Checklist: What Can My Organization Do?

Checklist: What Can My Organization Do?

2 Introduction About The Framework This is an evidence and consensus-based framework for successful clinical outcomes in long term and post-acute care. The framework was built by the AHCA Clinical Practice Committee with the goal of developing solutions for reducing rehospitalizations and adverse events. Quality of care drives business success or failure in long term and post-acute care. This framework acknowledges that clinical results need both an organizational and a clinical foundation. The framework outlines guiding elements such as individualized care approaches, effective transitions of care, QAPI concepts, safety, risk management, team-based care, and diagnostic quality. Care providers that use such a framework can more effectively apply knowledge through organizational approaches and clinical care that leads to optimal patient outcomes and quality of life. Vignettes and worksheets complement this framework to help build prevention into everyday practice. In addition, references at the end of the document provide additional detail on existing resources and tools that centers can readily acquire and use. The framework can be used as a desktop reference guide at various times when reflecting on one s practice or contemplating challenges and seeking solutions. Why Is This Important? Success in achieving positive resident/patient outcomes is even more critical now than ever before. The link between quality and payment in long term and post-acute care is growing stronger, as evidenced by the SNF Value Based Purchasing Program (VBP), Improving Post-Acute Care Transformation (IMPACT) Act, SNF Quality Reporting Program (QRP) and more. In addition, regulatory activity is intensifying through focused surveys on adverse events, dementia care and MDS. The Five-Star Rating system and Nursing Home Compare have been revised and will add items in the future as it broadens public reporting and transparency. Most importantly, consumers expect and deserve high quality care. Overall, applying the items in this framework will provide a strong foundation for improved resident/patient outcomes in addition to more efficient use of staff, time, and resources.

3 Framework Outline This framework outlines key elements from both an organizational and clinical nature that are critical to successful clinical and organizational outcomes. Positively, these elements reflect common denominators that cross multiple care situations. Therefore, instead of being yet another initiative or single focused project to achieve just one outcome, it is a way of acting, thinking and being that will benefit multiple areas across an organization. These are the common denominators and core elements that cross multiple care situations: Organizational Foundation Culture of safety Right thing in the right way thinking Systems driven Team based care Principles of person-centered care Clinical Foundation Consistent use of evidence-based practice First of all, do no harm thinking built into practice Diagnostic quality Cause identification Clinical assessment Effective monitoring Timely provision of necessary care Individualized care approaches reflected in care planning Each element is addressed in detail throughout this document. Key questions that are answered for each element include: What does this mean? Why is this important? What are some examples? What is my part (as an individual employee, manager or practitioner)? In addition, key takeaways, probing questions and some useful resources and tools are included for further exploration. This document is an excerpt of the sections for each element of the framework. Start somewhere, pick one element and work through it with your team. Enjoy the journey!

4 Organizational Foundation: Culture of Safety Leadership engages and empowers patients, residents, families, staff, visitors, and others to keep the culture of safety alive and well. Conduct a Survey on Patient Safety Culture. Leadership can create an environment that encourages and does not penalize observing and reporting safety concerns. Incorporate safety considerations into the center s QAPI program. The QAPI program should use appropriate tools and approaches to discuss safety issues and monitor whether they are addressed promptly and definitively. Organizational Foundation: Right thing in the right way thinking Make sure there are clear, complete, well organized, and easily accessible instructions and procedures that are consistent with reliable sources such as medical and geriatrics references. Share a good article about how to reduce risk. Make it an expectation that staff will ask for help in unfamiliar situations and receive a supportive response when doing so. Show examples of documentation about various aspects of care that are considered clear, accurate, and complete. Remind staff not to cut corners and support them in doing the right thing. Give staff an easy way to inform someone about procedures or instructions that are unclear, confusing, or incomplete. Show staff how to use a computer to search quickly for information needed to do the work. Organizational Foundation: Systems Driven Promote consistent approaches to care, to operations, and to overall problem solving and prevention activities Foster systems-driven decision making and an environment in which residents / patients are satisfied and experience the best possible outcomes. Ensure adequate training and development of staff. Ensure processes of various tasks are clearly defined. Promote pride in working for the organization and sharing in the reward of good service, which may help increase staff engagement and retention.

5 Organizational Foundation: Team Based Care Hold everyone accountable for proficient job performance, recognizing that the chain is only as strong as its weakest link. Create and reinforce a culture of giving care in the proper context of the big picture and not in silos. Ensure that individual disciplines practice within the scope of their licensure, knowledge, and skills, and that they review any significant potential recommendations for tests, treatments, and consults with the group to ensure that they are pertinent and have taken into account all relevant issues. Promote a culture of safety built in to everyday practice, including good clinical reasoning and problem solving that leads to proficient care and avoids doing harm due to erroneous conclusions and guessing. Encourage everyone to make and report relevant observations and information about the residents, including evidence of the effectiveness of care plan interventions. Embrace proficient interdisciplinary care as a means to the end of providing personcentered care and reducing adverse events. Management staff must support and train staff in culture change to focus on the person in their care as an individual. Organizational Foundation: Principles of Person-Centered Care Create a culture that focuses on individualized care. o Establish and enforce the mechanisms to make it happen, including systems-driven and team-based care, consistent use of evidence-based practice, proficient cause identification and diagnostic quality, accurate clinical assessment, effective monitoring, timely interventions, and individualized care planning. Educate everyone about early detection of signs of potential adverse events. Work with the medical director to hold all practitioners accountable and ensure that they try to tailor interventions to the individual residents or provide a valid clinical rationale why it is not feasible to do so. Clinical Foundation: Consistent Use of Evidence Based Practice Reinforce to staff that evidence-based practice is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and resident care data with clinical expertise and resident preferences and values. Continue to provide education about, and support the use of evidence-based practice in the work environment. Support the delivery of evidence-based practice in a context of caring and in a supportive organizational culture, which will lead to the highest quality of care and best patient outcomes

6 Clinical Foundation: First of All Do No Harm Thinking Built into Practice Inform staff about how to distinguish conclusions from rationale (information to support conclusions) and how to verify and validate significant information and not just accept conclusions. Have care-related discussions and meetings that emphasize the big picture and the context of all symptoms and test results. Foster a culture of care that focuses on obtaining adequate detail and not cutting corners. Show staff how to look up information in reliable references about medications and treatments, and how to interpret information such as side effects. Use readily available references at meetings to discuss resident/patient care, and to look up indications and side effects of medications and treatments. Emphasize the correct care delivery process and clinical reasoning and problem solving approaches and make sure they are used in resident/patient-related conferences and meetings. Set up a framework for discussing residents / patients that focuses on adequate and objective description of symptoms and condition changes. Foster a facility culture that focuses on validating assumptions, not jumping to conclusions, and minimizing guessing. Clinical Foundation: Diagnostic Quality Recognize that diagnostic quality is an organization-wide issue, not just the domain of physicians and other medical practitioners. Teach techniques to avoid cognitive error. Inform staff on how to distinguish conclusions from the rationale (objective supporting information) and how to verify and validate information and not just accept conclusions. Have care-related discussions and meetings that emphasize the big picture and the context of all symptoms and test results. Foster a culture of care that focuses on obtaining adequately detailed and objective description of symptoms and condition changes detail and not cutting corners. Use readily available references at meetings to discuss resident/patient care, including to look up how medication-related side effects can cause symptoms. Emphasize the correct care delivery process and clinical reasoning and problem solving approaches and make sure they are used in resident/patient-related conferences and meetings. Foster a facility culture that focuses on validating assumptions, not jumping to conclusions, and on minimizing guessing. Be vigilant about who is allowed to write orders and make recommendations, and ensure that they are acting within the scope of their knowledge and training when they propose causes of symptoms and related tests and treatments.

7 Clinical Foundation: Cause Identification Provide resources and tools to help identify causes, both for resident care and for systems issues. Incorporate proven cause identification methods into everyday processes so they are used in real time throughout the day to get the best possible results, as well as retroactively to analyze situations that already occurred. Provide education and training on how to gather information systematically to describe and clarify issues or problems, and how to use tools for improvement. Involve staff in performance improvement projects to examine and improve care in areas that have been identified as needing attention. Foster a culture that makes continuous quality improvement a priority. Set expectations around resident-centered choice, rights, safety, and respect, and ensure staff accountability. Create an environment that encourages and supports staff to identify and report quality issues as well as identify opportunities for improvement. Clinical Foundation: Clinical Assessment Teach and coach staff about the proper approaches to assessment. Check staff understanding of how to observe, examine, describe, define, document, and report information. Check that staff know how to organize, document, and report information as a coherent and meaningful story about a condition or situation. Help staff access references and resources that explain components of various assessments, whether comprehensive or focused, and check that the resources are used as needed. As part of the QAPI program: o Review assessment quality (for example, by reading and critiquing nursing and other progress notes) and look for ways to improve the documentation and reporting of information. o Evaluate the accuracy and pertinence of conclusions reached on the basis of assessments, to be sure that staff are not exceeding the scope of their training and knowledge and that residents / patients are not having adverse consequences such as hospitalization as a result of inadequate, incorrect, or misinterpreted information gathered during assessments. Clinical Foundation: Effective Monitoring Provide education, task practice and adequate resources to perform designed review activities as intended. Leadership can provide on-going feedback via process review and quality data as to how the processes are working. Focus attention on how to monitor appropriately and use results to adjust interventions, both for clinical care and for systems and organizational issues.

8 Clinical Foundation: Timely Provision of Necessary Care Scrutinize existing systems and processes to make them more efficient. Hold everyone accountable to doing their jobs, so that the system runs smoothly and does not waste staff time. Commit to a culture of safety. Review and address issues affecting timeliness of care as part of the QAPI program. Commit to staff training and coaching about task performance and use the information to improve systems and individual performance. Clinical Foundation: Individualized Care Approaches Reflected in Care Planning Support resources and processes that help familiarize staff more readily with each person s care plan; for example, through daily rounding; weekly IDT rounds at report time; point-of-care devices, and other means. Promote a culture of sound clinical reasoning, good problem solving, enhanced diagnostic quality, knowledge of potential treatment complications, and improved coordination and communication with practitioners.