Transcript Making Sense of the Data (Slides)

Making Sense of the Data
Centers for Medicare & Medicaid
Services
March 2005
Critical Thinking
• Consider a mountain from a distance
• What words come to mind?
Critical Thinking
• Consider that mountain when you’re
climbing it
• What are your thoughts?
Which is the Correct View?
• Both
The purpose of this presentation
• To make sense of the data,
– Know what you are looking at
– Determine the kind of thinking that the object
requires “Differential thinking” More to come
– Examples
• The temperature of hot water requires one mode of
thinking
• Determining if deterioration in health status is
preventable or not requires another
Data: all the objects you see in
the nursing home measured
against the requirements
How You See What You See:
Does what you see meet the
requirements or not?
• Differential Thinking – more on that later
Differential Thinking
• Based on the work of Benjamin Bloom and
his colleagues: Bloom’s Taxonomy
• CMS has adapted Bloom to the special
circumstances presented by surveyors
• Five modes
1. Fact Gathering and Reporting
• “Recall”
– Key words: defines, describes, identifies,
knows, labels, lists.
– Answers “who,” “what,” “where,” and “when”
2. Decisions Based on Rules
– “Comprehension”: Understand the meaning,
consistent interpretation of requirements
– Key words: explains, gives examples
3. Analytical Observation
- “Application”: Use a concept in a new situation
- Key Words: applies, demonstrates, discovers,
modifies, predicts, solves, uses
4. Synthesis
- “Integrate”: Take different pieces of
information and combine them into a whole,
complete picture
- Key Words: combines, explains, organizes,
plans, rearranges, reconstructs, relates
revises, summarizes
5. Making a Judgment
- Evaluate
- (Do the data meet the threshold necessary for
compliance decision)
- Within a specific framework:
- Requirements, interpretive guidelines, survey
procedures
Summary
- Discussion today:
- Perception – The mountain you see at a
distance and the one you climb are the same –
We will say more about that for the next
section: Observation
- How you think depends what requirements
you’re surveying
- Refer you to the self-instructional manual
Closing Credits
Observation
• Two umpires were arguing. One said to the
other, “I calls ‘em as I sees ‘em.” The other
said, “I sees ‘em as I calls ‘em.” Who is
right?
• Both are. Like the mountain.
• Perception–What I see
What goes into Perception
• Values
• Predispositions
• Knowledge, Skills, and Abilities
Values
• What I hold as important
• Influence of my
– Family history
– Culture
– Personal Belief System: e.g., surveyor:
“service”, more than money orientation
Predispositions
• Tendency to emphasize, discount, or ignore
what I see
• Example
– If I come from a bilingual household/ethnic
background, I may be more sensitive to seeing
the discomfort of a non-English speaking
resident, who must try to be understood using a
foreign language, and must adapt to eating food
that he or she may never have had before
Knowledge, Skills, Abilities
• Your work as a surveyor
• Know the requirements with all the modes
of thinking we discussed in the first module
• Skill in identifying the details in front of
you
• Ability to have “accurate empathy” (Burns)
• Ability to see what the resident sees from
the resident’s viewpoint
How Perception Works
Interplay of outer and inner world
What I see
What I think
What others do
Thoughts
Me
Emotions
Behaviors
Positive/Negative
You are the Instrument
• As a surveyor
• What you see or don’t see depends on your
– Knowing the requirements, interpretive guidelines, and
procedures and
– Focus on the resident through the prism of the
requirements, interpretive guidelines, procedures
• Rule: No matter what else is going on, if you’re
on the job, you’re on the job -- Examples
Potential Distractions and
Minimizing Them
• Personal, family, work-related stressors
• What are the thinking patterns that get in
the way of making consistent observations
on a survey?
Thinking Patterns that Get You
into Trouble (David Burns)
• Perfectionism: “I should/You should/They
should”
• Mental Filter: “Art is on the team. He
insulted me last year. I can’t stand that I’ll
have to listen to his voice”
• All or nothing: “Anyone who disagrees with
my opinion as TEAM LEADER, is one of
them”
Thinking Patterns . . .
• Magnification or minimization (“I’m the only
social worker/sanitarian/dietician on the team. All
these other people know much more than I do.
How can I do this?”)
• Emotional Reasoning. If I feel it, it’s true.
Intuition is not infallible
• Jumping to Conclusions (“This place was a mess
last year; they probably haven’t changed one bit”)
• Overgeneralization: “I’ll never make it as an abuse
investigator. I missed that detail about Mrs. C... ”
Typical Thoughts that Lead to
Problems
• Making mistakes is terrible
• If someone criticizes me, I must have done
something wrong
• I can’t change what I think/ who I am
• I must never show any weakness
• It’s us (the forces of goodness and justice)
versus them (the forces of greed and
selfishness)
How to Combat Distorted
Thinking
• EVIDENCE
• If no evidence, then remove the distortion
• How difficult? The woman in the elevator
story
• Know and Live the difference between
RESPONSIBILITY (for yourself) and
INFLUENCE (over others)
How does this play on a survey?
• A team leader with lots of “shoulds” in her
thinking who believes she’s carrying the
brunt of the work
– Is that true?
– If yes, then what to do to influence others on
the team – what do they value? Reward the
positive > criticize the negative
On a survey . . .
• A team member who “feels left out”
– What do you have control over?
– Do the best job you can and use that to influence the
other team members
• A team that argues over findings
– Identify positive aspects
– “Accurate empathy”
– Use the requirements and interpretive guidelines as
your anchor
Identify what you have influence
over and what you have to cope
with
• What you have influence over: behavior of others
• What you have to cope with: Requirements
– ECLECTIC is a four-letter word
• Stay focused on your responsibility
• Relax/Work out/ Meditate/Yoga – natural internal
medicines (Endorphins) to improve coping ability
Methods
• Triple column technique
Trigger
Automatic
Thought
Fight Back
“Evidence”
Methods
• Two Column Technique
– Anger
Advantages
I’ll tell her off
Disadvantages
Damages
the relationship -Next survey?
Reference
• Burns, D.(2000) Feeling Good (NY:
HarperCollins)
Summary
• Observation is dependent on you being the
instrument
• If you’re tired, distracted, depressed, angry, etc.,
you take away from your effectiveness
• Ability to observe consistently is dependent on
the extent to which you actively remove distorted
thoughts from your vision
• Provided two suggestions for doing that: based on
evidence
Closing Credits
Interviewing
– So far we’ve focused on you internally
• The differential thinking that you use to collect
information from the survey environment
• You as the survey instrument and the way how you
you think helps or gets in the way of what you see
– The next two modules focus on you interacting
with the outside world
• Interviewing
• Documentation
Interviewing is Primarily Internal
• Attitude > Techniques
• You are the instrument
• Before you leave home/the office is when
you start getting ready
– Remove distractions
Onsite
• Overall: establish and nurture a relationship
with the interviewee
• Explain why you’re there
• Purpose of the survey: to get a picture of
facility
• Establish a respectful stance
– I’ll ask you questions
– You ask me too
Be real
• Demonstrate genuineness, courtesy, respect,
empathy
• Encourage the interviewee to tell his/her
story
• Balance story listening with focusing on
your goal
• Use the interview protocol to keep you
focused
Rapport
• Accurate Empathy
– Not sympathy; not support – walk in my shoes
• Avoid “role playing”
• Make sure you speak the same language
• Keep in mind age, education, values,
vocabulary
• Both parties carry personal values, attitudes,
needs, culture, and experience.
Adapt to the Interviewee
•
•
•
•
Let the interviewee dictate the environment
Ask permission to enter the interviewee’s space
Keep societal/cultural differences in mind
Engage the person from the face on out – eye
contact
• Eye contact seen as a threat for some native
Americans
• Know when to hold ‘em and when to fold ‘em
Individuals with Language
Difficulties
• YOUR ISSUE
– Individuals who use communications devices
– Individuals with dementia
– Individuals who have English as a second
language
Delivery
• Speak clearly
• Ask one question at a time
• Know the interview protocol well enough to
refer to it without reading it verbatim
• Control your volume and pace
• As much as possible, interview in a quiet
place
Note Taking
• Tell interviewee if you’re going to take
notes and why
• Encourage interviewee to read your notes
Clarity
• Use language that the interviewee understands
• Clarify as you go, make sure the interviewee is
with you
• Be honest about any difficulties you have
understanding
• Make sure you understand an interviewee’s
question before giving an answer
• If you don’t know an answer, get back to
interviewee ASAP with appropriate information
Body Language
• Make sure there’s consistency between
verbal and nonverbal elements of your
conversation
• If there’s a distraction (e.g., a noise),
probably comment on that, rather making
believe it’s not there
Confidentiality
• Cannot promise and do not
• If there’s something against the law, abuse
and neglect, inform the interviewee that it
will be reported – “we’re here for your
safety”
• Focus on the interviewee’s benefit – make it
concrete
Techniques (1)
• Make sure you and your interviewee are on the
same page. How?
• Check facts.
– “This is what I’m getting from our conversation. How
does that compare with what you understand?”
• Paraphrase implications (Don’t put words in the
resident’s mouth).
– “Sounds like you might be worried that the same thing
might happen to you. Is that right?”
Techniques (2)
• Focus.
– Bring the subject back to the matter at hand.
– Useful when an interviewee would like to monopolize
the conversation.
– Use checking to get back to the point.
• Genuineness.
– Acknowledge if there’s a real difficulty in relating to an
embarrassing area (e.g., abuse)
– “It looks like you might be having difficulty getting
around, but you’re still working at it. That’s great. Now
what was your question about insurance?”
Techniques (3)
• Mix closed and open questions.
– Closed, yes or no and facts
• “Are you currently receiving social security?”
• “What is your address?”
– Open – room for a complex answer. Useful if an
interviewee is reluctant to talk, or to get information
about a complex matter.
• “What do you think about your care? How is it for you?”
• Comment on what you observe (the knock on the door story)
Techniques (4)
• Be ready to hear what you never wanted to
know
• Be a slow reactor. If necessary, work at it
Closing
•
•
•
•
•
Summarize the interview
Don’t promise what you can’t deliver
Paraphrase what you’ve learned
Ask if what you’ve said is an accurate picture
Give the interviewee the opportunity to ask
questions as well
• Tell the interviewee the next steps
• Thank the interviewee for his/her time
Documentation
• Principles of Documentation
• Reference:
http://www.cms.hhs.gov/manuals/107_som/so
m107_exhibit_007a.pd
Eight
Principles of Documentation
1. Entity compliance or non
compliance?
Record both
2. Write clearly, objectively, and
in a manner easily understood
3. Components of a Deficiency
Statement
A. Regulatory reference
B. Statement of Deficient Practice
C. Relevant Findings
3.A. Regulatory Reference
a. Survey data tag number
b. The regulatory reference
c. Language from the reference that specifies the
aspects of the requirement with which the
practice was non-compliant
d. State “NOT MET”
3.B. Deficient Practice
Statement
a. Draw the picture of the deficient practice or
lack of action
b. Where possible, the outcome
c. Picture of the extent of the practice (“5/7
residents . . .”)
d. Identifier of individual/s or units referenced
in c.
e. Source of information
3.C. Relevant Facts/Findings
a.
b.
c.
d.
e.
Who
What
When
Where
How
4. Relevance of Onsite
Correction of Findings
If during your survey, the facility corrects the
deficiency, still document NOT MET on the
2567.
The facility may indicate its correction in the
right hand column.
Follow guidance in Appendix Q.
5. Document how the facility
fails to comply
with REQUIREMENTS,
NOT INTERPRETIVE GUIDELINES
6. Citation of Local/State Law
Don’t on the 2567 unless the Fed requirement
refers to compliance with local/State law
7. Cross-Referencing
Requirements
Permissible on the 2567 only when it provides
additional strength to the linked
requirements
Most effective: Linked cites have a causeeffect relationship with the deficient
practice mentioned in both citations.
8. COP Deficiencies
Makes the case through documentation of the
COP level deficiency
Incorporate findings either through crossreferencing, or
Narrative description of individual findings
In a nutshell
Paint a picture such that a reasonable person
would come to the same conclusion that you
did.
Summary
Differential Thinking –
Think according to the aspects of the requirements you
are surveying
Observation –
You are the instrument; observe “without discrimination”
Interviewing –
Resident: mutuality, genuineness, respect
Documentation –
Follow POD
Draw a verbal picture – Reqts
Closing credits