Using Satisfaction Surveys To Improve Quality

1. Advancing Excellence in America’s Nursing Homes Using Satisfaction Surveys To Improve Quality

2. Campaign Mission To help nursing homes achieve excellence in the quality of care and quality of life for the more than 1.5 million residents of America’s nursing homes by: • Establishing and supporting an infrastructure of local QI networks • Strengthening the workforce • Improving clinical and organizational outcomes

3. What the Campaign Does Advancing Excellence is helping nursing homes make a difference in the lives of residents and staff.  Advancing Excellence provides free, practical and evidence-based resources to support quality improvement efforts in America’s nursing homes. Advancing Excellence is committed to providing support to those on the frontlines of nursing home care.  Advancing Excellence promotes open communication and transparency among families, residents, and nursing home staff. 3

4. Steve Levenson, MDMedical Director

5. Advancing Excellence Quality Improvement Tools: Process Framework for Satisfaction • Similar to all others • Systematic way to approach quality improvement • You only have to learn it once • Located on the AE website under Nursing Home Resources

6. Improving Resident and Family Satisfaction: Implementation • Step 1: Identify As Area For Improvement • Step 2: Identify Authoritative Information • Step 3: Identify Current Approaches • Step 4: Note Specific Areas for Improvement

7. Increasing Resident Satisfaction: Implementation Steps (cont.) Step 5: Identify Causes of Resident Dissatisfaction Step 6: Identify Pertinent Interventions Step 7: Implement Pertinent interventions Step 8: Monitor Results and Adjust Interventions

8. Step 1: Identify Resident Satisfaction As An Area For Improvement Use satisfaction survey data, focus groups, family and resident complaints, interviews and other tools to identify what residents and families are thinking. Tools are on the AE website!

9. Step 2: Identify Authoritative Information • Seek reliable and evidence-based information from literature and relevant professional associations and organizations • Satisfaction concerns generally focus on respectfulness of staff, choice, dining, grooming.

10. Step 3: Identify Current Approaches What is the best evidence-based way to measure satisfaction for your nursing home? • Choose the tool that best fits your organization for the kind of residents that you have • For example, a focus group may be more effective than a survey if you organize it correctly

11. Step 4: Identify Areas of Dissatisfaction to Improve • Analyze information from Steps 2 and 3 above • First, choose areas to work on that will give you the biggest bang for the buck – • Easy to fix • Large number of residents • Feedback to residents, families and staff is important

12. Step 5: Cause Identification • Identify factors (including root causes) of resident dissatisfaction • Based on both direct and indirect causes • Identify reasons given by those who do not adequately follow desirable approaches • What is rationale for doing it that way?

13. Factors to Consider When Evaluating Resident Satisfaction Direct Appropriate interactions with residents Informing and including residents and families in decision making Getting input about quality from residents and families Indirect Factors affecting worker performance Factors affecting facility operations Quality of clinical decision making and practices

14. Causes of Dissatisfaction: Real-Life Examples • Inadequate training / oversight to handle resident behavior problems • Inadequate involvement of resident and family in key decisions about care and services • Staff turnover due to inadequate support to deal with resident / family expectations • Facility culture of poor problem solving • Inconsistent, personality-dependent processes and systems, changing frequently

15. Step 6: Management (i.e., Interventions) • Use information and data collected about the organization, its processes and results • Reinforce optimal practice and performance • Continually promote “doing the right thing in the right way” • Follow steps of the Resident Satisfaction Process Framework, throughout the facility • Identify and use tools and resources to help implement the steps and address related issues

16. Step 7: Implement Pertinent Interventions • Implement pertinent generic and cause-specific interventions • Address diverse underlying causes (including root causes) of the challenges and obstacles to the nursing home’s efforts to reduce resident satisfaction

17. Step 8: Monitoring • Evaluate whether changes in process and practice have helped attain desired results • Adjust approaches, inteventions as necessary • Tools for this goal AND all the others are on the Campaign web site

18. Examples of Interventions • Generic: give residents more input into decisions, give staff feedback for performance • Cause specific: improve accountability, review care practices, provide additional support for addressing resident/family expectations, address physician communications issues • Refer to Resident Satisfaction Resources for resources and tools that can help to address this goal

19. Elizabeth GouldAlzheimer’s Association

20. Multiple Levels of Influence

21. Targeting Specific Care Areas Many things drive quality of life and satisfaction • Agitation • Aggression • Depression • End of Life Care • Food Intake • Fluid Intake • Incontinence • Pain Management • Personal Hygiene • Restraint Use • Safety • Sexuality • Sleep Disturbance • Social Engagement/ Activities • Spirituality • Walking & Mobility • Wandering • + Many More

22. Residents with Dementia • About 1.6 million nationwide • Difficulty communicating needs • Still maintain individual: • Interests • Preferences • Likes & Dislikes • Retain ability to express themselves

23. Understanding Residents Needs • Assessment • Formal • Informal • Communication • Behavior • Maintain independence in care approaches

24. Know the Person –Implications of Dementia Stages of Dementia may change the residents ability to express interests • Early Stage: Talk to them! • Mid-Stage: Talk to them and Observe • Late Stage: Constant observation

25. Encouraging Satisfaction Core Perspectives: • Information, understanding and involvement give power and a sense of ownership to consumers • Satisfaction is increased when residents and families: • Understand good care; • Can communicate effectively; • Are active in care planning.

26. Consumer Empowerment Key Resource: CareFinder Web-based empowerment education tool for consumers of residential care • Understand quality care • Advocate for better care in facilities • Long-term care decision making tool

32. Accessing Resources www.alz.org/carefinder

33. Carol BennerField Director, AE Cmpaign

34. New Goal – Staff Satisfaction Almost all NHs will assess staffs’ satisfaction with their work environment: • at least annually, and • upon separation, and *Incorporate this information into their quality improvement activities

35. Objectives: By 4Q 2010 A: The national average of NHs that regularly assess staff satisfaction, input their results on the website, & incorporate results into their quality improvement activities will exceed 75%. B: The majority of NH staff will be asked about their satisfaction with their work environment at least annually & upon separation. C: Regularly assessing staff satisfaction with their work environment & incorporating results into quality improvement will become the national standard.

36. Ways to Implement • NHs will set a target for improvement to increase the number of staff who are asked & complete satisfaction surveys • AE is developing methodology to implement goal such as: • Ability for NH staff to input satisfaction data directly on AE website • Standardized survey to be provided to NH Administrators and DONs (Survey Monkey)

37. Mary Tellis-Nayak RN, MSN, MPH Vice President of Quality Initiatives, MyInnerView

38. Objectives • To identify three items which are most important to long-term care employees in recommending your workplace to others. • To learn what long-term care employees tell us about what the components of a good workplace. • To understand the relationship between family, resident and employee satisfaction.

39. Quality pyramid • Loyalty Scale • 100% • Very Satisfied • Satisfied • Dissatisfied • 0% Unanticipated quality Customer-driven quality = Desired Community standards = Exp. quality Regulations = Basic quality

40. AN EXERCISE:WhatMatters Most

41. QUADRANT ANALYSIS: TWO KEY CONCEPTS 1. How residents, families and staff rate your care and services Your average score on each item: 1 – 4: “Poor” “Fair” “Good” “Excellent” Rank order all items by average score: 1 – 100: Lowest to highest ranking score 2. How much each item influences residents, families and staff to recommend to others Correlate each item with “Recommendation: 0 – 1: No correlation to strongest correlation Rank order all items by correlational strength: 1 – 100: Lowest to highest ranking correlation

42. Recom-mendation Goal Item score QUADRANT AND ACTION PRIORITIES Successes A. Secondary strengths B. Primary strengths 1 - Lowest to highest ranking score  100 You can meet customer expectations Challenges C. Secondary opportunities D. Primary opportunities 1 ----- Lowest to highest ranking correlation ------ 100 You have little control over customer expectations

43. SKILLED NURSING EMPLOYEE Survey items Quality of orientation Quality of in-service education Quality of resident-related training Quality of family-related training Comparison of pay Care (concern) of supervisor Appreciation of supervisor Communication by supervisor Attentiveness of management Care (concern) of management Safety of workplace Adequacy of equipment/supplies Sense of accomplishment Quality of teamwork Fairness of evaluations Respectfulness of staff Assistance with job stress Staff-to-staff communication

44. EMPLOYEES NATIONWIDE What matters most 10 - Care (concern) of management 9 - Attentiveness of management 17 - Assistance with job stress 11 - Safety of workplace 15 - Fairness of evaluations 6 - Care (concern) of supervisor 8 - Communication by supervisor 7 - Appreciation of supervisor 12 - Adequacy of equipment/supplies 3 - Quality of resident-related training

45. EMPLOYEES

46. EMPLOYEE Safety of workplace Care (concern) of supervisor Communication by supervisor Fairness of evaluations Appreciation of supervisor Adequacy of equipment/supplies Care (concern) of management Attentiveness of management Assistance with job stress

47. DATABYTE

48. What doesresearch have totell us aboutthe workplace?

49. Improve Care outcomes Relationships HR Decrease nurse absenteeism Decrease nurse turnover Decrease CNA turnover Resident/Family Satisfaction FinancialIncrease occupancy SUMMARY OF RELATIONSHIPS Staff Satisfaction

50. KEY PERFORMANCE DRIVERS higher family satisfaction lower nursing assistant turnover higher employee satisfaction higher family satisfaction