Advancing Excellence in Nursing Homes Making Nursing Homes Great Places to Live, Visit and Work

1. Advancing Excellence in Nursing HomesMaking Nursing Homes Great Places to Live, Visit and Work Chris Condeelis Senior Director of Quality American Health Care Association ccondeelis@ahca.org Carol Benner, National Director, Advancing Excellence in Nursing Homes Campaign cbenner@aahsa.org Tammy Rolfe, LANEs Field Director, Advancing Excellence In Nursing Homes trolfe@aahsa.org

2. Learning Outcomes • Describe the role of Advancing Excellence in Quality First Keeping the Promise. • Review the eight goals and targets for improving the performance of nursing homes. • Describe the array of comprehensive, customized, evidenced-based resources that are available at no cost. • Demonstrate the use of Advancing Excellence website to benchmark and track performance.

3. Quality has evolved • 7-5-5 • 7 Principles – no changes • 5 – Goals – refined, consensus, measures sources • 5 – Tools -- new

4. Why Update or Even Keep Quality First? • Our goals are more refined. • We have targeted 3rd- party data sources. • We can adjust our goals as our environment changes.

5. QFKTPStrategic Direction • Self-initiated – voluntary, proactive • Accountability, Transparency • Anchor point – across our membership • Positioning for the Affordable Care Act • Public Reporting • Pay for Performance • Bundling

6. What is quality ? “Quality is the combination of care and services that meet or exceed customer needs and expectations.” AHCA/NCAL

7. QFKTP -- 7 Principles Continuous Quality Improvement (CQI) – This principle encourages a collaborative approach to quality management that builds upon traditional quality assurance methods by emphasizing the organization and systems, with a primary focus on process, and utilizes objective data to analyze and improve these processes. In long term care CQI incorporates all the components that are necessary for quality care and services.   Public Disclosure and Accountability – This principle seeks to encourage transparency of information that is shared with patients, residents and their families as well as sources of state and federal funding. It also promotes accountability to meeting – and exceeding – patient needs and expectations, while simultaneously exhibiting accountability of government funding for the care provided. Patient/Resident and Family Rights –This principle embodies the critical importance for person-centered care and focus on individual outcomes through services provided. This is exemplified by presenting opportunities to patients and residents to best determine their care and shape the comfort of their environment.

8. QFKTP Principles – continued Workforce Excellence –This principle recognizes that a strong organization empowers leaders and develops and supports a stable, qualified and well-trained workforce that is engaged and committed to excellence.  Public Input and Community Involvement –This principle recognizes the interconnectednessof long term care facilities and the community. Facilities should strive to achieve positive visibility by promotingthemselves as health care providers within the community, becoming involved in issues impacting the community and by sustaining a robust volunteer program that actively engages individuals of all ages. Ethical Practices –This principle embodies the belief that all long term care providers should operate based on a foundation of trust. This includes promoting ethical business standards, corporate integrity and responsible financial stewardship. Financial Stewardship –This principle recognizes that the vast majority of long term care providers rely on government funding (Medicare, Medicaid) to provide quality care and services – and that our profession must operate in a manner that uses these resources responsibly. As a profession, we will endeavor to retain appropriate levels of governmental funding to allow facilities to provide health care and services to those in need.

9. QFKTP – 5 Goals Improve and Sustain: • Performance in all CMS quality measures • Compliance with the federal survey process • High rates of resident and family satisfaction • High rates staff satisfaction rates • Leadership and staff retention, and reduce turnover rates

10. QFKTP – Data to Measure Goals Improve and sustain performance in all CMS Quality Measures • Source: CMS Nursing Home Compare • Update: Quarterly Improve and sustain compliance with the federal survey process • Source: CMS OSCAR Data • Update: Quarterly Improve and sustain high rates of resident and family satisfaction • Source: My InnerView – National Survey of Customer and Workforce Satisfaction in Nursing Homes Report • Update : Annual Improve and sustain high staff satisfaction rates • Source: My InnerView – National Survey of Customer and Workforce Satisfaction in Nursing Homes Report • Update: Annual Improve and sustain leadership and staff retention and turnover rates • Source :AHCA 2008 Nursing Vacancy, Turnover, and Retention Report • Update: Annual

11. CMS Quality Measure Performance(CMS Nursing Home Compare)

12. Federal Survey Process(CMS Nursing Facility OSCAR Standard Health Survey Data)

13. 13 Resident and Staff Satisfaction (My InnerView, Inc.2009) • 86% of residents rated their nursing home as “good” to “excellent.” • 67% of staff rated their home “good” to “excellent” as a place to work.

14. 14 Retention Rates by Job Category(AHCA, Vacancy and Turnover Study, 2008)

15. Shared Goals Quality First and Advancing Excellence

16. Quality First: Keeping the Promise5 Tools • Advancing Excellence Phase II • AHCA/NCAL National Quality Award • AHCA LTC Trend Tracker® • Resident and Family Satisfaction Assessment • Staff Satisfaction Assessment

17. Thank-You for What You Do “The leaders who work most effectively, it seems to me, never say “I” They think “we”; they think “team.” “They understand their job to be to make the team function. They accept responsibility and don’t sidestep it, but “we” gets the credit…. This is what creates trust, what enables you to get the task done.” Peter Drucker

18. About the Advancing Excellence in America’s Nursing Homes Campaign

19. Campaign Overview • Largest national coalition (30 organizations) of nursing home stakeholders • Voluntary for nursing homes (43% registered!) • Based on measurement of meaningful goals • Initially a two-year campaign started in 2006 • Just celebrated our 4th birthday! • Incorporated in 2010 • And, the data show that it works!!!! www.nhqualitycampaign.org

20. Why Join? • Participate in a Quality Improvement method that works • Advancing Excellence tools are free, evidence-based and user-friendly • Up-to-date information on the website to help nursing homes quality of care and life • Robust website • Periodic newsletters • Participation encouraged for consumers and frontline staff in addition to nursing home leaders www.nhqualitycampaign.org

21. Campaign Benefits • Focuses on meaningful issues • Drives nursing homes to a culture of data and QI • Increases staff retention and focus • Improves customer satisfaction • Saves money due to improved quality and staff retention • Prepares for Pay-for-Performance • Brings stakeholders to the table • Complements other initiatives • Gets nursing homes ready for QAPI www.nhqualitycampaign.org

22. About Quality Improvement

23. Why is Nursing Home QI Important? • It’s the right thing to do • Affordable Care Act strengthens QA requirements in nursing homes • With the shift to MDS 3.0 and the change in quality measures, nursing homes are more accountable than ever for quality. www.nhqualitycampaign.org

24. Quality Assurance/Performance Improvement (QA/PI) • The Affordable Care Act, Section 6102 requires CMS to strengthen QA requirements in nursing homes • CMS must provide technical assistance to nursing homes in order to meet new requirements. • Law requires implementation by December 31, 2011 • QAPI Plans must be submitted to HHS Secretary one year later www.nhqualitycampaign.org

25. QA/PI • Meaningful problems or issues • Measureable • Benchmarks/data-driven • Evidence-based interventions • Evidence of improvement www.nhqualitycampaign.org

26. Quality Improvement Quality Assurance Proactive Aggregate Data Organizational process Improves overall performance Always measureable Concurrent Monitoring is continuous Positive change • Reactive • Single episode • Organizational mistake • Prevents something from ever happening again • Sometimes anecdotal • Retrospective • Monitoring based on audit • Sometimes punitive www.nhqualitycampaign.org

27. QI Model for ImprovementThree Questions and the PDSA Cycle • What are we trying to accomplish? • How will we know that we have been successful? • What changes can we make to achieve our goal? www.nhqualitycampaign.org

28. QI Model for Improvement • Aims are time-specific and measureable • Dependent on change • Uses P-D-S-A cycle to test small changes www.nhqualitycampaign.org

29. PLAN-DO-STUDY-ACT

30. PDSA

31. PDSA www.nhqualitycampaign.org

32. Example 1 • What are we trying to accomplish? • I want to lose weight • How will we know that we have been successful? • Size 6 dress • Lost 20 pounds • What changes can we make to achieve our goal? (First, have to figure out what process I have to change) • Change medicine? Eat less?Eat differently?Exercise? www.nhqualitycampaign.org

33. Example 1

34. Example 2 • What are we trying to accomplish? • I want to increase profits in my pizza store • How will we know that we have been successful? • 10% $$$ increase at the end of the 2011 • What changes can we make to achieve our goal? • First, have to figure out what process I have to change • Better marketing? More cooks? Efficient delivery practices? www.nhqualitycampaign.org

35. Example 2 www.nhqualitycampaign.org

36. Example 3 • What are we trying to accomplish? • Decrease number of in-house acquired pressure ulcers • How will we know that we have been successful? • No pressure ulcers and no deficiencies • What changes can we make to achieve our goal? • First, have to figure out what process I have to change • Right supplies on hand? Hire wound care nurse?Identification and care of residents at risk for PUs? www.nhqualitycampaign.org

37. Example 3 www.nhqualitycampaign.org

38. Campaign Phase 2 Goals • Staff Turnover • Consistent Assignment • Restraints • Pressure Ulcers • Pain (long and short-stay) • Advance Care Planning • Resident/Family Satisfaction • Staff Satisfaction www.nhqualitycampaign.org

39. Quality in Nursing Homes • To improve care, we need to stabilize the work force. • We need to reduce turnover, improve staff retention. • We need to improve relationships between staff and staff, staff and residents. www.nhqualitycampaign.org

40. Keep QI Simple • Focus on important, meaningful issues. • Make sure that your goal is measureable. • Figure out what change/process you need to make. • Involve the care team • Make QI come alive • Celebrate your success www.nhqualitycampaign.org

41. About the Advancing Excellence QI Tools

42. Advancing Excellence Tools • Staff Turnover Calculator • Consistent Assignment Calculator • Pressure Ulcer Monitoring Tool • Restraint Monitoring Tool • Pain Monitoring Tool • Advance Care Plan Monitoring Tool • Suggested tools for measuring Staff Satisfaction and Resident and Family Satisfaction • Find these tools at • www.nhqualityCampaign.org

43. The Campaign Tools • Evidence-based, tried and tested…they work! • Developed by experts • Similar to one another and user-friendly • Excel worksheets • Simple how-to instructions • Macros and formulas built-in • Monitoring built-in • Downloadable and ready to use • Free www.nhqualitycampaign.org

44. The Campaign Resources • Resources for each Campaign goal include: • Implementation Guide • Webinar • Fact sheet for consumers • Fact sheet for CNAs • Additional resources include: • Videos • Research references • Resources are regularly updated www.nhqualitycampaign.org

45. Using the AE Tools to improve Staff Turnover, Consistent Assignment and Pressure Ulcers

46. A Major Shift In Thinking It’s ALL about STAFF • Enough • Competent • Caring • Compassionate • Consistent www.nhqualityCampaign.org

47. Formula for Success Staff Stability + Consistent Assignment = Happier StaffBetter Care and Clinical Outcomes Higher Resident and Family Satisfaction Cost Savings

48. Proving The Link - References A Case For Consistent Assignment: When caregivers get to know their patients more intimately, it opens the way for improved quality and a reduction in staff turnover, Provider Magazine, June 2006 A Keystone For Excellence: Implementing consistent assignment provides a strong foundation for achieving the goals of the Advancing Excellence in America’s Nursing Homes program, Provider Magazine, July, 2007 Predictable scheduling: Nursing homes can boost quality, bottom line with consistent assignment, Modern Healthcare, August 2010 Interventions Table: Staff Retention: An overview of information published between 2004-2009 regarding successful or potentially successful interventions to retain staff

49. What is Staff Stability? • Low staff turnover • High staff retention • Low use of agency staff • Rare call-outs, absenteeism • High staff satisfaction www.nhqualitycampaign.org

50. Staff Turnover • Staff turnover is one component • of staff stability www.nhqualitycampaign.org