National Nursing Home Quality Care Collaborative Participation Agreement Nursing Home Participant Information Nursing Home Name: Telephone # Administrator: Email: Director of Nursing: Email: Owner: Telephone # Owner Contact: Email: Nursing Home Street Address: City: State: Zip Code: County: CMS Certification #: Licensed Beds: Medical Director: Medical Director Email Member: Advancing Excellence Yes/No CMS Partnership to Improve Dementia Care Yes/No Our facility would like to participate in the atom Alliance National Nursing Home Quality Collaborative (NNHQCC). atom Alliance is a regional, quality improvement initiative. Members of atom Alliance are IQH (Mississippi), AQAF (Alabama), and QSource (Indiana, Kentucky and Tennessee). Collaborative Aim and Goals: The aim of the NNHQCC is to ensure every nursing home resident receives the highest quality of care by instilling systemic quality improvement practices within the nursing home, eliminating healthcare acquired conditions and improving resident satisfaction. The goals of the NNHQCC are: Achieve facility, state and national improvement targets for improved mobility by 2019 Achieve facility, state and national improvement targets for reduction in the use of unnecessary antipsychotic medications among residents with dementia by 2019 Increase the number of nursing homes in the state and nationally attaining a score of six or better on the Nursing Home Quality Composite Measure Score by 2019 Achieve facility, state and national improvement targets for reduction in avoidable hospitalization and 30-day hospital readmissions Achieve other goals as identified by CMS during the Collaborative
Term of Participation: August 1, 2014 to July 31, 2019. As a condition of participation, senior leadership agrees to promote and support the facility's active engagement in two 18-month breakthrough learning Collaboratives. Collaborative I will commence on April 1, 2015 and end on September 30, 2016. Collaborative II begins on April 1, 2017 and ends on September 30, 2018. Guiding Principles and Expectations: While there is no fee to participate in the NNHQCC, the benefits of participation and the success of the NNHQCC depend on the mutual commitment, engagement and collaborative efforts of atom Alliance and participating nursing homes. Therefore, the nursing home and atom Alliance agree to the following conditions of participation: atom Alliance agrees to: 1. Provide technical support, coaching and consultation services by qualified staff with expertise in nursing home quality improvement 2. Promote the nursing home s efforts to engage residents, families, key partners and stakeholders in collaborative and quality improvement activities 3. Provide consultation, training and coaching to support systemic and sustained improvement through the adoption and deployment of the NNHQCC Change Package and various evidence-based interventions, tools and resources to: a. improve resident mobility b. reduce unnecessary antipsychotic drug use in individuals with dementia c. decrease healthcare associated infections d. improve staff stability and consistent assignment e. eliminate avoidable high risk pressure ulcers f. reduce physical restraints g. ensure an injury and violence free living environment h. reduce avoidable hospitalizations and 30 day hospital readmissions i. take advantage of other quality improvement opportunities such as team building, leadership, improving immunization rates and other self-selected areas of focus 4. Provide consultation, education and coaching to support and sustain the adoption and systemic deployment of Quality Assurance and Performance Improvement (QAPI) principles, tools, resources, including data submission and data sharing, and support the facility s active engagement in the Advancing Excellence in America s Nursing Homes Campaign and CMS National Partnership to Improve Dementia Care
5. Provide Learning and Action Network activities such as educational sessions, collaborative sessions, webinars, videos, conference calls, virtual affinity groups, and Peer Mentoring Programs designed to facilitate opportunities for networking and sharing 6. Recognize the accomplishments and best practices of participant nursing homes 7. Keep confidential all information collected from your facility in accordance with 1160 of the Social Security Act and the requirements of 42 CFR 480 Subpart B: This means that: No information can be shared with another party without the written permission of your facility. Information shared by your facility with the atom Alliance team will not be used for purposes other than for participation in this study. No proprietary information (such as business plans and strategies, policies, procedures) will be shared with other parties outside of the initiative unless the facility gives its written consent. Any information subject to HIPAA regulations will be collected and shared in a compliant manner. Nursing Home agrees to: 1. Designate an on-site champion to work closely with the atom Alliance consultant to organize, charter and lead a quality improvement team to support and sustain quality improvement in selfselected focus areas and promote the facility s engagement in the NNHQCC 2. Engage residents, families, key partners and stakeholders in collaborative activities. Specifically, facility agrees to include residents/beneficiaries and their family members in at least two quality improvement initiatives 3. Engage staff, residents, family members, partners, key stakeholders, the medical director, other physicians and consultants to promote a culture of quality that supports and sustains systemic improvement through the adoption and deployment of evidence-based tools, resources and interventions to: improve resident mobility reduce unnecessary antipsychotic drug use in individuals with dementia decrease healthcare associated infections improve staff stability & consistent assignment eliminate avoidable high risk pressure ulcers reduce physical restraints ensure an injury and violence free living environment reduce avoidable hospitalizations and 30 day hospital readmissions
address other quality improvement opportunities such as team building, leadership, vaccinations and other self-selected areas of focus 4. Adopt and support the systemic deployment of QAPI principles, tools, resources and processes as a data-driven and pro-active approach to quality improvement. Specifically: Initiate and periodically update a QAPI Assessment Tool Collect, submit and share outcome and process data/reports as required to achieve NHHQCC objectives and quality improvement results Address gaps in systems through planned interventions to improved overall quality of care Serve as a peer mentor or work in collaboration with a peer mentor as requested by NHHQCC leadership Collaborate with atom Alliance to observe work processes, create process workflow maps, conduct root cause analysis, deploy Plan-Do-Study-Act (PDSA) cycles and develop/deploy QAPI performance improvement plans [PIP] as needed to achieve goal Cooperate with atom Alliance to schedule and conduct on-site technical support visits as required to achieve goals Enroll and actively engage in the Advancing Excellence in America s Nursing Homes Campaign and the CMS National Partnership to Improve Dementia Care 5. Encourage staff members, residents, family members and stakeholders to participate in educational and Learning and Action Network activities as appropriate and share success stories, best practices and lessons learned with other Collaborative participants 6. Publicly disclose participation in the NHHQCC and serve as a person-centered care advocate and an ambassador for advancing excellence in nursing homes 7. Collect and submit data in a HIPAA compliant manner as required to achieve the objectives of the initiative. Data collection requirements include those data required to conduct quality improvement activities and improve facility performance related to the goals of the initiative.
Required Signatures Facility name (print): Participation in the NHHQCC requires the execution of this Participation Agreement signed by one or more of the following senior leaders: chief executive officer (CEO), chief operating officer (COO), the administrator or the owner. Chief Executive Officer (print): Chief Operating Officer (print): Administrator Officer (print): Other (print): Phone: 205-970-1600 Ext 3511 Fax: 205-970-1616 Return this form to: Beth Greene AQAF Two Perimeter Park South Suite 200 West Birmingham, AL 35243 Beth.greene@hcqis.org This material was prepared by the atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Content presented does not necessarily reflect CMS policy. 14.ASC2.08.007