Developing Quality Systems and Personnel

1. Developing Quality Systems and Personnel Putting the Pieces Together

2. Developing Quality Systems Objectives • Identify components of quality validation review process • Identify how to schedule and make assignments • Identify how to review findings with team • Identify how to monitor progress

3. Impetus for change • Average number of deficiencies per standard survey increased • Number of immediate jeopardy citations increased • QIS survey process

4. Quality Validation Review • Proactive • Process oriented • Collaborative • Initiated 6 months prior to anticipated standard survey • Follows 7 survey tasks • Uses Critical Elements from QIS survey

5. Annual Timeline

6. Quality Validation ReviewScheduling and Attendance • Scheduling Six (6) months prior to anticipated standard survey Twice a year for higher risk centers

7. Quality Validation ReviewScheduling and Attendance

8. Quality Validation ReviewAssignments

9. Quality Validation ReviewProcess • Entrance conference • Assignment review and completion target • Follows 7 survey tasks • Uses Critical Elements, QM/QI validation tools • Preliminary exit with administrator, DON • Conference with facility and regional or divisional management team • Quality Milestone Action Plan development

10. Critical Element

11. QM/QI Validation Tool

12. Summary of findings • Grouping of like findings by F tag • Team conference Agreement on: Citation or concern F tag Scope and severity Responsibility for POC & QMAP • Calculation of SFF points

13. Plan of Correction Development

14. Quality Milestone Action Plan

15. Monitoring • Responsibility of facility to assure completion of plan of correction • Regional consultant follow-up and assistance with education and audits • Re-validation 90 days later (STAT)

16. Survey Training and Tools • Re-validation of plan of correction from Quality Validation Review “Clear” previous citations Identify new citations • Preparation of survey expandable file • Education of staff regarding survey process

17. QVR to STAT to Survey QVR STAT SURVEY

18. Facility Perspectives Views from a facility team: Administrator – Matthew Baad Director of Nursing – Fran Brown

19. Developing Quality Personnel Objectives • Identify components of the licensed nurse orientation program • Identify the process steps needed for implementation • Identify components of the preceptor training program

20. Before… Turnover Rates 2007 • Licensed Nurses = 51%!!! YIKES

21. Getting Ready for Change Infrastructure • Human Resources • Regional Nurse Educators • Preceptors

22. Human Resources Considerations: • Role definition • Education calendar • General orientation schedule • Mastering Caring Leadership • Turnover and retention tracking system

23. Regional Nurse Educators Considerations: • Site selection • Clinical skills labs • Classroom settings • Equipment and Supplies • Skills validation process

24. Preceptors Considerations: • Compensation model • Training sites • Selection process • Training • Follow-up

25. Putting it all Together

26. …After Turnover Rates • Licensed Nurses = 15%!!! yippee

27. Facility Perspectives Views from a facility team: Director of Nursing – Henrietta Makowski Regional Nurse Educator – Rose Zlotecki

28. Thank You! Questions