Achieving Quality in the Pursuit of the Silver AHCA/NCAL National Quality Award

1. Achieving Quality in the Pursuitof the Silver AHCA/NCAL National Quality Award Steve Izzo LNHA, MPH, Administrator Karen Gentile RN, Assistant Administrator/DON Meredith Weil LSW, Director of Social Services Inglemoor Rehabilitation and Care Center (IRCC) Livingston, New Jersey

2. Objectives • Achieving and Sustaining Performance Excellence using the AHCA quality award application • Applying Best Practices to achieve and sustain quality • Involving and Empowering Staff in Performance Improvement Initiatives

3. Value of Participating in the AHCA/NCAL Quality Award • Focus on quality awareness throughout the organization • Framework for our Performance Improvement program • Tools, resources, education to achieve and sustain performance excellence • Engage and reconnect with staff

4. Tools and Resources • Best Practices models • CMS’s QI Indicators • Advancing Excellence • LTC Trend Tracker • MyInnerview surveys • AHCA quality award criteria • CMS Five Star Rating (nursing home compare)

5. Inglemoor’s Quality Journey • 2008 Bronze Award (awarded 2nd attempt) • 2010 Silver Award (awarded 2nd attempt) • 2011 Gold Award (1st attempt)

6. Quality Award Application • Start Early do it through out the year • Engage entire workforce • Small team to write • Professional review • Resources and tools • Network • Don’t lose focus on your core competency

7. OVERALL SATISFACTION RECOMMENDATION TO OTHERS QUALITY OF LIFE DOMAIN 98 95 93 89 88 85 85 89 87 84 82 82 80 82 81 90 90 QUALITY OF CARE DOMAIN QUALITY OF SERVICE DOMAIN 85 84 83 82 82 82 81 81 Post Acute

8. 100 94 93 93 89 89 OVERALL SATISFACTION 88 RECOMMENDATION TO OTHERS QUALITY OF LIFE DOMAIN 88 88 88 85 85 87 85 85 85 84 75 QUALITY OF CARE DOMAIN QUALITY OF SERVICE DOMAIN 90 88 87 86 83 83 81 82 79 79 78 74 Family

9. OVERALL SATISFACTION RECOMMENDATION FOR JOB RECOMMENDATION FOR CARE 95 93 92 91 87 87 87 84 84 80 80 80 80 77 73 74 69 67 WORK ENVIRONMENT DOMAIN TRAINING DOMAIN 82 79 74 71 70 73 74 72 68 67 65 64 Employee

10. Physical Restraints

11. High-Risk Pressure Ulcers

12. Post Acute Care Pain

13. Chronic Care Pain

14. Geographic Market: All (Nation) Peer Group: All (Peers)Metric: Occupancy rate Percentile Peer Group: State

15. Best Practice Karen Gentile RN, BSN Assistant Administrator/DON

16. Best Practice Guidelines A best practice guideline is a “systematically developed method for statements (based on best available evidence) to assist practioner and patient decisions about appropriate healthcare for specific clinical circumstances” (Field and Lohr – 2002, p.8) The idea is with proper processes a desired outcome can be delivered with fewer problems and complications.

17. The Expected Benefits of Using/Initiating Best Practices • Improved Quality of Care and Resident Outcomes • Increased knowledge; evidence based practice that will support the care of our geriatric patients • Provides support for nurses and staff in our facilities • Improved quality of work life for staff Implementing Best Practices 1. Evaluate your Facility Needs • Use of QI, resident/family surveys, employee surveys, complaint investigation, quarterly meetings, staff meetings • Identify which performance measure and evidence based practices offer the most promise for improving quality of care and life within your facility

18. Implementing Best Practices • Find a well developed, evidence based best practice guideline • identify whether a credible organization has evaluated the guideline process

19. Implementing Best Practices • Identify and engage stakeholders • Identify the stakeholders who have high influence and support the implementation

20. Implementing Best Practices • Assess the environment for readiness for Best Practice Implementation • Identify the barriers and facilitators of implementation

21. Implementing Best Practices • Use of Implementation Strategies • Hold interactive educational meetings for all staff • Provide reminders to prompt behaviors • Build consensus among team • Provide ongoing monitoring and support during the process

22. Implementing Best Practices • Evaluate the Implementation Process • Provide baseline data before implementation and benchmark to current data • Outcome  achievement of targets and goals, adherence to Best Practice Guidelines, increased health outcomes of our patients • Support staff/share with staff

23. Objective • Limit and/or prevent the occurrence of falls within the parameters that can be controlled through structured interventions • Minimize the severity of injuries sustained • Provide the professional staff with acceptable standards of practice that will enable them to perform effectively • Educate the resident, family and staff • Limit the liability and financial risk to the facility

24. Key Elements to a Fall Management Program • Assessment • Clinical Assessment by RN • Rehab Assessment • Pharmacological Assessment • Environment Assessment

25. Key Elements to a Fall Management Program • Dynamic Treatment Plan • Multidisciplinary implementation of interventions based on results of the assessments and resident preferences • The IDC Team must address: • Resident, staff and family education • Room modifications • Residents daily routines • Physical limitations • Pain Management • Medication use • Proper and consistent use of assistive device

26. Key Elements to a Fall Management Program • Evaluation • Post Fall Evaluation • Fall Management Investigation • Physical assessment • Contributing factors to fall • Reporting mechanism/tracking of falls within facilities • Facility Fall Summary • Action of the IDC Team • Collective review and analysis of trends in resident falls throughout the facility • Facility Protocol may include review by safety committee, QI committee

27. Key Elements to a Fall Management Program • Education / Awareness • Falls Program in service • Staff members • Resident / Family Content of Review: I. Instruction and information concerning safety awareness II. Proper uses of call bells, wheelchairs, assistive devices III. How they can assist

28. Key Elements to a Fall Management Program • Quality Improvement • Collect fall data • Post fall tool • Fall summary report • Conduct interdisciplinary analysis of information to gain knowledge • Review and revise Policies and Procedures (P&P) as appropriate - Retrain staff on new P&P

29. Performance Improvement Cycles Meredith Weil, LSW

30. Performance Improvement (PI) Cycle • Formal process of gathering meaningful data points • Data is turned into useful information through evaluation and analysis • The information is used to assess and determine the current system strengths and weaknesses.

31. Performance Improvement (PI) Cycle • The knowledge gained is applied to the current system in the form of action plans aimed to improve performance and outcomes. • Sustain deployed action plans through integration of learning from evaluation and repetition of cycles.

32. Performance Improvement Tools • Design, Measure, Assess, Improve and Control (DMAIC) Tool • Plan, Do, Check, Act (PCDA) Tool • Fishbone Diagram • Root Cause Analysis (RCA) • Cause and Effect Map • Failure Mode and Effects Analysis (FMEA) • SMART Tool • Pareto Analysis Chart (PAC)

33. Performance Improvement Tool PDCA • Plan – Identify and target root causes of problems and develop action plan • Do – Pilot planned solution and implement activity • Check – Measure, Audit, Evaluate outcomes • Act – Determine if improvements have been met, refine and expand solutions, and monitor progress

34. Inglemoor Rehabilitation and Care Center’s 2010 PI Initiatives • Dining Experience PI • Callbell Response PI

35. Dining Experience PI Initiative • The Dining experience was identified as an area for us to improve our performance as evidenced by poor customer satisfaction survey responses in the area of quality of meals, dining experience and an increase in customer complaint forms in the same areas over the past year.

36. Dining Experience PI Initiative The Dining Experience PI team was chaired by a department head and line staff from various departments and levels of responsibility. The team met and developed a resident questionnaire to identify the root causes of the problem. The team divided up the residents in house and completed the questionnaires with them, commencing the data gathering process.

37. Dining Experience PI Initiative • Identified Root Causes of problem • Wrong food temperatures • Un-timely tray pass • Wrong food orders being given and missing items on tray • Poor customer service dining staff impolite • Lack of menu selection and repetitious menu cycles

38. Dining Experience PI Initiative • Action Plans developed from gathered data • Complete necessary repairs to kitchen steam table to keep food hotter prior to serving • Tray passes started earlier and supervisor oversees timeliness of tray pass on units • Policy and procedure on selective menus revised to ensure they were being delivered timely and accurately.

39. Dining Experience PI Initiative • Action Plans continued • New system developed to have a second person checking trays on the line to ensure proper food and condiments are being given • Extensive inservicing with dining room staff on good customer service • Revised menus with dietary staff to widen the variety of meals to keep up with resident expectations.

40. Dining Experienced PI Initiative Checking Stage • This stage requires ongoing monitoring of action plans to determine if they are successful • Evaluate outcomes through the use of resident satisfaction surveys and feedback Acting Stage • We have continued to monitor our outcomes and refine and expand upon solutions. We repeat this cycle to sustain results

41. Callbell Response PI Initiative • Callbell Response was also identified in the same way our dining experience was identified as an opportunity for performance improvement • Through resident surveys and complaint forms we identified that our residents were dissatisfied with the wait time • We assembled a second PI team using the same method as Dining initiative

42. Callbell Response PI Initiative • Data was gathered through the use of a callbell response questionnaire created by our PI team and completed with the residents • Once data was gathered and evaluated, the root causes for long callbell wait times were identified by the PI team

43. Callbell Response PI Initiative • Identified Root Causes of problem • Perceived lack of staff • CNA’s are busy assisting other residents • Staff turns callbell lights off telling patients they will be right back and never return • Lack of oversight by nurses • High callbell volume during particular times of the day (AM, Shift change, etc.) • Staff takes extended breaks too often

44. Callbell Response PI Initiative • Action Plans developed from gathered data • Inservice nursing staff on all shifts on approaches for improving callbell response • Reinforce resident’s routine and customary preferences for care by developing a schedule if possible to anticipate resident’s needs • Inservice ALL staff on their mandatory participation in answering callbells, especially during AM care

45. Callbell Response PI Initiative • Action Plans continued 4. We created a callbell checklist for staff when answering call lights: does the resident have water pitcher, phone, callbell, tissues, tv remote in reach before staff exists room? 5. Asking “is there anything else I can do for you?” before you leave the room 6. Continued customer service training. A staff member’s positive/negative attitude can impact a resident who has been waiting for care 7. Maintain the highest staffing levels possible

46. Callbell Response PI Initiative • Checking stage • This stage requires ongoing monitoring of action plans to determine if they are successful • Evaluate outcomes through the use of resident satisfaction surveys and feedback • Acting Stage • We have continued to monitor our outcomes and refine and expand upon solutions. We will repeat this cycle to sustain results

47. The Power of an Engaged and Empowered Workforce “No company, small or large, can win over the long run without energized employees who believe in the company’s mission and understand how to achieve it.”Jack Welch, retired CEO of General Electric

48. The Power of an Engaged and Empowered Workforce • Building a Team of Engaged Employees starts with leaders clearly stating expectations and responsibilities of work along with purposes and function of work. • Recruitment phase – Purpose of work must be communicated from the beginning of the recruitment phase. This ensures the employee understands the ultimate purpose and mission of the organization which should help to attract potential employees to feel like they have found a “home” and they are aligned with the vision of the organization.

49. The Power of an Engaged and Empowered Workforce • The Hiring Phase – During this phase leaders should carefully select employees. Not just hire “a warm body” to do the job. • The Orientation Phase – During the orientation process employers should “set the bar high” and offer the employee a significant emotional opportunity to become invested in the mission of the organization.

50. The Power of an Engaged and Empowered Workforce • The Orientation Process – Employers should talk about the culture of the organization, the strategic objectives and why they are important and relevant to the facilities mission statement. Employers must identify those employee’s who have potential to foster the growth of their organizational culture. • As leaders identify these employees they should invest in them and involve them in quality improvement endeavors.