Improving Nursing Home Quality of
Life within a Performance
Improvement Framework
Elizabeth Weingast , RN, MSN VP Clinical Excellence
Orah Burack, MA Senior Research Associate
Jewish Home Lifecare
American Society on Aging, March 2013
Overview
• How to use a performance
improvement model to improve nursing
home quality of life within a person
centered framework.
2
Jewish Home Lifecare (JHL)
•JHL is over 160 years old.
• Provides a true continuum of aging services.
• Serves over 10,000 seniors annually.
• Manhattan, Bronx, & Westchester, NY
• Includes 3 large nursing homes with 46 long
term care & subacute communities.
• 1394 long term beds
• 236 subacute beds
Jewish Home Lifecare Values
• Committed to Person Centered Care
• Creating Green House® & Small Household
model throughout long term care
• Adopted a model of community based PI
4
Person Centered Care
Decision making based on individual elder needs
& preferences in all aspects of nursing home life
including:
• What food is available
• When meals are served
• What bathing choices are available
• How work is structured in the organization
5
Industry Focus on Person Centered Care
• Integral to long term care Green House® model
• Increasingly viewed as essential to the delivery
of quality care in the nursing home
• Resident perspective included in MDS 3.0 &
Quality Indicator Survey
6
What is PI concerned with in long term care?
• Cornerstone
of change management in nursing
homes
• Monitoring quality outcomes
• Responding when outcomes are suboptimal
•Traditionally used a department based model of
performance improvement (PI)
• Deliberate planning required to adjust PI model
to fit decentralized model
7
Performance Improvement (PI) model changes
with person centered care
•Importance of person centered care in
industry.
•QAPI – Quality Assurance Performance
Improvement regulations
•If PI program models are not adjusted
benefits and challenges of person
centered care will not be adequately
measured and potentially not adequately
managed.
8
Project Overview
Conduct a performance improvement initiative
on one community at each of Jewish Home
Lifecare’s 3 long-term care campuses that
addresses the findings from the 2010 resident
and family satisfaction surveys.
Funded by United Hospital Fund
9
Project Goals
• Obtain feedback from elders about their
nursing home satisfaction (↑response rates).
• Develop a community based replicable
satisfaction improvement process to further
person centered care in the nursing home
•Empower the community to engage in selfdirected collaborative decision-making to
improve community quality of life
• Improve elder satisfaction at the community
level
10
Steps to improve Survey Response Rate
•Flyers on communities
• Identified all interviewable elders
• Trained survey interview team
• English & Spanish surveys
• Mailed postcard reminders
• Followed up mailing with family phone calls
• Second mailing
11
Satisfaction Survey Response Rate
2010-2011
30%
28%
24%
25%
25%
22%
20%
Family
15%
Resident
10%
5%
0%
2010
12
2011
Identifying Teams
•Choosing study community
•Leadership required
•Who are the team members:
·Family Members
·Staff
·Residents
·Management
13
Educating Teams – PI process
Community Meetings
• Training staff, residents and family
members together.
• The Model for Improvement
• Brainstorming changes toward a goal of
improving quality of life and improvement
in clinical care.
14
The Model For Improvement – Institute for
Healthcare Improvement
Part I: The Three Questions
1. Setting Aims - What are we trying to accomplish?
•2. Establishing Measures - How will we know that a
change is an improvement?
•3. Selecting Changes - What changes can we make that
will result in improvement?
15
Part II: Plan – Do –
Study – Act Cycle
PLAN Establish
tasks required to
set up the test of
change
ACT Review impact
DO Implement change
Of change by evaluating data
and experience with change
Consider spreading change
As planned for specific
Period of time
STUDY
Measure impact of
change,
gathering
predetermined
data
16
Barriers To Implementing Process
•Facilitating weekly meetings with staff on study
community.
•Staffing issues that affected attendance
•Staff member changes (SW, TR, Nursing)
•Staff resistant to being identified as a
community “leader”
•Residents – core group
•Families – difficult to recruit
17
Solutions to Barriers
•Continued leadership participation led supported
team participation.
•Conducted one-to-one sessions regularly to
accommodate staff with busy schedules.
•Continuity bred enthusiasm and belief in project
grew among staff and residents.
•Catching new staff members up to speed
(individual meetings).
•Dedicated Project Coordinator
18
Identifying Survey Items for Change
Community 1. The quality of the meals.
The quality of the dining experience.
Community 2. The quality of the meals.
Elder /staff friendships.
Community 3. Control of pain.
Elder/staff friendships.
19
Translating Survey Items
What do the residents really
mean?
20
Community 1
Survey item - The quality of the meals.
The quality of the dining experience.
Identified problem:
Limited variety
Poor quality
Unpleasant dining environment
Overcrowding
21
Team Brainstorming
•Breakfast Requests: Special Breakfast
once a week Flavored coffee, Croissants,
Danish, Muffins, Bagels, Creamed cheese,
Butter
•Lunch Requests: More variety at mealtime
Lamb shank, oxtails, grilled sandwiches, Beef
tongue, Rice and beans more regular, improve
food & vegetable preparation, garlic, salt,
pepper, lemon juice, oregano, Mrs. Dash, onion
powder on table daily
22
Team Brainstorming
•Evening & night time snacks easily
available: cookies, cakes, bananas, yoghurt,
fruit cups, smoothies
•Enhance physical & social ambiance of
dining room: new table clothes &
centerpieces, plants, wall posters, flameless
candles, condiments on table
•Limited space: park wheelchairs at entrance
of dining room, assist & encourage residents to
“walk to dine
23
Priority areas selected for improvement
Problem
Too
crowded
Texture of
food too
soft or hard
24
Possible
Who
solutions
Walk to dine. CNAs
Smaller CNA Admin
chairs
Barriers
Solutions
Resident fear PT assess
CNAs Worry On hold
about falling
Different
food
preferences
Purposely
made soft all
can eat
Not
pursued
Priority areas selected for improvement
Problem
Possible
solutions
Environment Centerpieces
(flameless
candles)
Painting room
Throw out old
plants
Buy new
posters
Remove old
decor
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Who
Barriers
Solutions
Unit
Candles will Resident
Manager be taken
store in
Residentroom
MH
Environme
ntal
TR
Admin
TR
Measures Tracked
1. Process Measures – fidelity of the study
Are we doing what we say we are doing
2. Community Outcomes –change in result
Did we make a difference on the community
level
3. Resident Satisfaction Outcomes
26
Process Measures
Tool created to track components of intervention
& whether they are occurring.
Too crowded
Environment
Breakfast
Walk to dine
Painting dining room
Weekly special breakfast
Fewer wheelchairs
Throw out old plants and
décor
Flavored coffee
Smaller chairs for CNAs
Purchase new posters
Muffins, bagels
•Monitored on weekly basis.
• Review findings with team to encourage
successes & problem solve about barriers.
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Process Findings: 7/2011-2/2012
Environmental Changes
20
18
16
14
12
10
8
6
4
2
0
None
Some
All
Painted Redone Plants Posters Table Candles
Walls Floors
clothes
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Process Findings: 7/2011-2/2012
Food choices
All
Some/by request
20
18
16
14
12
10
8
6
4
2
0
Spices
29
Flavored
Creamer
Bagel
Muffins
Butter
Cream
Cheese
None
Process Findings: 7/2011-2/2012
Walk to Dine
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Community Outcomes
• Survey items examine satisfaction with
specific areas identified for change
•Conduct every 4 to 6 months.
•Review findings with team to encourage
successes & problem solve about barriers.
31
Resident Satisfaction with Interventions
Environmental Changes
Have you noticed any recent changes in the dining
room? (N=11)
10 Yes
1 No
How satisfied/dissatisfied are you with the appearance
of the dining room? (N=12)
7 Very Satisfied
2 Somewhat Satisfied
1 Very Dissatisfied
2 NA (Don’t eat in dining room)
32
Resident Satisfaction with Interventions
Environmental Changes
•There is a happier look to the dining room and
very much appreciated.
•The paintings brighten the room.
•It looks like a museum they are very nice
pictures.
•Some pictures are very attractive and I just want
to look at the bridge all the time.
•I love the new look it is really beautiful.
•It doesn’t matter much to me.
33
Resident Satisfaction with Interventions
Breakfast
Have you noticed any recent changes to the breakfast
menu? (N=11)
8 Yes
3 No
How satisfied/dissatisfied are you with breakfast?
(N=12)
5 Very Satisfied
5 Somewhat Satisfied
2 Very Dissatisfied
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Resident Satisfaction with Interventions
Breakfast
•It would be better if we got this [special
breakfast] every day.
•Unimproved.
•It makes breakfast better for me.
•It’s good for those who like it.
•Scrambled eggs and the danish/croissant are
very enjoyable with my coffee.
35
Resident Satisfaction Outcomes
• Annual resident satisfaction survey
•Review findings with team: assess
current state, continue to improve same
area, and/or focus on new area
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Annual Satisfaction Survey:
Quality of Meals
70%
60%
50%
55%
59%
58%
54%
47%
45%
42%
42%
40%
poor/fair
30%
good/excellent
20%
10%
0%
G6 2010
37
G6 2011 Bronx 2010 Bronx 2011
Annual Satisfaction Survey:
Quality of Dining Experience
90%
82%
80%
70%
60%
61%
52%
48%
50%
40%
60%
38%
41%
40%
good/excellent
30%
20%
10%
0%
G6 2010
38
poor/fair
G6 2011
Bronx 2010 Bronx 2011
Annual Satisfaction Survey:
Overall Satisfaction
90%
84%
80%
70%
74%
71%
73%
60%
50%
poor/fair
40%
30%
good/excellent
29%
20%
26%
27%
16%
10%
0%
G6 2010
39
G6 2011
Bronx 2010 Bronx 2011
Outcomes
•Consistent leadership and staff assignment is
essential
•PI model can be used to improve quality of live
as well as clinical outcomes
•Enthusiasm builds through persistence
•Need to involve all key individuals in planning
process
40
Priority areas selected for improvement
Problem
IDed
Possible
solutions
Who Responsible
Barriers
Solutions
1.More
variety
2. Too
bland
Special
Menus
Special
breakfast
flavored
coffees,
bagels,
muffin tops
Condiments
available
Meet with
Kitchen Staff
1.TR staff
2.Kitchen too
integrate in
regular breakfast
3.Back to TR
Kitchen & FSW
Some foods i.e.
lamb shanks
oxtails too
expensive
1. Many flavored
coffees difficult to
manage
2.TR staff changed
3. Kitchen said
would have to do
this on all units.
Therefore only
1X/23 weeks.
No safe place for
condiments
Consider alternatives
1.Flavored creamers
2.New TR staff agreed
to take on roll.
3.Kitchen will handle
as regular breakfast
1X/week.
4. TR again as weekly
activity b/c kitchen
“can’t be done if not
facilitywide.
Need locked space
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Improving Nursing Home Quality of Life within a Performance