
www.nhqualitycampaign.org
Quality Assurance
• Reactive
• Single episode
• Organizational mistake
• Prevents something from
ever happening again
• Sometimes anecdotal
• Retrospective
• Monitoring based on audit
• Sometimes punitive
Quality Improvement
• Proactive
• Aggregate Data
• Organizational process
• Improves overall
performance
• Always measureable
• Concurrent
• Monitoring is continuous
• Positive change
www.nhqualitycampaign.org
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?
www.nhqualitycampaign.org
QI Model for Improvement
• Aims are time-specific and
measureable
• Dependent on change
• Uses P-D-S-A cycle to test small
changes
www.nhqualitycampaign.org
PLAN-DO-STUDY-ACT
PDSA
PDSA
www.nhqualitycampaign.org
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?
www.nhqualitycampaign.org
Example 1
Aim
Plan
Do
Lose 10 pounds in two months using the
bathroom scales to measure
RCA: what has caused weight gain?
Poor eating practices
Change eating behavior and start Weight
Watchers
Study After two weeks, there is a 2-pound weight
loss
Act
Keep doing the same thing and monitor
closely
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?
www.nhqualitycampaign.org
Example 2
Aim
Plan
Increase profits by 10% by December 31,
2011 using monthly profit reports to
measure
RCA: what’s caused the loss of profits?
Bad economy
Do
Distribute coupons in neighborhood
newsletters
Study
After three months, sales are increasing!
Act
Standardize the new marketing procedure
www.nhqualitycampaign.org
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?
www.nhqualitycampaign.org
Example 3
Aim
Plan
Decrease in-house acquired pressure
ulcers from 4% to 2% by December 31,
2011 using AE tool to measure
RCA: what’s caused the pressure ulcers?
Lack of prevention
Do
Set up prevention protocol that includes ID,
hydration, turning and positioning, use of
devices to prevent, etc.
Study No new pressure ulcers for two weeks
Act
Standardize the new marketing procedure
www.nhqualitycampaign.org
Campaign Phase 2 Goals
1.
2.
3.
4.
5.
6.
7.
8.
Staff Turnover
Consistent Assignment
Restraints
Pressure Ulcers
Pain (long and short-stay)
Advance Care Planning
Resident/Family Satisfaction
Staff Satisfaction
www.nhqualitycampaign.org
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.
www.nhqualitycampaign.org
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
www.nhqualitycampaign.org
About the
Advancing Excellence QI Tools
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
www.nhqualityCampaign.org
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
www.nhqualitycampaign.org
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
www.nhqualitycampaign.org
Using the AE Tools
to improve
Staff Turnover, Consistent Assignment
and Pressure Ulcers
A Major Shift In Thinking
It’s ALL about STAFF
• Enough
• Competent
• Caring
• Compassionate
• Consistent
www.nhqualityCampaign.org
Formula for Success
Staff
Stability
+
Consistent
Assignment
=
Happier Staff
Better Care and Clinical Outcomes
Higher Resident and Family Satisfaction
Cost Savings
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 2004-2009 regarding successful or potentially
successful interventions to retain staff
What is Staff Stability?
• Low staff turnover
• High staff retention
• Low use of agency staff
• Rare call-outs, absenteeism
• High staff satisfaction
www.nhqualitycampaign.org
Staff Turnover
Staff turnover is one component
of staff stability
www.nhqualitycampaign.org
National Nursing Home Turnover Data
CNA
65.6%
RN
41.0%
LPN
49.9%
AHCA’s Staff Vacancy and Turnover Report 2007
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
www.nhqualitycampaign.org
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
www.nhqualitycampaign.org
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
www.nhqualitycampaign.org
QI Process for Consistent Assignment
ACT
• Using the measurement from the AE Tool
and the feedback received from the staff,
tweak the hiring practices.
The Staff Turnover Calculator Tool
• Only nationally available standardized
way to collect turnover data
• Developed for QIO’s 8th 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
Staff Turnover Calculator
57
Instructions TAB
58
Common Qs & As TAB
59
CNA Calc TAB
60
CNA Trending TAB
61
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
www.nhqualitycampaign.org
Consistent Assignment
www.nhqualityCampaign.org
What is Consistent Assignment?
The same person takes care of
the same resident every time he
or she is on duty…
www.nhqualitycampaign.org
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!
www.nhqualitycampaign.org
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!!!
www.nhqualitycampaign.org
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)
www.nhqualitycampaign.org
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
www.nhqualitycampaign.org
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.
www.nhqualitycampaign.org
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
www.nhqualitycampaign.org
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
www.nhqualitycampaign.org
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
www.nhqualitycampaign.org
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
www.nhqualitycampaign.org
QI Process for Consistent Assignment
ACT
• Using the measurement from the AE Tool
and the feedback received from the staff,
tweak the scheduling method.
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
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
Consistent Assignment Calculator
77
Instructions TAB
78
Common Qs & As TAB
79
CNA Tab
80
Residents TAB
81
Week 1 TAB
82
Summary TAB
83
Pressure Ulcer Tracking Tool
www.nhqualityCampaign.org
Pressure Ulcers– Goal Definition
Goal 4 Pressure Ulcers:
Nursing home residents receive appropriate
care to prevent and appropriately treat
pressure ulcers when they develop
www.nhqualitycampaign.org
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
www.nhqualitycampaign.org
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
www.nhqualitycampaign.org
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 %
www.nhqualitycampaign.org
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 Q3 2010
www.nhqualitycampaign.org
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
www.nhqualitycampaign.org
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
www.nhqualitycampaign.org
Pressure Ulcer Tool
- Data Entry Section
Pressure Ulcer Tool Graphs and Trends
Monthly Notes
Thank You!
Questions?
[email protected]
[email protected]
[email protected]
www.nhqualityCampaign.org