Advancing Excellence: The NH Quality Campaign Overview of the presentation

1. Advancing Excellence inAmerica’s Nursing HomesMary Jane Koren, M.D., MPHChair, Advancing ExcellenceVice President, The Commonwealth Fund

2. Advancing Excellence: The NH Quality Campaign Overview of the presentation • Background • Description of Advancing Excellence: • Purpose and structure • Process: how it works • Accomplishments • Evidence of impact • Other achievements • Building on what works • Using AE to test new ideas • Working with CMS: QA/PI and the QIO’s 10th SOW • Factors associated with why AE has been successful

3. Background

4. Context for the NH Quality Campaign

5. Antecedents to Advancing Excellence • The Sioux Falls Group formed in 2000 • Share information about each others’ initiatives and strategies; • Create effective coordination among themselves; and • Proactively, through their respective organizations, lead important national improvement initiatives • IHI’s 100,000 Lives Campaign 12/04-6/06 • “Some is not a number, soon is not a time” • Modeled on a political campaign • Based on 6 evidence-based practices • Established and promoted a set of achievable goals for US hospitals • Generated unprecedented amounts of social pressure for hospitals to participate

6. Description of AE: Purpose and Structure

7. Advancing Excellence is… • Largest national coalition of NH stakeholders (30 organizations) working together to help NHs improve care • An opportunity for NHs to demonstrate their commitment to self-improvement (>47% participate) outside regulation • An independent organization incorporated in 2010, recognized as 501(c)(3)in 2011 • Funded by • CMS for the web-site and analytic support • The Commonwealth Fund for program support • Members for communications and other special needs http://www.nhqualitycampaign.org

8. AE functions on 3 levels

9. Board of Directors Voting Members • Alliance for Quality Nursing Home Care • Alzheimer’s Association • American Academy of Nursing -- Expert Panel on Aging • American Association for Long Term Care Nursing (AALTC) • American Association of Nurse Assessment Coordinators (AANAC) • American College of Health Care Administrators (ACHCA) • American Health Care Association (AHCA) • American Health Quality Association (AHQA) • AMDA – Long Term Care • LeadingAge (formerly AAHSA) • National Association of Health Care Assistants (NAHCA) • National Consumer Voice for Long Term Care • The Commonwealth Fund • The Evangelical Lutheran Good Samaritan Society

10. PHI • Pioneer Network • Service Employees International Union (SEIU) • Non-voting/Government Members • Administration on Aging • Agency for Healthcare Research and Quality (AHRQ) • Assistant Secretary for Policy and Evaluation (ASPE) • Centers for Disease Control and Prevention (CDC) • Centers for Medicare & Medicaid Services (CMS) and its contractors, the Quality Improvement Organizations (QIOs) and State Survey Agencies • Department of Veteran’s Affairs • Association of Health Facility Survey Agencies (AHFSA) • Foundation of the National Association of Boards of Examiners of LTC Administrators (NAB) • Gerontological Advance Practice Nurses Association (GAPNA) • Hartford Institute for Geriatric Nursing • National Association of Directors of Nursing Administration in Long Term Care (NADONA/LTC) • National Association of State Long-Term Care Ombudsman Programs (NASOP) • National Gerontological Nursing Association (NGNA)

11. Advancing Excellence Goals 3. Restraints 5. Pain 7. Resident Satisfaction 1. Staff Turnover 2.Consistent Assignment 4. Pressure Ulcers 6. Advance Care Planning 8. Staff Satisfaction

12. AE is committed to three audiences: • NHs: • AE selects meaningful issues aligned with national initiatives • Provides free, practical, evidence-based resources to support organizational stability and performance improvement • Direct care staff: • AE’s tools designed so workers can join in on QI efforts • Solicits feedback about how they feel about their job • Residents and their families: • AE promotes open communication and participation of families and residents in care planning. • Encourages measurement of “customer” satisfaction as a part of the home’s QI process http://www.nhqualitycampaign.org

13. AE goals compared to other initiatives

14. Local Area Networks of Excellence (LANES) • Neutral space where stakeholders can come together to build working relationships • Divisive issues (e.g. 5 Star, reimbursement, the survey) are deliberately set aside or avoided • Must learn to work together toward a shared goal – better care for the resident • The aim is create ongoing learning networks or “learning communities” of stakeholders and of NHs http://www.nhqualitycampaign.org

15. Key Members of the LANE • QIO • Ombudsman • State Survey Agency • Nursing Home Association Reps • Culture Change Coalition Rep • Others can include consumer advocacy groups, state Medicaid agency, health care professionals (e.g. state AMDA chapters), unions, etc. http://www.nhqualitycampaign.org

16. Process: how it works

17. Becoming part of the AE Campaign • Nursing homes register on website • Choose 3 goals minimum – 1 clinical, 1 organizational plus 1 more (however, may pick all 8) • Identify benchmarks and set targets • Use the web-site to access AE’s resources and tools • Collect and monitor data using PDSA/PI methods • Enter data on AE website regularly http://www.nhqualitycampaign.org

18. Campaign Benefits • Focuses on things consumers, surveyors and payers are concerned about • Increased staff stability: less turnover, better retention • Saves money • Improves performance • Builds better relationships among staff and residents/families • Improves satisfaction (staff/resident/family) • Lets them be part of a learning network, lets them compare their performance with others • Complements other initiatives • QA/PI (ACA section 6102) • QIO program initiatives (10th SOW just starting) • Preparation for payment reforms http://www.nhqualitycampaign.org

19. Free Campaign Tools • Evidence-based or field tested • Downloadable, ready to use • Standardized formatting, user-friendly Excel worksheets for data collection • Clear, easy to understand instructions • Calculations, trend graphs and charting functions built-in • Compatible materials provided for consumers http://www.nhqualitycampaign.org

20. Advancing Excellence Tools • Staff Turnover Calculator • Consistent Assignment Calculator • Pressure Ulcer Monitoring Tool • Restraint Monitoring Tool • Pain Monitoring Tool • Advance Care Plan Monitoring Tool • Suggest tools to measure Staff Satisfaction and Resident/Family Satisfaction

27. Accomplishments

28. Recruitment • Participating nursing homes in Phase 2:+ 7398 ( 47%) 4726  Charter members 1965  New participants • Participating consumers:3053 • Participating nursing home staff: 1860 • September 1, 2011 www.nhqualitycampaign.org

29. Recruitment % by State

30. Recruitment % by State

31. The Relative and Absolute Number of Residents at High Risk for Developing Pressure Ulcers is Increasing

32. Physical Restraints

33. High Risk Pressure Ulcers

34. Campaign Progress • Campaign participants* have improved faster than non-participants in all things measured. • Campaign participants* improved faster in the goals they selected to work on in every case. • Campaign participants that set targets improved the most *In the aggregate…

35. Progress toward Campaign Goal

36. Change and Relative Improvement in National QMs Q3 2006 to Q3 2010 Change and Relative Improvement in National QMs Q3 2006 to Q3 2010 37

37. Advancing LANE Performance 21 Statewide Performance Improvement Projectsin 14 States • Increased use of Consistent Assignment • Decreased Staff Turnover • Decreased Pressure Ulcers • Decreased Physical Restraints • Increased Advance Care Planning • Increased website data entry www.nhqualitycampaign.org

38. LANE Participation in Advancing Excellence Fall 2010 More than 50% nursing home participation Accelerating LANE Performance States Critical Access Nursing Home State Changing LANEs Project

39. Arkansas Restraint Rate2005 Q3 through 2009 Q3 Residents who Were Physically Restrained (%) 13.6 6.2 4.2 3.3 2.6 2010 Q3 3.3

40. Finding new ways to measure quality: a new measure for Consistent Assignment Consistent Assignment: • Uses a person-centered frame for the measure by asking, “How many CNAs touched the resident in the course of the month” • Same CNA takes care of the same resident every time, all of the time • Optimally? Could be as low as 6 – 8 over the course of a month www.nhqualitycampaign.org

41. Promoting research on the impact of this staffing practice: • Using Consistent Assignment 85% of the time associated with fewer survey deficiencies, 41 % fewer empty beds, and 31% less turnover – recent study by Dr. Nick Castle • Small study by Dr. Barbara Bowers on consistent assignment – currently in progress www.nhqualitycampaign.org

42. Building on what works

43. 18 NHs from 4 States (GA, IL, IN, OH) NH selection based on quality measures, number of deficiencies, % Medicaid, % minority population, geographical area, media attention, etc. Only one nursing home has dropped out. One nursing home was added at the request of the State Health Department. The Critical Access NH Pilot:Can AE LANEs help to reduce disparities in NHs?

44. LANE members, and the NHs, stayed at the table NHs were enabled to share experiences with peers LANEs learned to take responsibility for overcoming impediments e.g. getting NH corporate offices to pay attention CMS Region IV very engaged Possible use of model following the project in at least 2 states CANH LANE Successes

45. “We used to have 5 or 6 call-outs a night. Now we only have one a week…” “We’ve gone back to Nursing 101. Instead of having the nurses call the doctor when a resident has a fever, we have empowered the nurse and allow him or her to try Tylenol, compresses and other nursing care… our hospital admissions have decreased” “The dietary staff that used to fight with each other all the time are now working together to help the residents…” DON and Administrators are doing MDS resident interviews and realize they have been “missing the boat.” CANH: Facility Successes CANH: Facility Successes

46. Quality Assurance/Performance Improvement (QA/PI) The Affordable Care Act, Section 6102 requries CMS to Strengthen QA requirements in nursing homes Provide technical assistance to nursing homes in order to meet new requirements. Law specifies implementation by December 31, 2011 QA/PI plans must be submitted to HHS Secretary one year later www.nhqualitycampaign.org

47. QIO 10th SOW Aims for the 10th SOW: • C.6 Beneficiary and Family Centered Care • Patient and Family Engagement Campaign • C.7 Improving Individual Patient Care • Reduction of Health-Care Acquired Conditions • C.8 Integrating Care for Populations and Communities • Improving Care Transitions Leading to the Reduction of Readmissions • Using Data to Drive Dramatic Improvement in Communities Drivers for creating change: Tasks under the 10th SOW • C.10.1 Supporting and Convening Learning and Action Networks; • C.10.2 Providing Technical Assistance; and • C.10.3 Care Reinvention through Innovation Spread

48. Lessons from IHI Why Learning Networks are Important • Engages leaders • Shared aims or goals • Welcomes everyone and harnesses energy • Self-conscious – participants are a part of the whole • Non-linear • Devolves control/bottom-up learning • Manages knowledge nimbly • Seeks critical mass – not total coverage • Values asking, not merely sharing www.nhqualitycampaign.org 13

49. AE is an example of a collective impact initiative Collective impact initiatives represent ongoing commitments by key stakeholders from different sectors to a common agenda for solving a specific social problem Use the LANE, often with major help from the QIOs, as the supporting infrastructure Forge new partnerships across interest groups Build strong working relationships among important players through continuous, ongoing communication Concentrate on identifying and then addressing the common problem Jointly agree on what success will look like and having a shared measurement system Use mutually reinforcing activities to maximize existing resources

50. Mary Jane Koren mjk@cmwf.org Or Carol Benner cb@leadingage.org www.nhqualitycampaign.org