LSSCC Action Period 1: Composite Score Reports June 25, 2015

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1 LSSCC Action Period 1: Composite Score Reports June 25, 2015

2 The National Nursing Home Quality Care Collaborative (NNHQCC) Composite Measure! Composite Measure tool used to help monitor NNHQCC progress not intended to replace or supersede existing local or federal initiatives, including the 5-star rating system another way to look at quality from a systems perspective! NNHQCC nursing homes focus on processes that improve their systems measure individual tests of change! Processes and tools include Performing RCA with PIPs

3 Composite Score Calculation! Based on the opportunity model concept numerators and denominators are summed across all 13 quality measures to determine the composite numerator and denominator! Composite numerator divided by the composite denominator and multiplied by 100 results in the composite score

4 13 Long-Stay Quality Measures Percent of 1. Residents with one or more falls with major injury 2. Residents with a urinary tract infection (UTI) 3. Residents who self-report moderate to severe pain 4. High-risk residents with pressure ulcers 5. Low-risk residents with loss of bowel or bladder control 6. Residents with catheter inserted or left in bladder 7. Residents physically restrained

5 13 Long-Stay Quality Measures (cont.) Percent of 8. Residents whose need for help with Activities of Daily Living (ADL) has increased 9. Residents who lose too much weight 10. Residents who have depressive symptoms 11. Residents who received antipsychotic medications 12. Residents assessed and appropriately given the seasonal influenza vaccine 13. Residents assessed and appropriately given the pneumococcal vaccine

6 Vaccine Measures! Since the two vaccination measures are directionally opposite (i.e., higher rate represents better performance), the composite numerator for these two measures is denominator minus numerator.! Interpreted as lower missed opportunities = better

7 Polling Question: What would this facility s composite score be with the following composite numerator and composite denominator? N: 60 D:

8 Composite Score Goal! The fewer missed opportunities in providing exceptional care, the lower the composite score.! Focusing quality improvement (QI) initiatives on areas with higher number of missed opportunities reduces the overall composite score. GOAL

9 An Example: Loving Our Residents Health and Rehab (LORHR)! Overall composite of 12.22! Missed opportunities, ranked from highest to lowest:! Composite Numerator: 158! Composite Denominator: 1293! Composite Score = 158/1293 = 12.22

10 Composite Score: Before Vaccination Improvement Number of Missed Opportuni:es 29 Composite Score Composite Score

11 Improving the Composite Score Focus on low hanging fruit! If LORHR would address giving immunizations in a timely manner, they could easily reduce their composite to 10.90! For example, if they reduced the missed opportunities Flu vaccination from 28 to 14 Pneu vaccination from 9 to 6 Composite Numerator will decrease by 17 (from 158 to 141)! Composite Score = 141/1293 = 10.90

12 Composite Score: After Vaccination Improvement Number of Missed Opportuni:es 29 Composite Score Composite Score

13 Quality Assurance and Performance Improvement (QAPI)! Next focus area at LORHR use of off-labeled antipsychotic medications! Missed opportunity score = 32! First step to improvement Perform a Root Cause Analysis (RCA) with Performance Improvement Projects (PIPs)

14 QAPI RCA Guidance Available online at: atomalliance.org/download/guidance-for-rca/

15 Performing an RCA with PIPs 1. Identify the event/issue to be investigated and gather preliminary information 2. Charter and select team facilitator and team members 3. Describe what happened or the issue 4. Identify the contributing factors 5. Identify root causes 6. Design and implement changes to eliminate root causes 7. Celebrate successes

16 Composite Score: Before Drug Reduction Number of Missed Opportuni:es 29 Composite Score Composite Score

17 RCA Findings LORHR s root causes for the high use of antipsychotic medications: 17 of the 32 residents admitted with medications; several gradual dose reductions were successful and the medications no longer needed but not discontinued Discontinuing the medication will decrease the numerator by 17 7 of the residents received the proper diagnosis of Schizophrenia (excluded from denominator) 5 residents discharged to a more appropriate healthcare facility (excluded from denominator)

18 Results LORHR reduced the missed opportunities as follows: Composite Numerator decrease by 24 (from 32 to 8) Composite Denominator decrease by 12 (from 1293 to 1281) Composite Score = 117/1281 = 9.13

19 Composite Score: After Drug Reduction 35 Number of Missed Opportuni:es Composite Score Composite Score

20 Overall Improvement in Care Addressing one focus area can cause changes in another; i.e., eliminating the use of off-labeled antipsychotic medications can reduce the number of falls improve resident mobility, alertness and appetite reduce the risk of pressure ulcers The composite score is steadily moving toward the goal:

21 Composite Score: After Drug Reduction 35 Number of Missed Opportuni:es Composite Score Composite Score

22 Composite Score: Impact of Drug Reduction 35 Number of Missed Opportuni:es Composite Score Composite Score ADL Pain PrUlcers WtLoss Incont Cath UTI Depr Restr Falls An:Psych Flu Pneu 0 2 6

23 Facility Share: Jefferson County Nursing Home, MS Sandra Sampson Director of Nursing

24 Facility Share: Jefferson County Nursing Home, TN Samantha Snapp, RN Director of Nursing

25 Facility Share: Harber-Laman Management, TN jj Jennifer Brown Corporate QAPI Coordinator

26 July 23 rd : Clinical Educational Webinar! MDS! Composite Data! Incontinence and ADL QMs

27 atom Alliance C.2 Team