3/24/2016. Value of Quality Management. Quality Management in Senior Housing: Back to the Basics. Objectives. Defining Quality

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1 Quality Management in Senior Housing: Back to the Basics Lisa Abicht-Swensen, M.H.A. Director of Home Health, Hospice and Assisted Living Services Objectives Understand the value of Quality Management in Senior Housing Settings Strengthen your ability to use simple data tracking and trending to identify and prioritize problems affecting quality of care and service delivery Identify tools that support quality improvement activities Gain perspectives into the art of intellectual curiosity in identifying and curing causative factors. Develop strategies for integrating Quality Management Activities into day-to-day operations 2 Defining Quality Value of Quality Management 3 Institute of Medicine (IOM) defines quality as degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. US Agency for Healthcare Research and Quality defines quality as doing the right thing, at the right time, in the right way, for the right person and having the best possible results. 4 1

2 Collecting Data Why Measure Data? Data Collection Complaints Incidents Medication Errors Intake/Admissions Discharges Length of Stay Satisfaction Patient (Annual) Employee Measures Drive Improvement Measures Inform Consumers Measures Influence Payment 7 8 Performance Data Your organization s performance is being compared, right now, to other senior housing settings across town and across the country. Performance data is becoming readily available Gathering meaningful data is vital in the era of pay for performance, and payers and agencies are calling for more transparency in quality improvement data. Need for benchmarking is growing 9 Making Data Meaningful Without a baseline or point of comparison, it is hard to judge your own performance. Quality Initiatives use performance indicators to monitor care processes and outcomes. Objective data (Numbers) will give you concrete information on improvement, decline or maintenance of goals! It is imperative that we know our data so that we can speak to our positive outcomes as Value Based Purchasing becomes a reality for postacute care providers. 10 Data is Key to Positive Outcomes Future of Assisted Living Prepare providers for possible reimbursement changes based on quality outcomes; Focusing on current national priorities and key indicators of quality care Encouraging efficiency with health care dollars Promoting consistent data measurement with continuing tracking Highlighting the importance of goal setting with sustainable improvement and fostering person-centered care State-of-the-Art, Person-Centered Care Recruitment, development and retention of quality personnel Best practice data collection and sharing Public policy and regulations Affordability

3 Best Practice Data Collection Best Practices Data Collection The Challenge Limited availability of data on care outcomes in assisted living Assisted Living consumers (residents and their children) are demanding quality measures Acute care systems are seeking strong outcomes as they evaluate potential partners The opportunity Identify valid quality measures Create and validate important measures where none exist Developing best practices in data collection, including risks and rewards, mentoring, and evidence-based studies Developing specifications for data collection systems Developing collaborations with data collection sources INTERACT Training The Future of Assisted Living in the Era of Healthcare Reform, October 2014 (Center for Excellence in Assisted Living (CEAL)) NCAL Quality Initiative Goals NCAL Quality Initiative Goals Staff Stability Keep nursing and direct care staff turnover below 40% through March 2018 NCAL Fast Facts 19.2% of the 1.5 million nursing in the long-term care sector work in residential care communities 82.1% of the nursing staff in residential care are CNAs 95% of AL communities have a licensed nurse available on-site or on-call 24 hours a day 15 Customer Satisfaction At least 90% of customers (residents and/or family members) are satisfied with their experience by March NCAL Fast Facts Almost 90% of communities measure resident and family satisfaction 88.7% have a resident council Of the communities that have a resident council 82.7% have leadership that meet with the council 16 NCAL Quality Initiative Goals NCAL Quality Initiative Goals Hospital Readmissions Safely reduce hospital readmissions within 30 days of hospital discharges by 15%, or achieve (and maintain) a low readmission rate of 5% or less by March 2018 NCAL Fast Facts 12% of residents in residential care visited the ER in the last 90 days 10% of residents were discharged from an overnight hospital stay 18% of residents were readmitted to the hospital within 30 days of discharge Antipsychotics Safely reduce the off-label use of antipsychotic medications by 15%, or achieve (and maintain) a low offlabel usage rate of 5% or less by March 2018 NCAL Fast Facts Almost 40% of assisted living residents have some type of dementia Antipsychotic drugs prescribed to persons with dementia cost Medicare $363 million in

4 Quality Management Features Quality Improvement Data Gathering, Tracking, Trending 19 Using data to identify your quality problems identify other opportunities for improvement, and set priorities for action Building on clients own goals for health, quality of life, and daily activities Bringing meaningful client and family voices into setting goals and evaluating progress Incorporating caregivers broadly in a shared quality mission 20 Quality Management Features Developing Performance Improvement teams Performing a Root Cause Analysis to get to the heart of the reason for a problem Undertaking systemic change to eliminate problems at the source Developing a feedback and monitoring system to sustain continuous improvement Opportunities to Improve Meaningful Data -- Keep it Simple What data is currently being collected that you could use? Audits Surveys (Tenant/Family/Staff Satisfaction, Department of Health) Other measures Identify Improvement Opportunities Consistent issues are present High volume, high risk Prioritize Examples of Meaningful Data Develop QI Team(s) Planning project Client Care Measures Client Falls Client hospitalization or nursing home stay 911 calls Medication errors Client/family complaints VAA reports Employee Measures Staff Turnover Staff satisfaction Staff injuries Business Measures Payer distribution of clients in residence Accounts receivable Overtime costs Team Members Team Leader PI Project Responsibilities aim statement outcome measures changes to be tested based on best practices Researching best practices process measures Planning PDSA cycles gathering data analyzing data graphing results testing change(s)

5 Plan-Do-Study-Act Cycle PDSA Model for Improvement Plan Learn Measure Change Do Carry out plan Study What did we learn? Act What should we do next? 25 Encourages learning by testing change on a small scale Pilot the change for a period of 90 days Eliminates studying the problem to death Moves the team from contemplation and analysis paralysis to action Minimizes data collection/data overload 26 Root Cause Analysis Identify the Tools Satisfy the Curiosity Getting to the Root of Problem Philosophy of Root Cause! There is danger in starting with a solution without thoroughly exploring the problem. Multiple factors may have contributed, and/or the problem may be a symptom of a larger issue Root Cause Analysis Focus on systems and processes, not individual performance Simply stated, Root Cause Analysis is asking why the problem occurred, and then continuing to ask why that happened until we reach the fundamental process element that failed 29 Each problem is an opportunity for improvement and program strengthening It is critical that everyone take a personal and active role in improving quality The true problem must be understood before action is taken Problems are often masked for a variety of reasons To do this well, we must be Both focused and open-minded Both patient and quick Above all, we must be relentless 30 5

6 Symptom Approach vs. Root Cause Tools Used in Root Cause Analysis If we do a poor job of identifying the root causes of our problems, we will waste time and resources putting band aids on the symptoms of the problem. Brainstorming Charts Symptom Approach Root Cause Flowcharts Errors are often a result of worker carelessness. We need to train and motivate workers to be more careful. We don t have the time or resources to really get to the bottom of this problem. Errors are the result of defects in the system. People are only part of the process. We need to find out why this is happening, and implement mistake-proofs so it won t happen again. This is critical. We need to fix it for good, or it will come back and burn us. Control Charts Diagrams Fishbone Scatter Tree Fishbone Diagram (regular) Fishbone Cause and Effect Category 1 Category 2 Brainstorm all the possible causes of the problem Ask: Why does this happen? Topic/ Problem Again ask Why does this happen? about each cause Category 3 Category 4 s and/or categories of factors Continue to ask Why? Generate deeper levels of causes. 34 Performance Improvement Illustrating Quality in Action Proactive approach Efforts are on-going Focus on system changes Plan involves input from staff representing all roles and disciplines within the organization Meet at regular intervals 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% More info on Help dealing Response to Tx for with breathing eve/we needs breathing Problem 12.5% 12.5% 35.3% QIS 12.0% 12.3% 19.0% The graph represents 3 quality indicator questions for which Hospice scores are the farthest from the Benchmark Scores. This score is the percentage of responses other than the most desirable response to the question. 36 6

7 Call Volume Wait TIme in Minutes Wait time in Minutes # of Calls by Reason 3/24/2016 Hospice Responsiveness to Needs Hospice Responsiveness to Needs After Hour Calls Average Wait Times Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec # of After Hour Calls Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Average Wait Time Wait Time Goal Hospice Responsiveness to Needs Hospice Responsiveness to Needs Wait times > 15 Minutes Reasons for After Hour Calls Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Wait times > Pain Care Code Died Med F/U O2 OrdC Fall RFI Adm Wr# 1st Qtr nd Qtr rd Qtr th Qtr Hospice Case Study Case Study Outcome Root Cause Analysis Analysis of hospice data and the answering service data Data review identified consistent lags between the time the call was received by the answering service to the time it was paged out to the on-call nurse Data review identified occasional lags when the on-call nurse was engaged in assisting other clients Plan, Do, Study Act Multiple meetings with on-call team and answering service Identification of other options for after hour responsiveness Implementation of 90-day trial of new option 41 Average Wait Times Jan Feb Mar Apr May June Avg Wait Time Wait Time Goal

8 Quality in Action Integrating Quality Strategies 43 Review and revise or develop and implement a quality management policy and procedure Include Quality roles and responsibilities in job descriptions Conduct selfassessment to identify areas for improvement 44 Quality in Action Quality in Action Ensure all staff are engaged in Quality Improvement activities Identify a natural Quality leader (Champion) Involve all disciplines in Quality Improvement Present Quality Improvement Updates at staff meetings Involve staff in self-assessments and satisfaction survey review and analysis Display Quality improvement progress in office Quality in Action Integrate Quality Agenda Develop a reward program for staff participation in identifying Quality Improvement opportunities Incorporate the Quality Agenda into existing meetings Make sure the Meeting Minutes reflect the Quality focus including: Quality Project(s) Data being evaluated and source of the data Process used for the performance improvement (e.g., Root Cause, PDSA) The timeline for the quality project Team members participating in the performance improvement process The resolution or changes made An evaluation of the project

9 Day-to-Day Quality Leadership Day-to-Day Quality Leadership Reflect a Quality Focus in everything you do and say Relay clear expectations Be visible conduct rounds when you arrive, at shift change, and before leaving for the day Know your team Strengths Weaknesses Opportunities Set realistic goals and objectives Take time to note and publicly praise accomplishments Maintain focus on following policies and procedures Encourage a do the right thing attitude Maintain survey readiness at all times to alleviate fear of the unexpected visit. Day-to-Day Quality Leadership Day-to-Day Quality Leadership Develop effective quality-focused teams Create a Supportive Environment Appoint Team Leads who encourage and engage all team members Educate your team Assure Care Competence Provide consistent onboarding process Peer mentoring 37 Assure team members understand what is expected of them and hold them accountable Lead by example Cheerlead! Be patient and consistent Provide excellent customer service to clients, families, vendors, partners 52 Take the Time to Celebrate!! Quality Celebrate all of your successes Offer thanks often Thank you cards E-cards Write personal notes of recognition and praise Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives. William A Foster 54 9

10 Questions Resources Lisa Abicht-Swensen, MHA Director of Home Health, Hospice and Assisted Living Services Agency for healthcare research and quality: Institute for Clinical System Improvement: An Introduction to Root Cause Analysis in Healthcarehttp:// ent_analysis.pdf United States Department of Veterans Affairs: Joint Commission Framework for conducting a RCA: Comparison of Common Root Cause Analysis Tools and Methods. Apollo Root Cause Analysis-A New Way of Thinking. Dean L. Gano 2007 Techniques for root cause analysis PATRICIA M. WILLIAMS, BS, MT(ASCP)SBB Health Care Benchmarking Dr Jan FL Kay The Hong Kong Medical Diary Vol 12 No 2 Feb, 2007 pg Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; The Plan-Do-Study-Act (PDSA) cycle was originally developed by Walter A. Shewhart as the Plan-Do-Check-Act (PDCA) cycle. W. Edwards Deming modified Shewhart's cycle to PDSA, replacing "Check" with "Study." [See Deming WE. The New Economics for Industry, Government, and Education. Cambridge, MA: The MIT Press; 2000.] Stratis Health Oklahoma Foundation for Medical Quality Quality Improvement Organizations (QIOs) Advancing Excellence in America s Nursing Homes My InnerView NCAL s data partner Center for Excellence in Assisted Living: Agency for Healthcare Research and Quality National Association of Health Care Assistants American Assisted Living Nurses Association 57 This presentation is copyrighted information of Pathway Health. This presentation is not to be sold or reused without written authorization of Pathway Health

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