Pathway to Performance Excellence

1. Pathway to Performance Excellence

2. About AHCA A non-profit federation of state affiliates that represent more than 10,000 non-profit and for-profit nursing and assisted living facilities that care for more than 1.5 million elderly and disabled individuals nationally, including veterans. AHCA currently represents 25% of state veterans homes nationwide. AHCA represents the largest number of not for profit nursing facilities nationwide: over 2,500 facilities. 2nd largest health care PAC at average $1 mil per year.

3. AHCA Support: State Veterans Homes Legislative and Regulatory Advocacy In-depth education: Annual convention and other events National Quality Recognition

4. Legislative and Regulatory Advocacy Over 80 full-time regulatory, legislative, research and other staff based in Washington, D.C.

5. Educational Opportunities Annual Convention: Over 70 sessions in 13 focus areas, including quality, care practice, workforce and leadership issues Keynotes: Cal Ripken, Jr. and Dr. Bob Arnot October 4-7, McCormick place in Chicago Annual Quality Symposium: February 9-10, 2010 at the Marriott Baltimore Waterfront Congressional Briefing: June 8-9, 2010

6. Pathway to Performance Excellence

7. Program Objectives

8. The Need and the Opportunity Rising costs cannot be fully offset by increasing revenue Regulatory compliance does not increase customer satisfaction Inconsistent performance causes employee dissatisfaction Traditional management systems are reactive rather than proactive and visionary Person-centered culture change will not be sustained without systems change

9. There is a Better Way! Act on a vision for what can be In all situations, lead by example Let customer expectations define the quality standard Engage and empower employees Develop a quality management system to sustain a focus on performance Develop a structure to fulfill the quality journey Commit to continuous learning and growth It is a leader�s choice. Do you settle for being pretty good, or do you strive for performance excellence � the place that our customers really expect us to be. Have everyone stand, put hand on heart, and spin in circle one time When you fill out evaluation of this session remember that I: brought you to your feet. touched your heart and turned you around Please don�t be shy about coming up to front with any questions you may have.It is a leader�s choice. Do you settle for being pretty good, or do you strive for performance excellence � the place that our customers really expect us to be. Have everyone stand, put hand on heart, and spin in circle one time When you fill out evaluation of this session remember that I: brought you to your feet. touched your heart and turned you around Please don�t be shy about coming up to front with any questions you may have.

10. Leadership and Culture Change Create a vision for performance excellence Change to systems thinking: It�s the system � how organizations approach getting things done Does caring and compassion trump system thinking? Systems create behaviors �My people won�t do what your people do� 85% of �people� problems are systems problems

11. Sharing the Right Vision Grasp your current reality Commit to innovation Vision sharing takes time and new system New language New tools Engage all in CQI

12. How Vision Developed New leadership � young or from other professions Education programs Pioneer Network, Eden Alternative, etc. Quality award program and similar models Never from regulatory change or survey enforcement

13. �Get a Vision� Exercise 3 minutes total Work individually or as a group from the same facility Develop a headline that you would like to see about your �community� in 5-7 years Headline should reflect a measurable result (i.e. Veterans Home staff satisfaction at 96% -- highest in nation) Write on handout

14. The Philosophical Principles of Quality Management

15. Definition of LTC Quality Is... �The totality of service features and characteristics that meet or exceed customer needs and expectations.�1 Requires the provider to: Comprehend individual and collective expectations Provide services and facilities that meet expectations Achieve a high level of performance and reliability in systems and processes used to deliver services

16. An Essential Measure of Quality Is� Customer Satisfaction Customers may not always know what is best for them; but they have right to be fully informed, respected, and in control of decisions regarding their service.

17. Customer External Customer: Ultimate user of the service Internal Customer: Anyone we hand off work to within the organization

18. Customer�s View of Quality (Kano)

19. Customer: Realization & Challenges We care a lot, but then assume we know what is best Learn to differentiate key customer groups Empower staff to respond Recognize every encounter as a quality moment for the customer

20. Remove �Blame� from the System Get the right people on the bus Believe that everyone wants to do a good job and have fulfillment from their work

21. Empowerment Parameters and Empowerment

22. �Most Important� Exercise 2 minutes total Meet with someone next to you Identify the three most important individuals or groups of employees

23. The Managers Gallup research: People leave managers, not organization

24. Managers Need Development Basic management skills Communication styles Conflict resolution Performance evaluation Coaching Team meeting skills, idea generating tools, consensus building tools, process management, improvement tools

25. Systems View of Quality

26. Cost of Quality Prevention Cost - Activities designed to prevent poor quality Appraisal/Inspection Cost - Assessing conformance to a standard Failure Cost - Correcting non-conformance to a customer�s requirement Cost increases as problem gets closer to customer

27. Does Inspection Work?

28. Classifying Work Value-Added Work - External customer sees benefit Required Work - Needed to keep organization operating Rework - Something was not done properly the first time Wasted Work - Not required and no value No Work - Authorized leave/waiting time

29. Do We See the Opportunity? Waste and Rework Cost Number of full-time equivalent employees 100 Average annual hours worked by each employee 1,950 Total hours worked annually Estimated rate of waste and rework (20%) .2 Total waste and rework hours Average hourly pay rate (including benefits) $12.00 Total cost of waste and rework

30. Process and System Process - Interrelated work activities producing a specific outcome System - A combination of related processes Process characteristics: Can be divided into a series of tasks Tasks can be put into order Performance can be measured Need standardized process

31. Variation Two Basic Kinds of Variation: Common Cause Variation: predictable and inherent in all processes Special Cause Variation: not predictable; often unsatisfactory; assignable to a cause � should be investigated

32. Example of Process Variation Sample food temperatures of meal entrees over a 10 day period from two facilities Average is the same�are both processes performing the same?

33. Organize for Quality

34. Process Management Cycle

35. Selecting a Process to Improve

36. Keep Score that Matters Performance is everything Efforts will earn you sympathy Compassion doesn�t cover up poor results If not getting results, change something Know key success factors, then Learning to measure quality is not easy

37. Principles of Measurement Measure the process, not the person Measure to improve, not to blame Keep simple, understandable, believable, accurate, and useful Measure performance against a customer-focused standard Measure the key process indicators Make comparisons meaningful (best, not average)

38. Is Alarm Disconnected?

39. The Tools of Quality Management

40. Nature of Problems Problem: Any situation/issue that separates you from your mission, vision, and goals Two primary categories: Strategic problems - organizational performance gaps Process problems - work process failures Responsibility for problems: Management responsible for all strategic problems and all process problems if: process handed down or �tweaked� by management employees are not empowered to correct Poor process results can come from strategic problems (poor allocation of resources, inadequate supplies, etc.) Poor process results may contribute to achieving strategic goals Teams take 5 minutes to read and discuss briefly each example (1-2 and 1-3) Poor process results can come from strategic problems (poor allocation of resources, inadequate supplies, etc.) Poor process results may contribute to achieving strategic goals Teams take 5 minutes to read and discuss briefly each example (1-2 and 1-3)

41. Key Root Cause Concepts Ask �why� rather than �who� Ask �why� at least five times Investigate the facts Why not Who - essential to removing blame from organization�s culture and creating environment where employees contribute to problem solving. Why X 5 - Ask in sequence, like pealing an onion. Keep asking why until you get to the root cause. Drives us past the temptation to react to symptoms or stop at the apparent cause. Use only facts from investigations as the basis for root cause analysis. Causes assigned by those involved or affected by the problem may be clouded by emotion or responsive to only one view.Why not Who - essential to removing blame from organization�s culture and creating environment where employees contribute to problem solving. Why X 5 - Ask in sequence, like pealing an onion. Keep asking why until you get to the root cause. Drives us past the temptation to react to symptoms or stop at the apparent cause. Use only facts from investigations as the basis for root cause analysis. Causes assigned by those involved or affected by the problem may be clouded by emotion or responsive to only one view.

42. Find the Root Cause Problem 1: Resident and daughter upset that expensive slip purchased for mother had returned from laundry in frayed condition. Symptoms: - Clothing damaged - Laundry chemical costs increased Why: Expensive booster chemical being added to every load Why: Laundry staff feel it is need to prevent rewash Why: Laundry supervisor directed Why: Vendor had not provided training. Why: Administrator did not include laundry supervisor in decisions and got too busy to schedule training Solution: Provide training, develop measurements, empower

43. Develop a CQI Methodology Helps create objectivity Can be adjusted to fit your QMS Provides a roadmap to solving problems Requires discipline to follow steps Everyone needs to be trained to use it

44. Sample CQI Methodology Identify the process and the customers� requirements Collect and analyze process data Describe the current process (flowchart) Select opportunities to improve and determine root causes Develop and implement potential solutions Hold the gains

45. PDSA Cycle of Improvement

46. Display and Analysis Learn to use the right tools to measure, analyze information and data

47. Models of Quality Management

49. Steps Toward Mature Processes Characterized by activities mostly responsive to immediate needs or problems rather than by processes Goals are poorly defined

50. Steps Toward Mature Processes Beginning stages of using operating processes with repeatability, evaluation, improvement, and coordination Strategy and quantitative goals are being defined

51. Steps Toward Mature Processes Systematic processes in place that are regularly evaluated for improvement Learning from processes shared Organizational units are coordinated Processes address well defined strategies and goals

52. Steps Toward Mature Processes Systematic processes in place that are regularly evaluated for change and improvement in collaboration with other affected organizational units Efficiencies across units sought and achieved through analysis, innovation, and sharing Processes and measures track progress on key strategic and operational goals

53. AHCA/NCAL Quality Award Step 1 - Commitment: Organizational Profile with mission and demonstration of ability to improve (5 pages; met/not met; no IJ) Step 2 � Achievement: Address how core values of quality are embraced with good results (18 pages; team of examiners; No IJ and 3 year weighted average above state) Step 3 � Excellence: Address all of Baldrige criteria with superior results; 55 pages; team of master examiners, No IJ and 3 year weighted average above state)

54. Benefits of Quality Award Model Develops providers� ability to improve services and internal processes Peer and public recognition as a quality champion Examiner feedback identifies strengths and opportunities for improvement Creates disciplined learning curve Webinars and other support resources available

55. Benefits of Quality Award Pathway Begins change in thinking Gives focus to the real customer Requires continuous learning at all levels Creates pride/celebration in achievement Requires long term commitment Creates shift in management style

56. QUESTIONS?

57. Resources Multiple resources for quality improvement listed at AHCA website: http://www.ahcancal.org/quality_improvement/quality_first_initiative/Pages/QF_ToolsResources.aspx Developing a Quality Management System: The Foundation for Performance Excellence in Long Term Care, Dana, AHCA revised 2008 (Order through AHCA bookstore � listed at above website) Guidelines for Developing a Quality Management System (Free download) http://www.ahca.org/quality/qf_qms_guidelines.pdf A Guide to Nursing Facility Performance Measures (also for MR/DD providers) (Free download) http://www.ahca.org/quality/qf_nf_perform_measure.pdf Good to Great, Collins, HarperCollins, 2001 First, Break All the Rules, Coffman and Buckingham, Simon and Schuster, 1999 Zapp! Empowerment in Healthcare, Bynam, Random House, 1993 The Deming Management Method, Walton, Perigee Books, 1986