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Health Facility Evaluation and Quality Improvement September 21, 2010

Health Facility Evaluation and Quality Improvement September 21, 2010 “The Indiana State Department of Health supports Indiana’s economic prosperity and quality of life by promoting, protecting, and providing for the health of Hoosiers in their community.”. Outline.

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Health Facility Evaluation and Quality Improvement September 21, 2010

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  1. Health Facility Evaluation and Quality Improvement September 21, 2010 “The Indiana State Department of Health supports Indiana’s economic prosperity and quality of life by promoting, protecting, and providing for the health of Hoosiers in their community.”

  2. Outline • Nursing Home Evaluation Process and Quality Measures • Healthcare Quality Improvement Initiatives and Their Outcomes

  3. Indiana Nursing Home Evaluation Process and Quality Measures

  4. Overview of Long Term Care Facilities

  5. Overview of Indiana Long Term Care Facilities Long Term Care Facility Types • Comprehensive care facility – nursing home • Skilled nursing facility (SNF) • Nursing facility (NF) • Non-certified comprehensive care (State only) • Residential care beds • Residential care facility • Assisted living facility • Intermediate care facility for the developmentally disabled (ICFDD) – group home

  6. Overview of Indiana Long Term Care Facilities Number of Indiana Long Term Care Facilities • Certified comprehensive care facilities (nursing homes) – 502 facilities • Non-certified comprehensive care facilities - 3 • Comprehensive care facilities with residential care beds – 110 • Freestanding residential care facilities – 109 Source: ISDH Data September 2010

  7. Overview of Indiana Long Term Care Facilities Indiana Long Term Care Beds • Certified comprehensive care facilities (nursing homes) – 48,636 comprehensive care beds • Certified comprehensive care facilities with residential care beds – 8,256 residential care beds • Non-certified comprehensive care – 1165 comprehensive beds • Non-certified with residential beds – 304 residential care beds • Freestanding residential care facilities – 8,861 residential beds • Total residential beds: 17,421 beds Source: ISDH Data September 2010

  8. Survey Process and Findings

  9. Overview of Nursing Home Survey Process Survey Frequency • State licensing and federal certification surveys conducted every 9-15 months • Indiana has met that standard • State and federal complaint survey conducted for all complaints based on a priority tier • Indiana has met that standard

  10. Overview of Nursing Home Survey Process Number of Nursing Home Surveys Completed (2009) • Number of Annual Licensing / Certification Surveys (2009) – 533 • Number of Complaint Surveys (2009) – 1,459 • Number of Annual Life Safety Code Surveys (2009) – 533 Source: CMS Casper Report

  11. Indiana Nursing Home Survey Findings Most Cited Deficiencies (2010) • F282: Services provided by qualified persons in accordance with care plan – 43% of providers • F323: Facility is free of accident hazards – 33% • F272: Comprehensive assessments – 33% • F514: Clinical records – 29% • F157: Inform of significant changes – 28% • F441: Infection control – 25% Source: CMS Casper System

  12. Indiana Nursing Home Survey Findings Most Cited Immediate Jeopardies (2010) • F323: Facility is free of accident hazards – 5 • F224: Facility prohibits abuse, neglect – 3 • F441: Infection control – 2 • F225: Facility does not employ persons guilty of abuse – 2 • F314: Pressure ulcers – 2 • F223: Residents right to be free from abuse – 2 Source: CMS Casper System

  13. Indiana Nursing Home Survey Findings Outcomes: Deficiency free surveys • 2005: 47 facilities • 2006: 47 facilities • 2007: 51 facilities • 2008: 59 facilities • 2009: 57 facilities • 2010: 66 facilities (through Sept. 13) Source: CMS OSCAR quarterly reports

  14. Indiana Nursing Home Survey Findings Outcomes: Deficiency free surveys (% of facilities with no deficiencies) IndianaRegion VNational • Q4 2006: 10.60% n/a 8.20% • Q4 2007: 11.70% 10.41% 8.30% • Q4 2008: 10.78% 9.09% 7.60% • Q2 2009: 12.25% 8.77% 7.83% Source: OSCAR quarterly reports

  15. Indiana Nursing Home Survey Findings Outcomes: Immediate jeopardy findings • 2006: 91 – Indiana 3rd highest • 2007: 106 – Indiana 5th highest • 2008: 76 - Indiana 13th highest (68 surveys) • 2009: 46 – Indiana 17th highest (35 surveys) • 2010: 25 (through September 13) Source: CMS CASPER data

  16. Indiana Nursing Home Survey Findings Outcomes: Immediate jeopardy findings (% of facilities with IJ) IndianaRegion VNational • Q4 2006: 4.50% n/a 2.20% • Q3 2007: 5.64% 3.36% 2.17% • Q2 2008: 5.08% 3.75% 2.58% • Q2 2009: 2.77% 3.23% 2.89% Source: OSCAR quarterly reports

  17. Indiana Nursing Home Survey Findings Average Number of Deficiencies Per Survey IndianaRegion VNational • 2006: 1.7 1.5 1.5 • 2007: 2.7 2.4 2.0 • 2008: 3.0 2.5 2.1 • 2009: 2.7 2.5 2.1 • 2010: 2.5 2.2 2.0 Source: OSCAR quarterly reports through Sept 13, 2010

  18. Indiana Nursing Home Survey Findings Data Variability Between States • Percent of surveys timely completed • Whether state citing all deficiencies • Whether citing associated tags

  19. Indiana Nursing Home Survey Findings Differences in Surveys Between Provider Types • Acute Care • Compliance based on status at time of survey • Regulations based on facility policy • Long Term Care • Compliance determination goes back to previous annual survey • Regulations based on descriptive requirements

  20. Indiana Nursing Home Survey Findings Reporting of Survey Findings • ISDH Nursing Home Consumer Report • All survey reports and plan of corrections will be added in 2010 to Consumer Report • CMS Nursing Home Compare

  21. Healthcare Quality Issues Identified Through the Survey Process Common Root Causes • Appropriate admissions / placement • Timely and accurate assessments • Care transition and coordination • Staff education, training, & sufficiency • Negative health care culture

  22. Healthcare Quality Issues Identified Through the Survey Process Quality of Care Issues • Pressure ulcers • Healthcare associated infections • Medication errors / patient safety • Falls / wandering • Behavior management • Abuse and neglect

  23. Health Care Staffing

  24. Staffing Staffing Initiatives • Leadership Conference Staffing Strategies September 17, 2009 (funded by Civil Money Penalty Fund) • Staffing Study of Long Term Care Facilities (funded by the ISDH Civil Money Penalty Fund)

  25. Staffing 2009 Long Term Care Staffing Study • Number of administrator changes per facility over past three years – 2.5 • Number of director of nursing changes per facility over past three years – 2.8

  26. Staffing 2009 Long Term Care Staffing Study • Turnover rate for Registered Nurses (RN) – 74.1% (46% nationally) • Turnover rate for LPN – 67% (43% nationally) • Turnover rate for certified nurse aides (CNA) – 98.1% (64% nationally)

  27. Staffing ISDH Senior Staffing for Survey Program • Three Division Directors (Acute Care, Health Care Education, Long Term Care) and all seven long term care area supervisors are new within the past three years

  28. CMS Quality Indicator Survey System

  29. Health Care Survey System Survey Program Quality Improvement • Implement CMS Quality Indicator Survey (QIS) system • Kick-off for QIS system occurred in August 2010 • Training of surveyors for QIS surveys to begin in January 2011

  30. ISDH Healthcare Quality Improvement Initiatives

  31. Goals • Promote health care quality and health literacy through educational initiatives • Increase public awareness and focus on a state health issues • Protect the public through oversight of quality of care provided by health care facilities

  32. Healthcare Quality Improvement Principles Principles for Improvement Summarize evidence into checklists Identify and mitigate local barriers to implementation Measure performance Ensure all patients reliably receive the intervention

  33. Healthcare Quality Competing Interests Regulatory Scientific Foundation OUTCOMES Feasibility Health Care Culture

  34. SUCCESSFUL AGING Rowe & Kahn, 1998 MAINTAINING HIGH COGNITIVE & PHYSICAL FUNCTIONING AVOIDING DISEASE & DISABILITY ENGAGEMENT WITH LIFE

  35. Quality Improvement Themes • Evidence-based • System-based • Incorporate care coordination principles • Incorporate assessment tools • Incorporate culture change principles • Include patient and family centered care principles • Measurable outcomes • Plan for continuity after the initiative

  36. Indiana Health Care Quality Improvement Initiatives Survey-based Initiatives

  37. Survey-based Initiatives • CMS Special Focus Facility Program • Adding a facility in October 2010 • Will be five special focus facilities • Funded by CMS and state funds • ISDH Consultant Program • Offered to facilities with substandard quality of care findings • Funded through ISDH Civil Money Penalty Fund • CMS Critical Need Nursing Home Project (Through Quality Improvement Organization – Health Care Excel) • Pilot program for 4-5 facilities in northwest Indiana • Funded by CMS grant to Health Care Excel

  38. Indiana Health Care Quality Improvement Initiatives Addressing Immediate Jeopardy Level Deficiencies

  39. Improving Survey Findings The Challenge • In 2007, Indiana had the 5th highest number of immediate jeopardy findings on nursing homes surveys

  40. Improving Survey Findings Quality Improvement Activities • Monthly meetings with provider associations to review findings • Quarterly meetings with advocate organizations to discuss quality of care concerns • Collaborative quality improvement initiatives with healthcare organizations

  41. Improving Survey Findings Quality Improvement Activities: • CMS and ISDH consistency workgroups • Review of all immediate jeopardy findings by provider associations • ISDH implemented a biweekly long term care newsletter in January 2008 (funded through ISDH Civil Money Penalty Fund) • Implemented collaborative healthcare quality improvement initiatives

  42. Indiana Nursing Home Survey Findings Outcomes: Immediate jeopardy findings 2006: 91 – Indiana 3rd highest 2007: 106 – Indiana 5th highest 2008: 76 - Indiana 13th highest (68 surveys) 2009: 46 – Indiana 17th highest (35 surveys) 2010: 25 - Through September 13 Source: CMS CASPER data

  43. Indiana Nursing Home Survey Findings Outcomes: Immediate jeopardy findings (% of facilities with IJ) IndianaRegion VNational Q4 2006: 4.50% n/a 2.20% Q3 2007: 5.64% 3.36% 2.17% Q2 2008: 5.08% 3.75% 2.58% Q2 2009: 2.77% 3.23% 2.89% Source: OSCAR quarterly reports

  44. Indiana Health Care Quality Improvement Initiatives Indiana Healthcare Leadership Conferences

  45. Healthcare Quality Leadership Conferences • Joint conferences for long term care providers, organizations, associations, and surveyors • Two conferences per year • Each conference covers one topic • Conferences serve as kick-off for quality improvement initiatives • Funded through the ISDH Civil Money Penalty Fund

  46. Healthcare Quality Leadership Conferences Previous Conferences • June 2007: Falls • October 2007: Pressure ulcers • March 2008: Restraints and behavior management • September 2008: Emergency preparedness • March 2009: Incontinence • September 2009: Staffing • March 2010: Healthcare Associated Infections

  47. Healthcare Quality Leadership Conferences Planned Conferences • Alzheimer’s and Dementia Care – October 14, 2010 • Nutrition and Hydration – March 31, 2011 • Abuse and Neglect – Fall 2011 • Patient Safety / Medical Errors – Spring 2012

  48. Healthcare Quality Leadership Conferences Conference Checklist • Attend conferences • Use information and resources to develop education and training program in facility • Implement quality improvement project in facility • Celebrate quality accomplishments

  49. Indiana Health Care Quality Improvement Initiatives Indiana Pressure Ulcer Initiative

  50. Indiana Pressure Ulcer Initiative Participating Facility and Agencies Phase 1 Phase 2 Total • Home Health / Hospice 27 13 40 • Hospitals 41 7 48 • Nursing Homes 94 62 156 • Totals 162 82 244 Funded through ISDH Civil Money Penalty Fund

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