State Veterans Homes VA Survey Overview

1. State Veterans Homes VA Survey Overview Valarie Delanko JoAnne Parker Office of Geriatrics & Extended Care (10NC4) Winter Conference 2019

2. Discussion Topics • SVH Background • 2018 Survey Overview • Sentinel Events Overview • SVH Analytics Update

3. SVH Program Census Current SVH Program Structure offering three levels of care: • 156 State Veterans Home Facilities • 148 Nursing Home Care programs (25,645 beds) • 53 Domiciliary Care programs (5704 beds) • 3 Adult Day Health Care programs (109 participant slots)

4. Number of SVHs

5. Survey Visits

6. Survey Totals

7. Top NH standards

8. Top NH standards

9. Survey Report Totals

10. Totals

11. Top DOM standards

12. Totals

13. Totals

14. Immediate Jeopardy Numbers

15. Topic Change:Sentinel Events Valarie Delanko Office of Geriatrics & Extended Care

16. Sentinel Events 38 CFR Part 51.120. A sentinel event is an adverse event that results in the loss of life or limb or permanent loss of function. Examples of sentinel events are as follows: (i) Any resident death, paralysis, coma or other major permanent loss of function associated with a medication error; or (ii) Any suicide of a resident, including suicides following elopement (unauthorized departure) from the facility; or (iii) Any elopement of a resident from the facility resulting in a death or a major permanent loss of function; or (iv) Any procedure or clinical intervention, including restraints, that result in death or a major permanent loss of function; or (v) Assault, homicide or other crime resulting in patient death or major permanent loss of function; or (vi) A patient fall that results in death or major permanent loss of function as a direct result of the injuries sustained in the fall.

17. Sentinel Events (3) The facility management must report sentinel events to the director of VA medical center of jurisdiction within 24 hours of identification. The VA medical center of jurisdiction must report sentinel events by calling VA Network Director (10N 1-22) and Chief Consultant, Office of Geriatrics and Extended Care within 24 hours of notification. (4) The facility management must establish a mechanism to review and analyze a sentinel event resulting in a written report no later than 10 working days following the event. The purpose of the review and analysis of a sentinel event is to prevent injuries to residents, visitors, and personnel, and to manage those injuries that do occur and to minimize the negative consequences to the injured individuals and facility.

18. Sentinel Event Reporting • The SVH determines their own mechanism…the SVH should not be asked nor required of them to perform an RCA, or PDSA cycle…the SVH can develop their own process and structure. • The SVH must send a written report to the Medical Facility Director in 10 business days of the known event. • It must be a review and analysis NOT a timeline.

19. Sentinel Event Reporting VACO GEC worked with NASVH Quality Enhancement Committee to develop 3 tools: • Sentinel Event Education Power Point

20. Sentinel Event Reporting 2. Criteria for a SVH Event: A word document to help remember what and when to share information to the Medical Center Director at the VAMC.

21. Sentinel Event Reporting 3. Investigational Report Template: A word document of elements to consider for a thorough Review and Analysis of the sentinel event that satisfies the intent of the regulation.

22. Topic Change:SVH Analytics Update Valarie Delanko/Lisa Minor Office of Geriatrics & Extended Care

23. SVH Analytics Background: • February 2018 NASVH Quality Enhancement Committee meeting: VACO GEC provided a demonstration of VA’s development of a Quality Metric report called “SVH Analytics” that includes SVH State and National comparisons as well as CMS State and National comparisons. • NASVH Quality Enhancement Committee agreed and requested VA to continue to pursue development and provide the general assembly a demonstration for feedback in summer 2018.

24. SVH Analytics Background: • July 2018 VA Updates: VACO GEC provided a demonstration of the “SVH Analytics” to the General Assembly. • During the summer conference, GEC provided 1:1 demo’s on specific SVH facility data and sought feedback. • VACO GEC continued work on the “SVH Analytics” Report…Here Are The Updates!!

25. SVH Analytics GEC can create a pdf for the SVH NEW Quintile Gauge

26. SVH Analytics Can see all measures Better closer to center Radar ranking

27. SVH Analytics No change

28. SVH Analytics No change

29. Change Scatter Plot Desired Direction Change in quintile from past year. 17 on left, 18 at bottom

30. Relative Performance vs Absolute Size of improvement from past year.

31. Opportunity Matrix New!

32. Monthly SPC Charts New!

33. SVH Analytics Challenges: • This link/database is behind the VA firewall, thus cannot provide the link to external VA employees. • Completion of the project is resource intense so as resources are available, VA continues to build, refine and pull data. • VA has established a “pdf” version from the database; may be a method to share. • Current data is updated to FY 18 Quarter 4.

34. Office of Geriatrics & Extended Care Program change: • Dr. ScotteHartronft is the Acting Executive Director for Geriatrics is & Extended Care. • Letters should be addressed to Dr. Hartronft.

35. Contacts • Valarie Delanko, RDN, LDN, CPHQ National Program Manager SVH Quality & Survey Oversight 814-860-2201 • Jo Anne Parker, MHA National Program Manager SVH Survey Process 202-623-8328