CORE CURRICULUM ON MEDICAL
DIRECTION IN LONG TERM CARE
July 21-27, 2012
Baltimore, MD
Core Curriculum on Medical Direction in Long Term Care
July 21-27, 2012  Baltimore, MD
SCHEDULE AT A GLANCE: PART I
TOPIC
DATE / TIME
Saturday, July 21, 2012
AGENDA ITEM
FACULTY
LOCATION
Grand Ballroom
Foyer
3:30 PM - 4:30 PM
REGISTRATION
Topic: 01
4:30 PM - 5:00 PM
Course Introduction
Burl
Grand Ballroom
Topic: 02
5:00 PM - 6:00 PM
Overview of Long Term
Care Lecture
Winn
Grand Ballroom
6:00 PM – 6:30 PM
Small Group Breakout
All Faculty
Breakouts
6:30 PM – 7:30 PM
MEET AND GREET
Grand Ballroom
Foyer
7:00 AM - 7:30 AM
BREAKFAST
Grand Ballroom
Foyer
7:30 AM - 9:45 AM
Regulatory Environment
Lecture
9:45 AM - 10:00 AM
BREAK
Sunday, July 22, 2012
Topic: 03
Topic: 03
10:00 AM - 11:00 AM
Topic: 04
11:00 AM - 12:00 PM
12:00 PM - 1:30 PM
Regulatory Environment
Breakouts
Medical Information
Management Lecture
Sponsored Lunch
Symposium:
Practical Considerations
in Stroke Risk Reduction
in Non-Valvular Atrial
Fibrillation
Leible/Baker
Grand Ballroom
Foyer
All Faculty
Breakouts
Kaplan/Baker
Grand Ballroom
Sponsored
University
Ballroom
All Faculty
Breakouts
Kaplan/Baker
Grand Ballroom
Bluestein
Grand Ballroom
Provided by Boehringer
Ingelheim
Topic: 04
1:30 PM - 2:15 PM
Topic: 04
2:15 PM - 2:30 PM
Topic: 05
2:30 PM - 3:30 PM
3:30 PM - 3:45 PM
Speaker: Steven N.
Singh, MD
Medical Information
Management Breakouts
Medical Information
Management (Wrap-Up)
Employee Health and
Safety Lecture
BREAK
Grand Ballroom
Grand Ballroom
Foyer
1
TOPIC
DATE / TIME
AGENDA ITEM
FACULTY
LOCATION
Topic: 06
3:45 PM - 5:15 PM
Infection Control Lecture
Kaplan/ Brechtelsbauer
Grand Ballroom
Monday, July 23, 2012
Grand Ballroom
Foyer
7:15 AM - 7:45 AM
BREAKFAST
Topic: 06
7:45 AM - 8:45 AM
Infection Control
Breakouts
All Faculty
Breakouts
Topic: 07
8:45 AM - 10:15 AM
Residents Rights Lecture
Brubaker/Bluestein
Grand Ballroom
10:15 AM - 10:30 AM
BREAK
Topic: 08
10:30 AM - 11:45 AM
Financial Issues Lecture
Brubaker
Grand Ballroom
Topic: 08
11:45 AM – 12:00 AM
Financial Issues: Coding
Lecture
Baker
Grand Ballroom
12:00 AM - 1:00 PM
Lunch: In-The-Trenches
Topic: 08
1:00 PM - 3:00 PM
3:00 PM - 3:30 PM
Financial Issues: Coding
(Continued)
Focus Session and
Evaluation of Part I
Grand Ballroom
Foyer
University
Ballroom
Baker
Grand Ballroom
Burl
Grand Ballroom
2
Core Curriculum on Medical Direction in Long Term Care
July 21-27  Baltimore, MD
SCHEDULE AT A GLANCE: PART II
TOPIC
DATE / TIME
Tuesday, July 24, 2012
Topic: 09
Topic: 10
Topic: 10
FACULTY
LOCATION
Grand Ballroom
Foyer
7:00 AM - 7:30 AM
BREAKFAST
7:30 AM - 7:35 AM
Introduction and Overview of
Part II
7:35 AM – 7:45 AM
CMD Presentation
7:45 AM - 7:55 AM
Personality Profiles Worksheet
Burl
Grand Ballroom
7:55 AM - 9:50 AM
Introduction to Medical Care
Delivery Systems Lecture
Brechtelsbauer
Grand Ballroom
9:50 AM - 10:05 AM
BREAK
10:05 AM - 11:30 AM
Essential Health Information &
Tools Lecture
11:30 AM - 12:30 PM
LUNCH
12:30 PM - 1:40 PM
Essential Health Information &
Tools Breakouts
1:40 PM - 1:55 PM
BREAK
Topic: 10
1:55 PM - 3:35 PM
Topic: 11
3:35 PM - 5:10 PM
Topic: 12
AGENDA ITEM
Essential Health Information &
Tools Lecture (Continued)
Medical Director’s Contract
Lecture
Burl
Grand Ballroom
Grand Ballroom
Grand Ballroom
Foyer
Leible/Baker
Grand Ballroom
University
Ballroom
All Faculty
Breakouts
Grand Ballroom
Foyer
Leible/Baker
Grand Ballroom
Burl
Grand Ballroom
Grand Ballroom
Foyer
5:10 PM - 5:30 PM
BREAK
5:30 PM - 6:30 PM
Personality Profiles Lecture
Burl
Grand Ballroom
Wednesday, July 25, 2012
Topic: 13
7:45 AM - 9:00 AM
Influencing Empl. Behaviors
Lecture w/ BREAKFAST
Bluestein
Grand Ballroom
Topic: 14
9:00 AM - 10:00 AM
Medical Staff Oversight Lecture
Kaplan
Grand Ballroom
10:00 AM - 10:15 AM
BREAK
Topic: 14
10:15 AM - 11:00 AM
Topic: 14
11:00 AM - 11:30 AM
Medical Staff Oversight
Breakouts
Medical Staff Oversight Lecture
(Wrap-Up)
Grand Ballroom
Foyer
All Faculty
Breakouts
Kaplan
Grand Ballroom
3
TOPIC
DATE / TIME
AGENDA ITEM
FACULTY
LOCATION
11:30 AM - 1:00 PM
Sponsored Lunch Symposium:
MDS 3.0 and Management of
Moderate to Severe
Alzheimer's Disease in LTC
Sponsored
University
Ballroom
Provided by Forest
Pharmaceuticals, Inc.
Speaker: Roger J. Cadieux, MD
Topic: 15
1:00 PM – 2:15 PM
Biomedical Ethics Lecture
Winn
Grand Ballroom
Topic: 15
2:15 PM – 3:00 PM
Biomedical Ethics Breakouts
All Faculty
Breakouts
3:00 PM – 3:15 PM
BREAK
3:15 PM – 5:15 PM
Working with Families Lecture
Topic: 16
Grand Ballroom
Foyer
Brechtelsbauer
Grand Ballroom
Thursday, July 26, 2012
Grand Ballroom
Foyer
7:30 AM – 8:00 AM
BREAKFAST
8:00 AM - 8:05 AM
Opening Remarks
Burl
Grand Ballroom
8:05 AM - 9:05 AM
Quality Management Lecture
Bluestein/Leible
Grand Ballroom
9:05 AM - 9:20 AM
BREAK
Topic: 17
9:20 AM - 10:00 PM
Quality Management Cont.
Bluestein/Leible
Grand Ballroom
Topic: 17
10:00 AM – 12:00 PM
Quality Management
Breakouts
All Faculty
Breakouts
12:00 PM – 1:00 PM
LUNCH
1:00 PM – 2:30 PM
Risk Management Lecture
2:30 PM - 2:45 PM
BREAK
Topic: 19
2:45 AM – 3:45 PM
Systems Theory Lecture
Brechtelsbauer
Grand Ballroom
Topic: 19
3:45 PM - 4:45 PM
Systems Theory Breakouts
All Faculty
Breakouts
Topic: 19
4:45 PM - 5:15 PM
Systems Theory Lecture
(Wrap-Up)
Brechtelsbauer
Grand Ballroom
5:15 PM - 5:30 PM
Focus Session and Evaluation
Burl
Grand Ballroom
5:30 PM - 6:00 PM
Workshop on Action Plan
Burl
Grand Ballroom
Topic: 17
Topic: 18
Grand Ballroom
Foyer
University
Ballroom
Winn/Kaplan
Grand Ballroom
Grand Ballroom
Foyer
Friday, July 27, 2012
Grand Ballroom
Foyer
6:30 AM - 7:00 AM
BREAKFAST
Topic: 20
7:00 AM - 7:45 AM
Governance Lecture
Brubaker
Grand Ballroom
Topic: 21
7:45 AM - 8:30 AM
Committees Lecture
Brubaker
Grand Ballroom
8:30 AM – 8:45 AM
BREAK
Topic: 21
8:45 AM – 9:15 AM
Committees Breakout
All Faculty
Breakouts
Topic: 22
9:15 AM - 11:15 AM
Leadership in the Organization
Lecture
Burl
Grand Ballroom
Grand Ballroom
Foyer
4
TOPIC
DATE / TIME
AGENDA ITEM
FACULTY
LOCATION
11:15 AM – 11:30 AM
Closing Remarks
Burl
Grand Ballroom
5
Core Curriculum on Medical Direction in Long Term Care
DAILY REMINDERS and INFORMATION
Welcome to the AMDA Core Curriculum on Medical Direction in Long Term Care! We are very excited
about the week ahead since we know the course will offer you opportunities for interaction with one
another and faculty, as well as the chance to provide feedback through the audience response system
(the keypads you see on your desks) and several evaluations – allowing us to check in with you to
learn your thoughts as we go along. The information you provide us is vital to us as we attempt to
tailor the Course onsite to your needs and wishes as a group, and later, to shape future courses to
better meet the overall needs of students in medical direction. We know you’ll find our work this week
intensive, challenging and rewarding.
MATERIALS
As far as materials go, you have each received a bag with several items. The bag includes a flash drive
containing the course materials, slide sets, answer keys and JAMDA reference information. You have
also been provided with an attendee folder including the course agenda, CME tracking form,
commitment to change form, MDS 3.0 booklet, two blank Individualized Action Plan forms and course
evaluation. NOTE: If you will only be joining us for Part I you will not have the course
materials for Part II. We hope you enjoy these resources, a small sampling of the products and
tools AMDA has to offer. AMDA staff will have a display set up later in the week with products
available for sale. We encourage you to take a look.
BREAKOUTS
For several modules, we’ll be working in small groups in breakout sessions. For these sessions you
have been given a participant workbook, which is located on your flash drive. Please bring the flash
drive with you to the breakout session.
FORMING GROUPS
If you have not already done so, please complete the Pre-Course Assessment Form and return to the
AMDA staff ASAP. We will use this information to place you in the appropriate small group assignment.
Group assignments are posted on a board near the registration desk.
EVALUATIONS AND ASSESSMENTS
One goal of this course is to measure learning and changes in attitude at various points throughout the
week. In addition to the pre-course assessment, we ask that you complete the evaluation form we’ve
provided. At the course conclusion, you will also be asked to complete 2 Individualized Action Plan
(IAP) forms. In approximately 6-months you will receive a Post-Course Assessment to complete and
return. Please do not forget to include your name on all forms. We need to be able to match
pre and post assessments to collect data. Your names will only be used for culling information and will
not be noted or referenced in any other way.
6
CME TRACKING FORM
The CME Tracking Form located in your Attendee Folder is a 2-part form. Do not lose it. This is your
record and ours of your participation in this conference. Remember that you must attend both
morning and afternoon sessions to make the most of your educational experience. Please keep one
copy to serve as YOUR certificate of attendance and drop off the other at the registration desk at the
end of the week. A separate certificate will NOT be mailed to you after the conference.
SIGNING IN
Please be sure to sign in each morning and afternoon at the registration desk. We will use the sign-in
sheets to verify your attendance. You need to sign in twice a day.
BATHROOMS
Restrooms are located outside of the General Session room and will be directly on your right.
PHONES
We ask that you limit distractions by turning off your cell phones or turning them to vibrate.
LUNCH
If you requested a special meal, please be sure to bring your meal ticket and give it to your server to
ensure the appropriate meal.
Please return the following forms to AMDA staff by the end of the week:
- Evaluation Form
- The CME Tracking Form
- Pre-course Assessment Form (If you have not previously filled it out online)
- White Copy of the Two IAP Forms
- White copy of the Commitment to Change Form
Thank you and we look forward to learning your thoughts on your evaluation forms and to keeping in
touch with you as AMDA follows up with your progress on your Individual Action Plans.
7
Core Curriculum on Medical Direction in Long Term Care
WHAT HAPPENS AT THE END OF THE CORE?
1. At the end of Part II, Core attendees complete 2 Individualized Action Plans
(IAP) based on the Functions and Tasks that have been covered throughout the
Core.
2. These IAPs can only be done after the full completion of the entire Core
Curriculum (parts I and II) as the knowledge from both parts is needed to fully
implement any plan of action.
3. Development of the IAP is considered to be part of the course Part I and Part II
and is required to be completed in order to obtain the 46 credit hours of
CME/CMD for the course.
4. Return a copy of your IAPs to staff and keep a copy as your guide and reminder.
5. Additionally sign your ‘Commitment to Change’ form and return one copy to
AMDA
WHAT HAPPENS AFTERTHE CORE?
1. Once back in your practice setting, take steps to implement your action plans.
2. Over the following 6 months, you will receive a reminder(s) from faculty to be
working on your action plan
3. At 6 months post-Core, AMDA staff will send you a Post-Course Assessment to
complete and return.
4. In order to obtain all of the 20 additional Performance Improvement (PI) credit
hours of CME/CMD, an attendee must complete the course in its’ entirety.
Full completion of the course includes:
 Pre-Course Assessment
 Part I and Part II of the course
 Development of the IAP
 Implementation of the IAP (successfully or not, with reasons)
 Post-Course Assessment.
The 20 additional credits is a separate activity from the 46 hours awarded for
full participation at Part I and Part II of the Core Curriculum. The 20-hour
activity is a performance improvement activity which allows learners to selfassess and implement improvement to their practice over time. There is no
partial credit for the PI portion of the course.
8
CORE CURRICULUM ON MEDICAL DIRECTION
Learning Objectives
Part I
Part I Overall
 Describe the framework and expected outcome of the course work.
 Explain the concept and levels of care in the continuum of long term care.
 Discuss the effects of influencing factors and emerging trends on the continuum of care.
 Identify regulatory requirements and delineate how the medical director can assist the facility in compliance.
 Assess the survey process and the medical director’s role in the process.
 Recognize the components and functions of a comprehensive medical record in long term care and employ
processes to ensure the integrity and usefulness of the medical record.
 Develop and recommend ways to monitor infectious disease and improve infection control within the facility.
 Critique components and processes that provide adequate employee health and safety programs.
 Integrate awareness of residents’ rights into the differing scopes of practice of medical director and attending
physician within an ethical framework.
 Define the medical director’s functions and tasks relative to financial issues in long term care facilities.
Topic
Topic Objectives
01 Course
1. Delineate the content, format and rationale of the Core Curriculum.
Introduction
2. Define roles, functions and tasks as they apply to medical direction.
3. Describe the behavioral expectations for the participants after the course, including the
development of a personalized action plan.
4. Share data about perceptions of participants’ current behavior.
02 Overview
of Long Term
Care
1. Discuss the history and evolution of systems of long term care.
2. Understand the concept of the continuum of care and identify key organizations that provide
that care.
3. Identify the levels of care provided and the differences between delivery sites.
4. Be able to match the needs of long term patients with the appropriate level of care.
5. Describe the influence of other factors in the long-term care environment.
6. Understand the effect of emerging trends and patterns on the roles and responsibilities of
long term care organizations.
03
Regulatory
Environment
1. List the long term care regulatory agencies and describe their process of developing and
enforcing regulations.
2. Describe the survey process, the types of surveys, and responses to deficiencies.
3. Delineate the ways in which the medical director may assist the facility in complying with
local, state and federal regulations.
4. Define medical director’s role in a survey visit.
5. Describe the role of the medical director and the associated investigative protocol.
6. Describe the special emphasis and regulations regarding medication use in long-term care.
04 Medical
Information
Management
1. Recognize the components and describe the functions of a comprehensive medical record in
long term care.
2. Describe the tasks of the medical director that help ensure the integrity and clinical usefulness
of the medical record.
3. Describe and use a process to critique and improve the usefulness of the medical record.
4. Describe legal and regulatory forces that may impact clinical data.
5. Recognize existing computer technologies designed to facilitate medical record keeping and
promote effective use of facility-wide data.
6. Recognize the differences in record-keeping between nursing facility and non-nursing home
settings.
9
CORE CURRICULUM ON MEDICAL DIRECTION
05 Employee
Health &
Safety
Learning Objectives
1. Describe components and processes of an effective employee health program.
2. List important (common and uncommon, but serious) illnesses and injuries seen in the LTC
setting.
3. Assess the adequacy of the employee health and safety program at the participant’s facility.
4. Define the medical director’s tasks that contribute to a successful facility employee health
program, including workman’s compensation.
5. Manage the potential ethical and legal conflicts resulting from establishing a physician-patient
relationship with an employee while having a fiduciary relationship with the facility.
06 Infection
Control
1. Develop or make recommendations for improving the infection control program in the
participant’s facility.
2. Help control and prevent important (common, or uncommon but serious or emerging)
infectious illnesses dealt with in the LTC continuum, including particularly nosocomial
infections.
3. State the regulatory basis for an infection control program.
4. Describe the medical director’s tasks that contribute to the facility’s infection control program
5. Access current regulations and clinical guidelines that impact this area of medical direction.
6. Choose and utilize appropriate techniques and data sources for facility-wide monitoring of
infectious disease.
07 Residents
Rights
1.
2.
3.
4.
5.
08 Financial
Issues
1. Explain the differences between the sources of Long Term Care funding.
2. Communicate effectively with the administrator concerning the expense and revenue aspects
of the facility budget.
3. Define the nature of the Medical Director’s roles and responsibilities relative to financial issues
in long term care facilities.
4. Identify issues related to documentation, coding and physician reimbursement in long term
care.
Enumerate basic categories of Residents Rights.
Discuss factors that influence the ability of residents to exercise their rights.
Describe common situations where Residents Rights are relevant.
Discuss the prevention of and response to abuse and neglect.
Compare and contrast the medical director’s role and the attending physician’s role in
honoring Residents Rights.
10
CORE CURRICULUM ON MEDICAL DIRECTION
Learning Objectives
Part II
Part II Overall
 Relate the training and typical tasks of the members of the multidisciplinary team and realize how each
contributes to total resident care.
 Explain how the collection and use of data supports quality management and initiatives.
 Delineate the medical director’s responsibility in ensuring facility-wide ethical decision making.
 Employ communication strategies to learn the basic concepts of each family system and to address complex
family situations.
 Analyze the content of the medical director’s contract to ensure that all elements are covered, including risk
management and liability insurance.
 Establish policies, procedures, and tools that enhance care, quality management, and reduce facility risks.
 Assimilate the concepts of leadership, organizational culture, and values that enhance management and care
processes.
 Develop an individualized action plan to implement new strategies or problem solutions at the site of
practice.
09 Introduction
to Medical Care
Delivery
Systems
1.
2.
3.
4.
10 Essential
Health
Information
Tools in
Medical
Direction
(MDS, RAI,
Oasis, others)
1.
2.
3.
4.
5.
6.
11 Medical
Director’s
Report and
Contract
1.
2.
3.
4.
Describe the basic elements of systems theory.
Discuss the characteristics of organization.
List the types of care delivery systems to patients in Long Term Care Facilities.
Describe the training and typical roles and functions of the members of the
multidisciplinary team.
5. Value the contributions of the different members of the multidisciplinary care team.
Trace the history and relevance of the MDS.
Explain the process of data collection in creating the MDS.
Utilize the MDS in the Resident Assessment Instrument for care planning.
Describe how the MDS is utilized as a reimbursement tool.
Demonstrate how the MDS is utilized by CMS for monitoring quality.
Evaluate the application of additional data sets (Oasis, UDS-FIM, pharmacy and lab
composite reports).
7. Recognize potential uses of MDS data for outcomes evaluations, research and quality
management.
Define the purpose and content of the Medical Director’s report.
Describe the elements and content of the medical director’s contract.
Ensure that all of the essential elements are in the participant’s contract.
Discuss elements of risk management including liability insurance and anti-kickback
provisions.
12 Personality
Profiles
1. List the four domains of Myers-Briggs.
2. Explain the differences between the four domains and how they help create a personality
profile.
3. Recognize the potential impact of the four domains may have on Medical Director's
functions.
13 Employee
Behavior
1. Describe situations in which employees may not know why and what they should be doing.
2. Explain why no positive consequences for the right thing could negatively influence
employees’ behaviors.
3. Apply concept of Fourniers differential diagnosis to help correct negative behaviors.
11
CORE CURRICULUM ON MEDICAL DIRECTION
14 Medical
Staff Oversight
Learning Objectives
1. Explain rationale and discuss basic Medical Director responsibilities for Medical Staff
oversight.
2. Describe models of Medical Staff organization and oversight, including non-physician staff
members.
3. Define responsibility in credentialing and privileging.
4. Delineate issues and develop strategies to address medical staff issues concerning roles,
functions or tasks, including non-physician staff.
15 Biomedical
Ethics
1.
2.
3.
4.
16 Working
with
Families
1.
2.
3.
4.
5.
6.
17 Quality
Management
1. Describe QA and TQM principles and tools.
2. Use QA and TQM tools to evaluate and enhance health professional and system
performance.
3. Assist facility in developing and/or maintaining compliance program.
18 Risk
Management
1.
2.
3.
4.
19 Systems
Theory and
Problem
Solving
20 Governance
21 Committees
Discuss basic principles (concepts) relevant to biomedical ethics.
Identify key process steps in managing ethical issues.
Apply key ethical principles and processes in various situations.
Delineate Medical Director responsibilities in helping to ensure facility-wide ethical
decision-making.
5. Use appropriate resources for good decision-making.
6. Discuss ethical considerations of research in vulnerable subjects.
Define basic concepts of family systems, including boundary, structure, and culture.
Relate chronic disease to patient and family relationships and interactions.
Identify common patterns of family behavior that arise in the LTC setting.
Discuss effective strategies to enhance physician communication with families.
Employ appropriate strategies to deal with complex family situations.
Delineate the Medical Director’s tasks that address family issues.
Establish policies and procedures for an effective facility risk management program.
Define the core elements contained within an incident report.
Describe the relationship of unions and medical director.
Identify risk management strategies to reduce medical director's liability.
1. Describe the process of problem solving.
2. Apply systems theory and medical direction tools and skills to problem solving in long-term
care settings.
1. Describe relationships between Medical Directors and governing body, boards,
administrators, and staff.
2. Illustrate basic governance arrangements.
1. Define the role and functions of committees and committee members.
2. Develop and define the role and functions and tasks of committees and committee.
members, and the specific role the medical director will play.
12
CORE CURRICULUM ON MEDICAL DIRECTION
Learning Objectives
Define basic leadership and management principles.
Compare and contrast the differences.
List the skills helpful to exert leadership as a medical director in a long term care facility.
Demonstrate two leadership skills which may be helpful in your facility.
Understand the potential power sources in your facility.
Describe how the behavior of leaders and managers create and define an organizational
culture.
7. Apply an understanding of personality types to your leadership role and how it may
influence team process.
22 Leadership
1.
2.
3.
4.
5.
6.
23 Integration
of the Medical
Director’s Role
and
Development of
Individualized
Action Plan
1. Synthesize the functions and tasks of the medical director to fulfill the role of the medical
director.
2. Develop an individualized action plan.
3. Review the content, format and rationale of the Core Curriculum and agree to participate
in the evaluation and follow-up of the course.
13
Core Curriculum on Medical Direction in Long Term Care
Target Audience
Medical directors practicing in any setting or combination of settings across the long term care
continuum, including skilled nursing facilities, assisted living, CCRCs, hospice, and home care
are encouraged to attend.
Geriatric fellows in training who are considering the inclusion medical direction in their practices
are also encouraged to attend.
This course is the foundation for certification as an AMDA CMD. Taking the course does not
make you a CMD. There are other requirements to complete. Contact AMDA at 800-876-2632
for a CMD Brochure outlining the details of certification as an AMDA CMD.
Course Objectives
The goal of this comprehensive course is to create a stronger sense of the leadership role of the
medical director and to provide opportunities to hone skills and interact with peers. Following
the conference, participants should be able to:
 Develop practical skills needed to fulfill the role and responsibilities of the medical director.
 Identify the unique aspects of the long term care environment that impact the medical director’s
job.
 Describe the organizational responsibilities and dynamics of the medical director and the
interdisciplinary team.
 Develop communication skills to deal with responsibilities for the interdisciplinary team, residents,
and their families.
 Explain the resident care responsibilities of the medical director, including emergency care, quality
management, family systems, and ethical considerations.
 Enhance leadership skills and team building towards a stronger role for the medical director with
the interdisciplinary team.
 Develop human resource skills to deal with difficult situations and improve personal effectiveness
in this area.
 Improve the medical director’s ability to learn and practice in the evolving environment of health
care delivery.
 Apply newly acquired knowledge to daily facility and practice activities.
Accreditation
The American Medical Directors Association is accredited by the Accreditation Council for
Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
CME Credit
AMDA designates this educational activity for a maximum of 46 AMA PRA Category 1
Credit(s)TM. Physicians should only claim credit commensurate with the extent of their
participation in the activity.
14
Certified Medical Director (CMD) Credit
The AMDA Core Curriculum on Medical Direction has been approved for a maximum of 46 credit
hours in medical direction. Credit hours may be applied toward certification as a Certified
Medical Director in Long Term Care (AMDA CMD). The AMDA CMD program is administered by
the American Medical Directors Certification Program (AMDCP). Physicians should only claim
credit commensurate with the extent of their participation in the activity.
AAFP Credit
This program has been reviewed and is acceptable for up to 44.25 prescribed credits by the
American Academy of Family Physicians.
AGS Credit
This program has been endorsed by the American Geriatrics Society. Credits earned from this
activity may be counted toward the AGS Geriatrics Recognition Award.
Tracking and Sign-In Sheets
Attendees should sign in daily (morning and afternoon). All attendees seeking credit should
track their participation on the tracking sheet that AMDA has provided. At the end of the
course, keep the white copy for your records and return the yellow copy to AMDA, as you will
not receive an additional certificate.
AMDA Disclaimer Statement
Participants understand that medical and scientific knowledge are constantly evolving. The
views and treatment modalities of the authors are their own and may reflect innovations
(including off-label or investigational use of medical products) and opinions not universally
shared. Every effort has been made to assure the accuracy of the data presented in the
context of accepted medical practice. Physicians should check specific details such as drug
doses and contraindications, off-label uses, or other details in standard sources prior to clinical
application. The views and treatment modalities of the authors are not those of the American
Medical Directors Association (AMDA), but are presented in this forum to advance scientific and
medical education.
Requirement for Author Disclosure
ACCME and AMDA policy requires everyone in a position to control the content of this
educational activity to provide full disclosure of any affiliation or financial interest that is directly
relevant to speaker’s presentation(s). In addition, speakers are required to disclose when
references to pharmaceuticals, medical devices, or other therapeutic products used in
treatments are “off-label” (not approved by FDA for the use described). Disclosure information
is reviewed in advance to manage and resolve any conflict of interest that may affect the
balance and scientific integrity of an educational presentation.
Faculty Disclosure Information
Faculty are required to provide verbal disclosure prior to each talk. If the learner perceives any
bias toward a commercial product or service, please report this to AMDA staff.
All program planners and faculty have provided full disclosure and report no
relationships relevant to this course.
15
Core Curriculum on Medical Direction in Long Term Care
Faculty Roster and Biographies
Jeffrey B. Burl, MD, CMD (Course Chair)
Sutton, MA
jeffrey.burl@fallon-clinic.com
Jeffrey Burl, MD, CMD is Medical Director of the Overlook Masonic Nursing and Rest Home and Clinical Director of
the Fallon Clinic Division of Geriatrics. He is the director of the AMDA Core Curriculum as well as member of the
education, finance and competency committees.
Alva S. Baker, MD, CMD
Sykesville, MD
dr.alva.baker@grnmd.com
Alva S. Baker, MD, CMD began caring for frail elderly patients in the long term care setting in 1972. He served as
the Medical Director for Episcopal Ministries to the Aging (EMA) from 1980 until his retirement in June of 2009 as
Vice President for Health and Wellness Services for EMA. He concurrently served as the Executive Director of The
Copper Ridge Institute, wherein his focus of research and teaching has been on the care of persons with
Alzheimer’s disease and other forms of dementia. He serves on the faculty of the Division of Geriatric Psychiatry
and Neuropsychiatry of the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins University
School of Medicine. He is also serves on the Gerontology faculty at McDaniel College, where he holds the position
of Director of The Center for the Study of Aging. Board certified in Geriatrics and in Hospice and Palliative
Medicine, he serves on the Professional Advisory Committee of Carroll Home Care/Carroll Hospice, as an Associate
Medical Director for Carroll Hospice, and on the Board of Directors of the Partnership for a Healthier Carroll County.
Dr. Baker is an Emeritus member of the Medical Staff of Carroll Hospital Center in the Department of Internal
Medicine. He has taught extensively about medical direction issues and continuous quality improvement to medical
directors and staff at all levels in residential care facilities throughout the long term care continuum. He is a
Certified Medical Director and a member of the American Medical Directors Association, for which he served as
President in 2007-2008.
Daniel Bluestein, MD, MS, CMD
Norfolk, VA
bluestda@evms.edu
Daniel Bluestein, MD, MS, CMD, AGSF holds the Certificate of Added Qualification in Geriatrics and is Professor of
Family & Community Medicine, Eastern Virginia Medical School. As Director of the Department's Geriatrics Division,
he is responsible for geriatrics training offered to Family Medicine and Family Medicine-Internal Medicine Combined
program trainees. He is also an AMDA-certified Medical Director at multiple long-term care facilities. Dr. Bluestein is
faculty for the AMDA Core Curriculum, has presented at multiple AMDA and other national Geriatrics meetings and
is the holder of two AMDA Foundation/Pfizer Continuous Quality Improvement awards. He is also a past chair of
the ADMA Communications Committee.
16
J. Kenneth Brubaker, MD, CMD
Mount Joy, PA
jkbrubak@masonicvillagespa.org
J. Kenneth Brubaker, MD, CMD completed his geriatric fellowship in 1989 and works fulltime as a geriatrician.
During the past 20 years, Dr. Brubaker has worked as a medical director in several large CCRC in addition to caring
for residents. Presently, he is the medical director of Masonic Village in Elizabethtown, PA and Willow Valley
Retirement Communities in Willow Street, PA. Together the two facilities serve over 500 skilled residents, over 300
personal care residents, and several thousand independent living residents, In addition to running a 35 bed
dementia unit, Dr. Brubaker serves as the PDA/OLTL for the PA Dept. of Aging /Office of Long Term Living and as a
faculty member of the Lancaster General Geriatric Fellowship Program.
David A. Brechtelsbauer, MD, CMD
Sioux Falls, SD
david.brechtelsbauer@usd.edu
David A. Brechtelsbauer, MD, CMD is an Associate Professor in the Department of Family Medicine at The Sanford
School of Medicine of The University of South Dakota, and an Associate Director at the Sioux Falls Family Medicine
Residency. In addition to being Board Certified in Family Medicine, he holds a Certificate of Added Qualifications in
Geriatric Medicine and is a Certified Medical Director. He was awarded the James Pattee Excellence in Education
Award Presented by the American Medical Directors Association in March 2005. He is a past President of the
American Medical Directors Association.
Robert G. Kaplan, MD, CMD
Longwood, FL
drrkaplan@aol.com
Robert G. Kaplan, MD FACP CMD is Board Certified in Internal Medicine with a CAQ in Geriatrics, and a Certified
Medical Director. He has an extensive background in Long-Term Care, and serves as a Multi-Facility Medical
Director and Attending Physician. He is a Board member of the Florida Medical Directors Association and currently
President elect. Dr. Kaplan is a Fellow of the American College of Physicians, was a practicing Internist for
approximately twenty years, and a former Chairman of the Department of Medicine and Medical Staff President of
South Seminole Hospital in Longwood, Florida. A graduate of New York University and the University of Brussels
School of Medicine, Dr. Kaplan completed his residency at the Genesee Hospital in Rochester, New York.
Karyn Leible, MD, CMD
Rochester, NY
kpleible@gmail.com
Karyn Leible, MD, CMD is an internist with a Certificate of Added Qualifications (CAQ) in Geriatrics. During her
geriatric fellowship, she concentrated on long term care and palliative care medicine. She has practiced in 3 states,
Colorado, Florida and Georgia. She has spent time doing clinical practice in academic medicine at Emory University
in Atlanta as well as private practice in Colorado and Florida. Currently, she is in Rochester New York where she is
Sr. VP of Medical Services for Jewish Senior Life. She is Immediate Past President for the American Medical
Directors Association.
Peter Winn, MD, CMD
Oklahoma City, OK
peter-winn@ouhsc.edu
Peter Winn, MD, CMD is a Professor at the University of Oklahoma for the Department of Family Medicine and
Adjunct Professor for the Department of Geriatric Medicine. Dr. Winn is Board Certified in Family Medicine in the
United States and Canada and has CAQs in Geriatrics and Hospice. He is a Palliative Medicine Medical Director for
the long term care (LTC) Unit at the Fountains at Canterbury and is the Medical Director for Mercy at Home
Hospice.
17
Core Curriculum on Medical Direction in Long Term Care
Commonly Used Acronyms and Terms in Long Term Care
ACLS
Advanced Cardiac Life Support
ADE
Adverse Drug Event
ADL
Activities of Daily Living
ADR
Adverse Drug Reaction
AIMS
Abnormal Involuntary Movement Scale
AL / ALF / ALC
Assisted Living / Assisted Living Facilities / Assisted Living Center
ATLS
Advanced Trauma Life Support
BBA
Balanced Budget Act
BBRA
Balanced Budget Refinement Act
BLS
Basic Life Support
CCRC
Continuing Care Retirement Community
CF
Conversion Factor
CFR
Code of Federal Regulations
CMD
Certified Medical Director (through AMDA)
CME
Continuing Medical Education
CMN
Certificate of Medical Necessity
CORF
Comprehensive Outpatient Rehabilitation Facility
CPT
Common Procedural Terminology – a system of codes for billing for physician
services.
CQI
Continuous Quality Improvement
CR
Chemical Restraints
DJD
Degenerative Joint Disease
DME
Durable Medical Equipment
DNR
Do Not Resuscitate
DON
Director of Nursing
DRGs
Diagnosis Related Groups
18
ECF
Extended Care Facility
EMR
Electronic Medical Record
FQHMO
Federally Qualified Health Maintenance Organization
FPL
Federal Poverty Level
F-Tags
A designation used by state survey agencies to identify particular tag sets
within the state operation manual’s interpretative guidelines.
HCPCS
HCFA Common Procedural Coding System
HCR
Health Care Reform
HEDIS
Healthplan Employer Data and Information Set – An automated database for
Managed Care; HEDIS is a set of standardized performance measures designed
to ensure that purchasers and consumers have information to compare the
performance of managed health care plans.
H&P
History and Physical
HHC
Home Health Care – Care provided to individuals in their homes. Patients
must need a skilled service (nursing, PT, OT, ST) to qualify for Medicare
home health benefit; also have to be homebound and need help only
intermittently. If patient qualifies, patient can also get assistance from a
home health aide.
Hospice
Program of palliative (comfort) care for persons who are dying. Medicare
covers hospice services, which may be provided at home or in a hospital or
SNF. Individual must be certified by physician as having less than 6 months to
live.
ICF
Intermediate Care Facility
IPO
Insured Product Option
LMRPs
Local Medical Review Policies
LTC
Long Term Care
LTCF
Long Term Care Facility
MCO
Managed Care Organization
MDS
MICU
Minimum Data Set – used for assessment and care, quality assurance and
improvement, reimbursement, and survey process.
Medical Intensive Care Unit
MLP
Midlevel Practitioner
MSS
Medical Social Services
MSW
Master of Social Work or Medical Social Worker
NDC
National Drug Code
NF
Nursing Facility – can be used to denote a nursing home that is not certified
for Medicare (e.g. not a SNF)
NF
National Formulary
19
OASIS
Outcome and Assessment Information Set (for home care patient)
OBQI
Outbound-Based Quality Improvement (used by Medicare certified home
health care agencies to measure patient outcomes)
OBRA
Omnibus Budget Reconciliation Act
OSCAR
Online Survey Certification and Reporting
PA
Physician Assistant
PASARR
Preadmission Screening and Annual Record Review
PDP
Prescription Drug Plan (with Medicare Part D)
PHO
Physician-Hospital Organization
POS
Point of Service
Post-acute care
Services patients receive after an acute illness (usually entailing a hospital
stay.) Can refer to SNF/NF and home health services, as well as other
rehabilitation services.
PPO
Preferred Provider Organization
PRIT
Physicians Regulatory Issues Team
PPS
Prospective Payment System
PSO
Provider-Sponsored Organization
PSRO
Professional Standards Review Organization
QA
Quality Assurance
QAAC
Quality Assessment and Assurance Committee
QI
Quality Improvement, Quality Indicator, based on MDS data, or Qualified
Individual (Medicare)
QIO
Quality Improvement Organization
QM
Quality Management or Quality Measure, based on MDS data
QMB
Qualified Medicare Beneficiary
RAI
Resident Assessment Instrument
RAP
Residential Assessment Protocol – used for decision making, care planning
and implementation, and evaluation.
RBRVS
Resource Based Relative Value System
RNAC
Registered Nurse Assessment Coordinator
RUGs
Resource Utilization Groups
RVUs
Relative Value Units – components (e.g., physician work, practice expense,
malpractice expense, etc.) used in calculating Medicare physician fee
schedule.
S&C
Survey and Certification
20
SCU
Specialized Care Unit
SLMB
Specified Low-Income Medicare Beneficiary
SNF
Skilled Nursing Facility – A nursing facility (or specially certified part of one)
that participates in Medicare.
SOAP
Subjective Objective Assessment and Plan for progress notes
SOM
State Operations Manual (published by CMS)
TQM
Total Quality Management
UM
Utilization Management
UR
Utilization Review
21
Commonly Used Acronyms for Medical Organizations
AAAHC
Accreditation Association for Ambulatory Health Care
AAFP
American Academy of Family Physicians
AAHCP
American Academy of Home Care Physicians
AAHPM
American Academy of Hospice and Palliative Care
AAHSA
American Association for Homes and Services for the Aging – represents nonprofit providers of nursing facilities, home health agencies, assisted living
communities, and continuing care retirement communities.
ACHCA
American College of Health Care Administrators
ACP – ASIM
American College of Physicians – American Society of Internal Medicine
ADA
American Dietetic Association
ADC
Alzheimer’s Disease Center
ADEAR
Alzheimer’s Disease Education and Referral Center
AHCA
American Health Care Association – represents for-profit owners of nursing
facilities and assisted living facilities.
AHRQ
Agency for Healthcare Research and Quality
AIR
American Institute of Research
ALFA
Assisted Living Federation of America
ALZ ASSN
Alzheimer’s Association
AMDCP
American Medical Directors Certification Program
APIC
Association for Professionals in Infection Control and Epidemiology
ASCP
American Society of Consultant Pharmacists
BQC, BQA
Bureau of Quality Compliance or Assurance
CDC
Centers for Disease Control
CERTs
Centers for Education & Research on Therapeutics
CMS
Centers for Medicare and Medicaid Services (formerly HCFA)
DEA
Drug Enforcement Authority
DHHS
DSS
Department of Health and Human Services
Department of Social Services
FDA
Food and Drug Administration
FEHBP
Federal Employees Health Benefit Program
22
GSA
Gerontological Society of America
HCFA
Health Care Financing Administration (now CMS) – agency that administers
Medicare and Medicaid.
HHS
Health and Human Services
JCAHO
Joint Commission on Accreditation of Healthcare Organizations
MedPAC
Medicare Payment Advisory Commission
MSO
Management Services Organization
NADONA
National Association of Directors of Nursing Administration
NAGNA
National Association for Geriatric Nurse Aides
NAIC
National Association of Insurance Commissioners
NANDA
North American Nursing Diagnosis Association
NCCNHR
National Citizens Coalition for Nursing Home Reform
NCI
National Cancer Institute
NCQA
Managed Care Association
NCQA
National Committee for Quality Assurance
NFCA
National Family Caregivers Association
NIH
National Institutes of Health
NIMH
National Institutes of Mental Health
NLN
National League for Nursing
NPDB
National Practitioner Data Bank
NQF
National Quality Forum
OCI
Office of the Commissioner of Insurance
OIG
Office of the Inspector General
OMB
Office of Management and Budget
OPHC
Office of Prepaid Health Care
OSHA
Occupational Health and Safety Administration
OTA
Office of Technology Assessment
PRO
Peer Review Organization (also known as QIO)
QIO
Quality Improvement Organization
SHEA
Society for Healthcare Epidemiology of America
USP
United States Pharmacopeia
USPHS
United States Public Health Service
23
ORIGINAL STUDIES
Impact of Medical Director Certification
on Nursing Home Quality of Care
Frederick N. Rowland, PhD, MD, CMD, Mick Cowles, BA, MS, Craig Dickstein, BA, MS, and Paul R. Katz, MD, CMD
Objective: This study tests the research hypothesis
that certified medical directors are able to use their
training, education, and knowledge to positively
influence quality of care in US nursing homes.
Design: F-tag numbers were identified within the
State Operations Manual that reflect dimensions of
quality thought to be impacted by the medical
director. A weighting system was developed based
on the ‘‘scope and severity’’ level at which the nursing
homes were cited for these specific tag numbers.
Then homes led by certified medical directors were
compared with homes led by medical directors not
known to be certified.
Data/participants: Data were obtained from the
Centers for Medicare & Medicaid Services’ Online Survey Certification and Reporting database for nursing
homes. Homes with a certified medical director (547)
were identified from the database of the American
Medical Directors Association.
Measurements: The national survey database was
used to compute a ‘‘standardized quality score’’ (zero
representing best possible score and 1.0 representing
Since the introduction of the concept of nursing home
medical directors in the 1970s there have been multiple
papers, guidelines, and books published on the role of the
medical director and how this should affect the quality of
care in the nursing home.
Section of Geriatric Medicine, Saint Francis Hospital and Medical Center,
Hartford, CT (F.N.R.); Mercy Community Health, West Hartford, CT (F.N.R.);
Cowles Research Group, McMinnville, OR (M.C.); Tamarack Professional Services, LLC, Caratunk, ME (C.D.); Division of Geriatrics/Aging, University of
Rochester School of Medicine and Dentistry, Rochester, NY (P.R.K.)
The authors have no conflicts of interest regarding this article.
Address correspondence to Frederick N. Rowland, PhD, MD, CMD,
Department of Medicine, Section of Geriatric Medicine, Saint Francis
Hospital and Medical Center, 114 Woodland Street, Hartford, CT
06105–1299. E-mail: frowland@stfranciscare.org
Copyright Ó2009 American Medical Directors Association
DOI:10.1016/j.jamda.2009.05.012
ORIGINAL STUDIES
average score) for each home, and the homes with
certified medical directors compared with the other
homes in the database. Regression analysis was then
used to attempt to identify the most important
contributors to measured quality score differences
between the homes.
Results: The standardized quality score of facilities
with certified medical directors (n 5 547) was 0.8958
versus 1.0037 for facilities without certified medical
directors (n 5 15,230) (lower number represents
higher quality). When nursing facility characteristics
were added to the regression equation, the presence
of a certified medical director accounted for up to
15% improvement in quality.
Conclusions: The presence of certified medical
directors is an independent predictor of quality
in US nursing homes. (J Am Med Dir Assoc 2009; 10:
431–435)
Keywords: Certified medical director; quality of care;
medical director; nursing facility; skilled nursing
facility
There has, however, been no clear quantification of the
impact that a well-trained medical director can have on the
quality of care within a facility.
The official mission statement of the American Medical Directors Certification Program (AMDCP) is to ‘‘.advance physician leadership.thereby enhancing quality of care.’’1 Since
its inception in 1991, the AMDCP has certified more than
2500 medical directors. The certification process follows an ‘‘experiential’’ model that incorporates existing mechanisms such
as fellowship programs, board certification, continuing medical
education programs (offered by major provider organizations),
courses in medical direction (approved by AMDCP), and other
continuing education programs. Familiarity with the medical
director certification process leads to the expectation that medical director certification is positively correlated with quality of
care. Although such a correlation is commonly and reasonably
asserted, we have found nothing in the literature empirically
demonstrating such a relationship.
Rowland et al 431
24
This study tests the hypothesis that certified medical directors
are able to use their training, education, and knowledge to positively influence quality of care in US nursing homes. The alternate hypothesis (or null hypothesis) is that certification makes
no appreciable difference to nursing home quality of care.
This project was granted institutional review board (IRB)exempt status by the IRB of Wright State University via the
American Medical Directors Research Foundation. The
project was sponsored by generous grants from the American
Medical Directors Certification Program and AMDA state
chapter contributions.
METHODOLOGY
FINDINGS
F tags from the State Operations Manual2 (N 5 27) were
identified that appear to reflect dimensions of quality potentially directly impacted by the medical director. These were
chosen by consensus of the research team including the authors, AMDCP staff, and the AMDCP Executive Committee
on the premise that these were areas of quality potentially
influenced by medical director activity. A weighting scheme
based on the ‘‘scope and severity’’ level at which the nursing
homes were cited for these specific tag numbers was also developed. This was constructed to emphasize serious, widespread, or patterns of deficiencies. It was thought that
a better prepared medical director would be able to reduce
the incidence of deficiency citations for these 27 specific F
tags, or, at a minimum, reduce the scope and severity level
at which they were cited. A listing of the 27 F tags and our
scope and severity–based weighting scheme is listed in
Appendix 1. The weighting scheme is similar, though not
identical, to that used by the Nursing Home Compare
Five-Star Rating guide.3
Using the Centers for Medicare & Medicaid Services’ Online Survey Certification and Reporting (OSCAR) database
as of March 2008, a ‘‘raw quality score’’ was computed, and
a ‘‘standardized quality score’’ for all 15,777 certified nursing
homes that were in operation in the United States in March
2008.4 The raw quality score was computed by summing the
weights of the relevant deficiency citations. We then divided
the raw quality score by the state average raw quality score to
yield a standardized quality score. Standardization of the quality score is necessitated by wide state-to-state variation in the
survey process. For example, New Jersey nursing home surveys
result in an average of 4 total deficiencies per survey, whereas
in neighboring Delaware the comparable average is 13.5
Dividing the raw quality score by the state average ‘‘standardizes’’ the score, creating a measure that is comparable across
states. Note that lower adjusted quality scores denote better
quality, and an adjusted quality score of unity denotes average
quality.
Records of the American Medical Directors Association
(AMDA) were then used to identify 547 nursing homes
that had certified medical directors during the year immediately preceding and during the survey contained in our data
capture. The first step was to compare the average standardized quality score in facilities with certified medical directors
to those without certified medical directors. A ‘‘t test’’ was
then computed to evaluate the degree to which the difference
between the averages was statistically significant. Finally,
other variables were considered that could also affect quality,
and multiple regression analysis was used to better understand
the relationship between medical director certification and
quality of care.
432 Rowland et al
As shown in Table 1, the average standardized quality score
(SQS) in facilities with certified medical directors was 0.8958
compared with 1.0037 for facilities without certified medical
directors. Recall that lower numbers represent better quality,
with zero representing the best possible score. The difference
of 0.1079 represents a 12% improvement in quality associated
with the presence of a certified medical director, and the t test
indicated that the difference is statistically significant at the
98% level.
It was suspected, however, that other nursing home characteristics are correlated with quality, such as facility size, class of
ownership, case mix, staffing, and urban/rural status. Smaller
facilities should tend to have fewer deficiencies because of
fewer opportunities for errors, and not-for-profit facilities are
known to have better surveys than for-profit facilities.5 The
higher case mix associated with more medically complex cases
might result in more deficiencies, higher staffing would be
expected to result in fewer deficiencies, and rural facilities
might have better surveys than urban facilities. The urban/rural impact on quality, if there is one, might more accurately be
associated with size or staffing differences between urban and
rural nursing homes.
There appears to be significant potential for the statistical
relationships hypothesized in the preceding paragraph to confound the initial findings reported in Table 1. For example,
what if facilities with certified medical directors are more
likely to be small, or more likely to be not-for-profit? If that
were the case, then the variation in quality of care that is
attributed to medical director certification in Table 1 might
in fact be attributable to these other factors. Stepwise multiple regression analysis was used to help determine if this
might be the case and to better understand the relationship
between quality and medical director certification. Data
from the best specified equation are reported in Table 2. It
was found that the strongest predictors of adjusted quality
were whether or not the nursing home had a certified medical
director, whether or not the total number of beds in the facility was greater than 99, whether or not it was a proprietary
(for-profit) facility, and the number of registered nurse
(RN) staffing hours per patient day.
Recall that the average adjusted quality score is 1.0000
and that lower numbers reflect better quality. Thus, the
Table 1. Average Standardized Quality Score With and Without
a Certified Medical Director (CMD)
With CMD (n5547)
Without CMD (n515,230)
Difference #
Difference %
0.8958
1.0037
0.1079
12.05
JAMDA – July 2009
25
Table 2.
Regression Equation Predicting Standardized Quality Score
Dependent Variable: Adjusted Quality Score
Number of observations read
Number of observations used
Number of observations with missing values
15777
15618
159
Analysis of Variance
Source
Model
Error
Corrected total
DF
Sum of Squares
4
15613
15617
562.03592
37431
37993
Root MSE
Dependent mean
Coefficient of variation
Mean Square
140.50898
2.39739
1.54835
1.00559
153.97489
F Value
Pr.F
58.61
\.0001
R-Square
Adj R-Square
0.0148
0.0145
Parameter Estimates
Variable
DF
Intercept
Certified medial director present
Beds .99
For profit
Registered nurse hours per patient day
1
1
1
1
1
Parameter Estimate
0.98780
0.14705
0.22309
0.08987
0.24987
estimated regression coefficient of –0.14705 for the certified
medical director variable indicates that, holding other predictors constant, the presence of a certified medical director
will improve quality by about 15%. Other results from the
regression equation were consistent with stated preconceptions, ie, larger facilities, proprietary facilities, and facilities
that staff fewer RN hours per patient day tend to have
poorer quality. Urban/rural status and case mix are not
included in the equation as they did not improve equation
specification.
DISCUSSION
For the first time, this study demonstrates that the certified
medical director has a measurable positive effect on the
quality of care provided in facilities in which they serve.
In 1975, regulations were promulgated that required skilled
nursing facilities to have a medical director. In response to
this, AMDA was formed in 1977 to organize the medical
directors and provide a venue for education of the medical
directors in their role and responsibilities. Numerous articles
(representative articles in references) have been written since
that time about the role of the medical director.6–10 Articles
have been written on specific problems in which the medical
director can and should make a difference.11–13 Textbooks
on the role of the medical director14,15 and long-term care
medicine16,17 have been published. To the best of our knowledge, only one has made an attempt to show via survey of
medical directors and administrators in Maryland that requiring medical director training makes a positive difference in
the quality of medical directorship provided.18 In that study,
which reports on a survey of medical directors and administrators following the institution of mandatory medical director education, there was consensus that the relationship
between the medical director and other administrators in
ORIGINAL STUDIES
Standard Error
0.03461
0.06783
0.02546
0.02744
0.02918
T Value
28.54
2.17
8.76
3.7
8.56
Pr./t/
\.0001
.0302
\.0001
.0011
\.0001
the nursing home was improved, that the medical director
spent more time in the facility working on system issues,
and that the medical director spent more time with the administrator reviewing the care provided. In contrast, the present study uses a comparison of actual survey data from the
facilities.
The current study was initiated in an attempt to demonstrate whether the presence of a certified medical director
made a measurable difference in the quality of care provided
within long-term care facilities. The results support the
conclusion that the presence of a certified medical director
makes an appreciable and positive difference on the quality
of care provided within long-term care facilities. The data
also support the premise that there are other important
factors determining the quality of care provided.
OTHER FACTORS AFFECTING RESULTS
There is great confidence that all 547 nursing homes that
were flagged as having certified medical directors during the
study period actually did have certified medical directors
because all certified medical directors identified their facility
as where they worked in their medical director role for
AMDA records in the time frame immediately before this
study. The comparison group of 15,230 facilities that are
treated as not having a certified medical director may actually
contain facilities that may have had a certified medical
director during all or part of the study period. This is likely,
because of the 2500 certifications awarded, it is estimated
via AMDA records that approximately 1500 of these individuals are still working. If the truth is that certified medical
directors are associated with higher quality, then including
facilities in the control group that actually had certified medical directors would tend to reduce the difference between the
2 comparison groups. Thus, if there were inadvertently
Rowland et al 433
26
included facilities in the comparison group that had certified
medical directors, then the true difference between the
certified and noncertified groups was larger than what is
reported, ie, the research results are even more robust than
what is reported.
The probability values reported in Table 2 are for a 2-tailed
t test. We could argue on theoretical grounds that the 1-tailed
test is more appropriate. Interpreting our t ratios using
a 1-tailed test would also make our results more robust,
ie, double the level of statistical significance for each
predictor variable.
Of note on the statistical analysis of the linear regression
model is that the multiple correlation coefficient (R squared)
is relatively low (0.0148); however, it needs to be placed in
the context that the goal of this study was to test whether
the presence of a certified medical director made a positive
impact on the quality of care in that nursing home, not to
explain the total variation in the quality measured. Thus,
the magnitude of the partial correlation coefficient associated
with the certified medical director variable (–0.14705) and its
associated level of statistical significance (.0302) are of much
greater importance than the absolute value of the multiple
correlation coefficient.
Other factors that theoretically could bias the outcome are
that 2 of the authors are currently certified medical directors
and medical directors of facilities included in the database,
however it is doubtful that 2 individual homes would bias
the overall results in comparison with either the 547 identified facilities with a certified medical director or the 15,230
other facilities. A potentially more important variable is
that many AMDA members have trained in geriatric fellowship programs and have certification in geriatric medicine. Of
the certified medical director–led facilities in this study, 18%
(101 of the 547) are led by medical directors with geriatric
fellowship training. We did not attempt to separate out the
contribution of this training in the current project, but
a recent survey study examined barriers to care and visit
time expectations, which revealed that geriatric-trained physicians may have a higher level of expectation in their care of
long-term care patients.19
Currently, all long-term care facilities are required to
have a physician identified as medical director. The data
now reported suggest that there is a clear and measurable
positive effect on quality if that medical director is a certified
medical director. This may have policy implications in all of
long-term care. Because the certified medical director designation indicates a minimum level of experience and education in medical director management and clinical geriatric
medicine, it suggests that every long-term facility and program should have a certified medical director or the equivalent. An alternate explanation is that certified medical
directors are a self-identified group of dedicated, experienced
individuals who are willing to be held accountable as longterm care providers and leaders, and that they would be so
whether or not they had attained recognition as a certified
medical director. Whatever the reason, our patients deserve
the best of all of us.
434 Rowland et al
CONCLUSION
This research demonstrates that the presence of a certified
medical director in a facility makes an appreciable positive difference in the quality of care provided in that facility. The data
also identify other factors—small facility size, not-for-profit
status, and higher RN hours per patient day—as important determinants of higher quality offered by a facility. It is hoped
that this will lead to further recognition of the knowledge
and skills of trained medical directors, and encourage all medical directors to work to attain and improve these skills.
REFERENCES
1. AMDA. Certified Medical Director in Long Term Care (AMDA CMD).
Available at: http://www.amda.com/certification/overview.cfm. Accessed June 17, 2009.
2. Interpretive Guidelines for Long-Term Care Facilities. Available at:
http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.
pdf. Accessed June 17, 2009.
3. NursingHome Compare. Design for Nursing Home Compare Five-Star
Quality Rating System: Technical Users Guide. January 2009. Available
at: http://www.cms.hhs.gov/CertificationandComplianc/13_FSQRS.asp.
Accessed June 17, 2009.
4. Obtained from the files of Cowles Research Group. Available at: http://
www.longermcareinfo.com/about_oscar.html. Accessed June 17, 2009.
5. Cowles CM. Nursing Home Statistical Yearbook: 2007. McMinnville,
OR: Cowles Research Group; 2008. pp.70, 72–73.
6. American Medical Directors Association. Roles and responsibilities of
the medical director in the nursing home: position statement A03.
J Am Med Dir Assoc 2005;6:411–412.
7. Schnelle JF. Total quality management and the medical director. Clin
Geriatr Med 1995;11:433–448.
8. Schnelle JF, Ouslander JG. CMS guidelines and improving continence
care in nursing homes: The role of the medical director. J Am Med Dir
Assoc 2006;7:131–132.
9. Zimmer JG, Watson NM, Levenson SA. Nursing home medical
directors: Ideals and realities. J Am Geriatr Soc 1993;41:127–130.
10. Smith RL, Osterweil D. The medical director in hospital-based
transitional care units. Clin Geriatr Med 1995;11:373–389.
11. Colon-Emeric CS, Casebeer L, Saag K, et al. Barriers to providing
osteoporosis care in skilled nursing facilities: perceptions of medical
directors and directors of nursing. J Am Med Dir Assoc 2005;6:S61–S66.
12. Richards CL Jr.. Preventing antimicrobial-resistant bacterial infections
among older adults in long-term care facilities. J Am Med Dir Assoc
2005;6:144–151.
13. Munir J, Wright RJ, Carr DB. A quality improvement study on calcium
and vitamin D supplementation in long-term care. J Am Med Dir Assoc
2006;7:305–309.
14. Pattee JJ, Otteson OJ. Medical Direction in the Nursing Home: Principles and Concepts for Physician Administrators. Minneapolis, MN:
North Ridge Press; 1991.
15. Levenson SA, editor. Medical Direction in Long-Term Care: A Guidebook
for the Future. 2nd ed. Durham, NC: Carolina Academic Press; 1993.
16. Katz PR, Calkins E, editors. Principles and Practice of Nursing Home
Care. New York: Springer Publishing; 1989.
17. Ouslander JG, Osterweil D, Morley J. Medical Care in the Nursing
Home. 2nd ed. New York: McGraw-Hill; 1997.
18. Boyce BF, Bob H, Levenson SA. The preliminary impact of Maryland’s
medical director and attending physician regulations. J Am Med Dir
Assoc 2003;4:157–163.
19. Caprio TV, Karuza J, Katz PR. Profile of physicians in the nursing home:
Time perception and barriers to optimal medical practice. J Am Med Dir
Assoc 2009;10:93–97.
JAMDA – July 2009
27
Appendix 1
F-tags Included in Standard Quality Scores
The following list of F-tags was determined by consensus to be those most likely to be directly influenced by the medical
director.
F-Tag
Area of Medical Direction
202
221–222
223
280
281–282
309
314
319–320
323–324
325
329
385, 386, 387, 388, 390
441, 442, 443, 444
492
Identify appropriate ways to minimize avoidable transfers
Restraints: Policies and procedures; alternatives to use
Freedom from abuse
Train attending physicians to help staff develop resident care plan
Medical direction—additional duties
QA relative to MDS
Pressure ulcers
Access to mental health treatment
Minimizing and reporting accidents
Weight loss and nutrition
Unnecessary drugs
Quality assurance issues around physician performance
Infection control
Compliance with federal, state, and local laws and regulations; physician oversight;
additional duties (see also 281–282)
Medical direction
Establish and implement a relevant facility-wide quality assurance program,
including a QA committee
501
520
At the same time, the following weighting scale based on scope and severity was approved:
Scope and Severity Designation
Weight
A – isolated event, no actual harm
B – possible pattern, no actual harm
C – widespread, no actual harm
D – isolated, no actual .minimal harm, no immediate jeopardy
E – possible pattern, no actual .minimal harm, no immediate jeopardy
F – widespread, no actual .minimal harm, no immediate jeopardy
G – isolated, actual harm, no immediate jeopardy
H – pattern, actual harm, no immediate jeopardy, substandard care
I – widespread, actual harm, no immediate jeopardy, substandard care
J – isolated, immediate jeopardy, substandard care
K – pattern, immediate jeopardy, substandard care
L – widespread, immediate jeopardy, substandard care
deleted, not significant to our study
0
1
1
2
2
3
10
10
15
20
20
ORIGINAL STUDIES
Rowland et al 435
28
09 Medical Care Delivery Systems
Learning Objectives
09 Introduction to Medical
Care Delivery Systems
A - General Systems Theory
B - Care Delivery Processes
C - Communication Issues
D - The Interdisciplinary Team “In action”
Core Curriculum on Medical Direction
 Describe the basic elements of systems theory.
 Review some of the organization types of care
delivery processes in long term care facilities.
 Describe the training and typical roles and
functions of the members of the
interdisciplinary team.
 Optimize the contributions of the different
members of the interdisciplinary care team.
2
1
Introduction to Medical Care
Delivery Systems
A – Systems Theory
 There will be an explicit and deliberate
effort to incorporate the principles of
systems theory and systems thinking
throughout the remainder of the course.
 Evolved in the 1920’s.
 At least in part to counteract reductionist
[or Newtonian, or linear] thinking.
 Not a scientific theory to be proven or
disproven.
3
Systems Theory
4
Systems Theory
 Systems:
 Are goal oriented, they have specific
functions.
 Have inputs from the environment.
 Have outputs that they send into the
environment.
 Are impacted by the inputs and outputs,
there are feedback loops.
 Has demonstrated utility in
understanding and impacting the
behaviors of complex organizations.
5
6
183
09 Medical Care Delivery Systems
Systems Theory
Systems Theory
 Organizations are systems, with definable
and predictable characteristics and
behaviors.
 Organizations have a boundary, a
structure, and a culture.
 Organizations contain subsystems and
are part of larger suprasystems.
 Characteristics of organizations
 An assembly of roles (structure).
 Creating a stream of activities (processes).
 To achieve a shared goal (outcome).
http://ide.ed.psu.edu/change/systemsoverview.htm
7
Systems Theory
8
Role of the Medical Director
 Role: The set of behaviors an organizational
member is expected to perform and feels
obligated to perform.
 In 1974 the role of nursing home medical
director was mandated by Federal legislation.
 Roles contain:
 Functions - major domains of activity within
the role and
 Tasks - specific activities used to carry out a
function
 A 1987 national survey of Medical Directors
and a 1988 consensus conference lead to the
definition of eight basic Medical Director
functions, each with from five to eight
associated tasks.
Pattee & Otteson, The Health Care Future, 1997
Pattee & Otteson, Medical Direction in the Nursing Home, 1991
9
Introduction to Medical Care
Delivery Systems
The Big Picture
• Group of related interdependent
processes working together to achieve a
 Systems theory will now be utilized to:
goal
System • common
Made up of a culture, structure and
boundary
Process
People
10
 Examine typical care delivery processes in
LTC.
 Understand the roles, functions, and tasks
of the Medical Director, as well as other
members of the LTC interdisciplinary team.
• Sequence of tasks aimed at
accomplishing a goal
• Produce data which can be
analyzed
• Have beliefs, values,
interests, needs
• Have roles which are
made up of functions
and tasks
11
12
184
09 Medical Care Delivery Systems
B – Typical Care Delivery
Processes in LTC
Typical Care Delivery
Processes in LTC
 The process to move patients (residents)
and information in and out of the LTC
organization.
 Process(es) to assure timely, accurate,
precise and relevant communication
between the LTC facility and other
providers.
 Process(es) to assure optimal ongoing,
routine care.
13
Medical Care Delivery Systems
 What is your process for dealing with a new
admission?
 What do you, as a facility, need to know in
order to provide good care? Accurate and
complete
14
Assure Compliance with
Regulations
42 CFR 483.40 Physician Services
 A physician must personally recommend in writing to admit someone to a
facility.
42 CFR 483.20 Preadmission Screening for Mental Illness or Retardation
(PASAR)
 A state agency must screen and approve the admission…of anyone with
mental retardation or a serious mental illness, and ensure that a facility
can provide appropriate programs and services to meet the individual’s
needs.
 1.
 2.
 3
42 CFR 483.20
Resident Assessment
 Upon a resident’s admission, a facility must have those written physician
orders needed to provide essential care, consistent with the resident’s
current mental and physical status.
 4.
 5.
 Process(es) to provide appropriate
response to unexpected situations.
 Process(es) to assure appropriate
physician care is provided.
 Process(es) to assure provision of
appropriate end-of-life care.
 Process(es) to facilitate effective
functioning of the multidisciplinary team.
15
Admitting a New Resident
16
Admitting a New Resident
 Turn to your neighbor, and discuss :
 Think about:
 Something that works relative to the
admissions process in your facility, or
 What you, as Medical Director, did to solve
a problem that arose relative to an
admission.
17
 Your facility’s process for admitting new
residents.
 Your role as Medical Director: What functions
and tasks are necessary to make the process
work?
 Your role as Medical Director if the process
breaks down?
18
185
09 Medical Care Delivery Systems
The New Admission
The New Admission
 Pre-admission data needed:








Care needs, rehab potential, discharge potential
Admitting and other, chronic diagnoses
Assessment of cognitive status
Psychiatric diagnoses - PASSAR
Infection control issues
Safety issues
Orders - for medications, other orders
Assessment of financial impact
19
The New Admission
 Care needs, rehab potential, discharge
potential
 Is there a “fit” between resident needs and
facility abilities?
 Into which general category will this resident
likely fall?
 Are the goals of care clear? Is there an
advanced directive?
20
The New Admission
 Care needs, rehab potential, discharge
potential




Who needs to know?
When do they need to know?
Whose responsibility is it to find out?
How will information be recorded and
shared?
21
22
The New Admission
The New Admission
 Admitting diagnosis and other, chronic
diagnoses.
 Assessment of cognitive status
 What is their “story.”
23
24
186
09 Medical Care Delivery Systems
The New Admission
The New Admission
 Psychiatric diagnoses - PASSAR
 Infection control issues
25
26
The New Admission
The New Admission
 Safety issues
 Orders - medications, other
27
28
Identifying and Responding to a
Change of Condition
The New Admission
 Assessment of financial impact
 What process(es) does your facility have
in place to assure significant changes are
identified?
 Communication to relevant parties?
 Functions and tasks of the Medical
Director.
29
30
187
09 Medical Care Delivery Systems
Identifying and Responding to a
Change of Condition
C - Communication Issues in LTC
 Potential Resources:
 Chain or facility protocols
 AMDA CPG on Change of Condition
 Policies and procedures, or protocols, you
might implement
31
32
Communication
Verbal Communication




 Advantages
Albert Mehrabian
UCLA Professor of Psychology
Verbal, Vocal, Visual
Interpretation based on 55% visual,
38% vocal and ONLY 7% verbal





In person, or on telephone.
Allows bidirectional information exchange.
Creates sense of urgency.
Allows for immediate response.
Utilizes 2 or 3 modalities- verbal, vocal and
visual (in-person).
33
34
Verbal Communication
Written Communication
 Disadvantages
 Advantages
 Understanding is often assumed.
 Prone to background distractions.
 May not be recorded in chart, dependent
on hearing, memory.
 Significant filtering may occur.
 Creates sense of urgency.
35
 Permanent record
 Flexible (e.g. fax transmissions)
 May allow for broader explanation and
context.
 Legal order, does not require additional in
person signature in most states.
36
188
09 Medical Care Delivery Systems
Written Communication
Written Communication
 Disadvantages
 Characteristics of a good Fax:
 Perception as time-consuming, therefore
may be hurried or incomplete.
 Statement may be responded to out of
context (only have one input-words).
 Assumption that receiving party actually
received and read message (e.g. fax).
 Wrong numbers.
 Allows for easy response.
 Facilitates appropriate distribution.
 Legible, even after multiple faxings and
copies.
 HIPAA compliant.
 Used in appropriate circumstances.
37
D - The Interdisciplinary Team
38
The Case of the Frequent Faller
 Many of the complex problems that present
themselves in geriatrics and long term care are
addressed utilizing the interdisciplinary team
approach.
 An educational drama, starring:





 Solving problems with this approach is not a
given. Given the frequency with which the
approach is used, it is critical that the medical
director learn to function effectively as a
member of the IDT.
Administrator
Director of Nursing
Consultant Pharmacist
Physical Therapist
Medical Director
39
The Case of the Frequent Faller
40
The Case of the Frequent
Faller




 Who did the most talking?
 Who did the least talking?
Personality and assertiveness
Information, knowledge, power
Moderator skill
Team members skill, knowledge of the
“rules”
 Why were there differences?
41
42
189
09 Medical Care Delivery Systems
The Case of the Frequent Faller
The Case of the Frequent Faller
 What values or beliefs seem to motivate
individuals on the team?
 Was there any other information that
could have been brought to the
meeting?
43
The Case of the Frequent Faller
44
The Case of the Frequent Faller
 Was there anyone on the team who did
not need to be there?
 Which approaches used by the Medical
Director were particularly effective?
 Was anyone absent who could have
been helpful?
 Were counterproductive?
45
The Case of the Frequent Faller
46
The Case of the Frequent Faller
 Summary comments:
 What appeared to facilitate the team’s
work?
 What could enhance team efficiency or
effectiveness?
 What might interfere with the team’s
efforts?
47
 They had a team with skilled team players.
 They apparently have had successes, there
was a sense that something could be done.
 They had precise data - probably by their
incident reporting process.
 Would it help to have had a recorder who is
not otherwise a team member?
48
190
09 Medical Care Delivery Systems
Team Essentials
Expert Team in LTC





 Effective use of the medical care
delivery process.
 Awareness of team members skillsets
and roles that effectively use those
skillsets.
 Working effectively as a team.
Trust
Conflict
Commitment
Accountability
Results
 The Five Dysfunctions of a Team, Lencioni
49
50
191
10 Essential Health Information and Tools
Essential Health Information
Tools in Medical Direction

10 Essential Health Information
Tools in Medical Direction


Minimum Data Set
Resident Assessment Instrument (RAI)
Using Data for Quality Improvement
Core Curriculum on
Medical Direction
2
1
Learning Objectives
Learning Objectives
1. Trace the history and relevance of the
MDS.
3. Utilize the MDS in the Resident
Assessment Instrument for care
planning.
2. Explain the process of data collection in
creating the MDS.
4. Describe how the MDS is utilized as a
reimbursement tool.
5. Demonstrate how the MDS is utilized by
CMS for monitoring quality.
3
4
Learning Objectives
Learning Objectives
6. Recognize potential uses of MDS data
and other data sources for outcomes
evaluations, research, and quality
management.
5
1. Trace the history and relevance of the
MDS.
6
192
10 Essential Health Information and Tools
Resident Assessment:
Resident Assessment:
Statutory and Regulatory
Requirements
Statutory and Regulatory
Requirements


Statutory authority from Title 18
(Medicare) and Title 19 (Medicaid) of
Social Security Act as amended by
OBRA 1987
OBRA 1987:

Required Secretary of DHHS to specify a
minimum data set of core elements to use in
conducting comprehensive assessments.
7
8
Resident Assessment:
Statutory and Regulatory
Requirements

Resident Assessment:
Statutory and Regulatory
Requirements
OBRA 1987:

Required Secretary of DHHS to designate
one or more resident assessment
instruments based on the minimum data set.

Federal requirement (42CFR
483.20(b)(1)(I) – (F272) for facilities to
use a resident assessment instrument
that has been specified by the State.
9
10
Resident Assessment:
Statutory and Regulatory
Requirements


Resident Assessment:
Statutory and Regulatory
Requirements
Initial function of database
 1987 OBRA - Care Planning


Added functions of database
 1997 PPS
- Billing
 1999 QI
- Quality management
 2002 QM
- Quality management

11
April 1995 - MDS Version 2.0
October 2010 – MDS Version 3.0
Developed by geriatricians and
gerontologists for HCFA (CMS)
12
193
10 Essential Health Information and Tools
Resident Assessment
General Approach
Resident Assessment
Overall Goals: Long Term Care
(to differentiate from Acute Care)




Quality of Care
Quality of Life
Individualized Program of Care



Resident problem identification



Assessment
Decision- making
Care Planning
Implementation
Evaluation
Whole Person
13
Resident Assessment

Resident Assessment
Goals for resident assessment
instrument




14

Benefits

Comprehensive
Accurate
Reproducible
Standardized



Residents respond to individualized care.
Improved staff communication.
Increased resident and family involvement.
Clearer documentation.
15
16
Learning Objectives
2. Explain the process of data collection in
creating the MDS.
10.1-10.2
17
18
194
10 Essential Health Information and Tools
Resident
Assessment
Resident Assessment

Resident problem identification
 Assessment
 Decision- making
 Care Planning
 Implementation
 Evaluation

Resident problem
identification
 Assessment
 Decision-making
 Care Planning
 Implementation
 Evaluation
19
20
MDS


MDS
Minimum information required to develop
a comprehensive plan of care.
Four components





Face sheet


Completed on admission
Section A Identification Information
Face sheet
Body of the MDS
Quarterly Review
Discharge MDS
21
22
MDS

MDS

Data Set divided into sections A to W
A. Identification and background
B. Hearing screening and vision
C. Cognitive patterns
D. Mood
E. Behavior
23
Data set
F. Preferences for Customary and
Routine Activities
G. Physical function and structural
problems (ADLs)
H. Bladder and Bowel
I. Active diagnosis
J. Health conditions
K. Swallowing/Nutritional Status
24
195
10 Essential Health Information and Tools
MDS

MDS
Data set

L.
M.
N.
O.
Oral/dental status
Skin condition
Medications
Special Treatments, Procedures and
Programs
P. Restraints
Q. Participation in Assessment and
Goal Setting
Data set
V. Care Area Assessment
(CAA) Summary
X. Correction Assessment Request
Z. Assessment Administration
25
26
MDS


MDS
Assessment date (ARD) is date of MDS
completion.


Most sections have a 7 day look back
period. The look back is from the ARD.





Pain assessment in section J is a 5 day look
back.
PHQ-9 depression assessment is 14 days.
UTI past 30 days.
Number of falls since last assessment.
27
28
MDS
MDS

Resident record

RN required.
RN “coordinator” is responsible for
completion of the MDS.
Each individual completing a section or
portion of the MDS must sign off, with
date of section completion.
15 months of data required to be maintained
in the active clinical record.

Sources of information



Facilities are required to produce a hard
copy of each RAI (MDS, CAA) on request.

Can be kept in separate binder, but must be
in a centralized and accessible location.
29
Medical records- transfer notes, physician
orders, medication sheets
Direct communication with and observations of
the resident
 Over all shifts
30
196
10 Essential Health Information and Tools
Assessment Schedule
OBRA – RAI
Medicare – PPS
MDS

One MDS
Sources of information



Direct care staff - CNA
Licensed professionals
 Physician
 PT, OT, Nursing
 Other
Family
Two assessment schedules
Can combine if scheduled properly:
1. OBRA – Care planning
2. PPS – Reimbursement
31
32
Assessment Schedule
Assessment Schedule
OBRA - RAI
OBRA - RAI

Types
 Initial
 Annual
 Significant Change
 Discharge

Quarterly

Timing - Schedule

- Full
- Full
- Full
- Full


- Partial

33
Initial – By 14th day of stay (7 more days to
finish care plan).
Annual – Within 12 months of most recent full
assessment.
Significant Change – By 14th day following
change.
Quarterly – No less than every 3 months,
based on Annual.
34
Assessment Schedule
Assessment Schedule

Medicare – PPS
Discharge MDS




On discharge from facility.
On admission to acute care.
Hospital observation stay greater than 24
hours.
May be combined with a PPS or OBRA
assessment if due.
Day
5
Day
14
Day
30
Day
60
Day
90
Readmit and/or discharge
35
36
197
10 Essential Health Information and Tools
Assessment Schedule
Medicare – PPS
Assessment Schedule
Medicare – PPS

Admission
Discharge
Significant change
All therapies discontinued for Rehab
group and continues to receive SNF
services
Readmission/return
39


Option for Medicare payment
submission
1. Is not self-limiting (2 weeks).
2. Impacts on more than one area of the
resident’s health status; and
3. Requires interdisciplinary review or revision
of the care plan.
Consistent pattern with either 2 or more
areas of decline or 2 or more areas of
improvement.
40

Side effect of medication.
Resident making steady progress.

Short term acute illness from which
recovery is usually expected.


Resident Assessment
Not Significant Change
Discrete and easily reversible cause.

Rugs IV items
A major change in the resident’s status
that:
Resident Assessment
Not Significant Change


Resident Assessment
Significant Change
It is the responsibility of the professional
staff (RN, MD, Rehab) to decide if
changes in condition are significant or
major and appear permanent.

Shorter version of MDS
38
38



37
Resident Assessment
Significant Change?

Medicare Assessments for SNF (MDS
3.0 NP PPS)

URI
UTI

Reassessment done when stable.
Resident stabilized and expected
discharge in immediate future.
End stage status.
Well-established, predictable cyclical
patterns.

Depression with bipolar disorder.
41
42
198
10 Essential Health Information and Tools
Resident Assessment
OBRA Quarterly Review
Resident Assessment
OBRA Quarterly Review
Mandated Sections
Mandated Sections
A
B
C
D
E
G
H
I
J
K
L
M
N
O
P
Q
Identification and background
Vision and hearing
Cognition
Mood
Behavior
Functional status
Bowel and Bladder
Active diagnoses
Health Conditions (pain assessment)
Swallowing/nutritional status
Oral/ dental status
Skin Condition (new, healed, worsening)
Medications
Special treatments and procedures
Restraints
Participation in assessment and goal setting
43
44
Learning Objectives
OBRA RAI
3. Utilize the MDS in the Resident
Assessment Instrument for care
planning.
Resident Assessment Instrument
46
46
45
Resident Assessment
Instrument

Resident Assessment
Instrument

Problem Identification
 Assessment
 Decision-making
 Care Planning
 Implementation
 Evaluation
Three Components:
 MDS (Minimum Data Set)


CAA (Care Area Assessments)


47
Core set of screening clinical, and functional
status elements.
Structured, problem oriented frameworks for
organizing MDS information, and examining
clinically relevant information to identify social,
medical, and psychological problems about an
individual.
Utilization Guidelines (Care plan)
48
199
10 Essential Health Information and Tools
Resident Assessment: RAPS
Resident Assessment Protocols
Resident Assessment
Instrument
Care Area Assessments (CAA)


Decision – making
From MDS: Individual items or
combinations of items can “trigger”
additional assessment by use of one or
more of 20 CAA’s (Care Area
Assessments).
49
Care Area Assessments



Care Area Assessment: CAAS
19 conditions are recognized by the
CAA.

50
1.
2.
3.
4.
5.
6.
20th CAA is discharge goals.
90-95% of all resident problems are
identified.
5-10% are other acute and/or chronic
problems.
Delirium
Cognitive Loss / Dementia
Visual Function
Communication
ADL Function / Rehabilitation
Urinary Incontinence and Indwelling
Catheter
52
52
51
Resident Assessment: RAPS
Resident Assessment Protocols
Resident Assessment: RAPS
Resident Assessment Protocols
14.Dehydration/ Fluid Maintenance
15.Dental Care
16.Pressure Ulcers
17.Psychotropic Drug Use
18.Physical Restraints
19.Pain
20.Return to Community Referral
7. Psychosocial Well-being
8. Mood State
9. Behavior Symptoms
10. Activities
11. Falls
12. Nutritional Status
13. Feeding tubes
53
54
200
10 Essential Health Information and Tools
CAA

CAA
Guides the interdisciplinary team
through a structured comprehensive
assessment of resident’s functional
status to set resident specific objectives
in order to meet the physical, mental,
and psychosocial needs of the resident.
55


Triggered CAAs specify conditions that
warrant care plan intervention.
Triggers detect:
1. Current problem.
2. Resident is at risk to develop a problem.
3. A problem that has rehab or improvement
potential.
56
CAA

Therefore, it is recommended that the facility’s
IDT members collaborate with the medical
director to identify current evidence-based or
expert-endorsed resources and standards of
practice that they will use for the expanded
assessments and analyses that may be needed
to adequately address triggered areas. The
facility should be able to provide surveyors the
resources that they have used upon request as
part of the survey review process.
July 2010 CMS RAI
Manual
57
58
59
60
201
10 Essential Health Information and Tools
CAA
CAA

Triggers


Frequency of using CAA guidelines

Specific items will trigger a CAA
Example: Section N question 0400g
diuretics if checked will trigger
dehydration CAA (14)
1.
2.
3.
4.
Completion of full MDS for OBRA-RAI.
Identification of acute or chronic problems.
Anytime.
Not required for only Medicare-PPS
assessments (non-combined).
61
62
CAA


CAA
Federal regulations state the application
of the CAAs must be documented with
the rationale to proceed or not proceed.

Brief focus statement to include key
issues.
 Problems
 Complications
 Risk factors
CAA summary is required

Section V –MDS
1.
2.
3.
4.
Problem area
Triggered?
Location of information
Care plan decision
63
64
Care Planning
Resident Assessment Instrument


Problem Identification
 Assessment
 Decision-making
 Care Planning
 Implementation
 Evaluation

Developed with problem oriented Care
Area Assessment: CAA
Individualized to address the resident.



65
Know which item response on MDS triggered
that CAA to “steer” assessment to individual
factors.
Done by the IDT.
Physician and family input desired.
66
202
10 Essential Health Information and Tools
Care Planning



Care Planning
Quality of Care F309: “Highest practicable.”
 Requires that the facility monitor the resident’s
condition and respond with appropriate care
planning intervention.
Completion of MDS/RAI does not necessarily
fulfill a facility’s obligation to perform a
comprehensive assessment.
Responsible to assess areas that are relevant to
individual residents regardless of whether or not
the areas are included in the RAI.





67
68
Resident Assessment Instrument
Care Planning

2006 Deficiency Citations







Quality of Care
Accidents
Professional Standards
Accidents
Pressure Sores
Comprehensive Care Plans
Incontinence/Urinary Care
Resident Assessment Instrument
Care Planning

38%
30%
29%
24%
20%
21%
20%
http://www.statehealthfacts.org/profileind.jsp?cat=8&sub=97&rgn=24
Accessed 4/48/08
F 279 - Interpretive Guidelines
 Is the care plan oriented toward preventing
avoidable declines in functioning or
functional levels?

69
F 279 - Interpretive Guidelines
 Does the Care plan build on resident
strengths?
Resident Assessment Instrument
Care Planning

F 279 - Interpretive Guidelines
 Do treatment objectives have measurable
outcomes?


Does the care plan reflect standards of
current professional practice?
71
How does the care plan attempt to manage
risk factors?
70
Resident Assessment Instrument
Care Planning

Evaluation should not be limited to MDS
triggered CAA guideline only.
Supplements clinical judgment.
Need creative thinking to understand or
resolve difficult or confusing symptoms.
Clinical geriatrics
Integration into a meaningful resident
assessment and care plan.
Has information regarding the resident’s
goals and wishes for treatment been
obtained - especially if a resident wishes to
refuse treatment? Has the resident been
given sufficient information?
72
203
10 Essential Health Information and Tools
Resident Assessment Instrument
Care Planning
Resident Assessment Instrument
Care Planning


F 279 - Interpretive Guidelines
 If a resident refuses treatment, does the
care plan reflect the facility’s efforts to find
alternative means to address the
problem?
F 280 - Interpretive Guidelines
 Was interdisciplinary expertise utilized to
develop a care plan to improve a resident’s
functional ability?

In what ways do staff involve residents,
families, and other resident representatives
in care planning?
73
74
Resident Assessment Instrument
Care Planning

F 282 - Interpretive Guidelines
 Is there evidence of assessment and
care planning sufficient to meet the
needs of newly admitted residents, prior
to the completion of the first
comprehensive assessment?
Resident Assessment Instrument
Care Planning

F 282 - Interpretive Guidelines
 Are direct care staff fully informed about
the care, services and expected outcomes
of the care they provide? Do direct care
staff have general knowledge of the care
and services provided by other staff and
the relationship of those services to the
resident’s expected outcomes?
75
76
Resident Assessment Instrument
Care Planning

F 280 - Interpretive Guidelines
 Additional care planning areas that could be
considered in the long term care setting:
Functional status
Rehabilitation/restorative Nursing
 Health maintenance
 Discharge potential
 Medications
 Daily care needs

Resident Assessment Instrument

Functions

Primary data source for documenting a
resident’s status.

Identifies important geriatric conditions that
may need further assessment.

Generates management strategies for the
resident’s care plan.

Determines resident’s progress over time.

77
78
204
10 Essential Health Information and Tools
Resident Assessment Instrument

Questions and
Answers
Problem Identification
 Assessment
 Decision-making
 Care Planning
 Implementation
 Evaluation
79
80
Resident Assessment
The Tasks of the Medical Director

Implement Resident Care Policies

Coordinate Medical Care
Resident Assessment
The Tasks of the Medical Director

Ensure adequate and accurate clinical
data: The initial H&P is the foundation
of much of the RAI – MDS.

Review the output of the assessments:
the care plan (recall that Medical
Director is responsible for “coordination
of medical care in the facility”).
81
82
Resident Assessment
The Tasks of the Medical Director


Coordination of Care
Ensure that attending physicians
perform (adequate) assessments as
needed, with appropriate
documentation.
Review the integration of consultant and
ancillary service data into the
assessment and care planning process.
83

Assuring that the facility is providing
appropriate care as required.

Monitoring and ensuring implementation
of resident care policies.

Providing oversight and supervision of
physician services and medical care of
the residents.
84
205
10 Essential Health Information and Tools
Coordination of Care

Overseeing overall clinical care of
residents to ensure to the extent
possible that care is adequate.

Evaluating reports of inadequate care
and taking appropriate steps to try to
correct the problem.
Coordination of Care

Consulting with resident and resident’s
physician about care and treatment.

Assuring the support of essential
medical consultants.
85
86
Resident Assessment
The Tasks of the Medical Director

Periodically review a randomly chosen
MDS in detail.





Is it complete?
All triggers defined?
Corresponding CAA’s completed?
Resultant data incorporated into care plan?
Care plan implemented and monitored?
10.3-10.7
87
88
Learning Objectives
4. Describe how the MDS is utilized as a
reimbursement tool.
Small Group
Sessions
89
90
206
10 Essential Health Information and Tools
Medicare in NH:
New System
Nursing Home (SNF)
Prospective Payment System

Nursing Home Case Mix Payment
PPS
And Quality Demonstration Project


Medicare
Balanced Budget Act of 1997
Medicaid
BBA97
“BUBBA 97”
91
Federal Rate Calculation
Case Mix System

92

Minimum Data Set
Based on FY 1995 costs
a. Hospital and freestanding
b. Freestanding alone
c. Arithmetic average of a & b

Adjustments
a.
b.
b.
c.
93
Rates - PPS





Only certain items used for
calculations!

Only 108 out of ~ 450
PPS rate covers:

94
MDS 3.0 - Billing
Medicare Part A residents and Part B
costs for residents in Part A stay

Urban / rural
Add-on part B in part a stay
Geographic - wage index
Case-mix from MDS / RUGS III
Routine costs
Ancillary costs
Capital related costs
Case mix adjustments

MDS
95
96
207
10 Essential Health Information and Tools
MDS - “Grouper”
Case Mix Adjustments

Data from MDS run through software
program algorithm called “Grouper” to
assign patients to proper classification
in the case mix system.

Resource Utilization Groups Version VI
(RUGS VI)
8 major classifications
66 group classification
Adjusts for resources used
Based on staff time measures






Classified from MDS
Each group has different payment.
97
98
Case Mix Adjustments
RUGS Categories
Case Mix Adjustments
RUGS Categories








Rehab plus extensive services
Rehabilitation
Extensive services
Special care high
Special care low
Clinically complex
Behavioral symptoms and cognitive
performance problems
Reduced physical function

All categories except extensive services.


Special care high, special care low and
clinical complex categories


Further divided ADL needs.
Also divided by presence of depression.
Behavioral symptoms ,cognitive performance
problems and reduced physical categories

Divided by provision of restorative nursing.
99
100
Case Mix Adjustments
RUGS Categories

Case Mix Adjustments
RUGS Categories
Rehab plus extensive services





All 3 conditions
Having a minimum ADL score or 2 or >
Receiving PT, OT, and/or SLP
Receiving complex clinical care involving
trach care, ventilator/respirator and/or
infection isolation
Rehabilitation


Extensive services

101
Receiving PT, OT, SLP
Resident satisfies 2 conditions
 Having a minimum ADL score of 2 or more.
 Receiving complex clinical care involving
trach care, ventilator/respirator and/or
infection isolation while resident in SNF.
102
208
10 Essential Health Information and Tools
Case Mix Adjustments
RUGS Categories

Case Mix Adjustments
RUGS Categories

Special care high
Minimum ADL score of 2 or higher.
Receiving complex clinical care or have serious
medical conditions:
 Comatose, septicemia, diabetes with insulin,
quadriplegia with higher than minimum ADL
needs (score of 5 or greater), COPD with
dyspnea when lying flat, fever with
pneumonia, vomiting, weight loss, or tube
feeding, IV feeding or resp therapy
103


Case Mix Adjustments
RUGS Categories

ADL score of 2 or more.
Receiving complex clinical care or have serious
medical conditions:


CP, MS, Parkinson’s (with ADL scores of 5 or more),
resp failure with Oxygen therapy, tube feedings,
ulcer treatment with 2 or more ulcers including
venous ulcers, arterial ulcers or Stage II pressure
ulcers, ulcer treatments Stage III or VI, foot
wounds/infections, radiation therapy, dialysis

104
Case Mix Adjustments
RUGS Categories
Clinically complex

Special care low

Residents receiving clinically complex care or
have conditions requiring skilled nursing
management, interventions or treatments
involving any of the following:
 Pneumonia, surgical wounds, burns,
chemotherapy, oxygen therapy, IV
medications, transfusions, hemiplegia with
ADL score of 5 or greater.
Behavioral symptoms and cognitive
performance


Residents with 2 conditions.
Symptoms involving any of the following:
 BIMS score <9, hallucinations, delusions,
physical behavior towards others, verbal
behaviors towards others, other
behavioral symptoms, rejection of care,
wandering.
105
Assessment Schedule
Medicare - PPS
Case Mix Adjustments
RUGS Categories

Reduced physical function

106
Assessment Type
Residents whose needs are primarily for
support with activities of daily living and
general supervision.
107
Reference Date
Payment Days
5 DAY
DAYS 1-5
1 through 14
14 DAY
DAYS 11-14
15 through 30
30 DAY
DAYS 21-29
31 through 60
60 DAY
DAYS 50-59
61 through 90
90 DAY
DAYS 80-89
91 through 100
108
209
10 Essential Health Information and Tools
Assessment Schedule Medicare
PPS
RAI - OBRA

Assessment Schedule
Medicare – PPS

Two assessment schedules
Factors impacting schedule:


OBRA – Care planning

PPS – Billing



One MDS


Can combine if scheduled properly.

Resident expiration / transfer
Discharge to hospital prior to admission
assessment completion.
Resident admitted to an acute care facility
and returns.
Resident leaves facility and returns during
the middle of an ARD period.
Resident discharged from SNF and returns
to SNF level.
109
Assessment Schedule
Medicare – PPS

110
Medicaid
Factors impacting schedule:








Resident in Part A stay begins therapy
Physician hold occurs
Combining assessments
Non-compliance with assessment schedule
Early assessment
Default rate
Late/missed assessment
Errors
111
112
Medicaid

Use of MDS is State Specific.
10.8-10.10
113
114
210
10 Essential Health Information and Tools
Quality Indicators and Quality
Measures:
Learning Objectives
5. Demonstrate how the MDS is utilized
by CMS for monitoring quality.

Quality Improvement
115
116
Historical Background



Quality Indicators
Mid 1980’s Institute of Medicine report
recommended a re-design of the survey
process.
Goal to standardize the survey process.
Use a data driven approach.

Developed as part of HCFA’s National
Nursing Home Case-mix and Quality
Demonstration Project.

Center for Health Sciences Research
and Analysis, University of WisconsinMadison
117
118
Quality Indicators

Quality Indicators

Defined by a national expert panel of:



Nurses
Physicians
Therapists

Pharmacists
Dieticians
Others



119
MDS based
Empirically derived by CHSRA under contract with
HCFA using MDS.
Initial 175 indicators narrowed to 24 (more recently
expanded to 34 with the merging of QI’s and QM’s.
Accuracy of MDS elements from which system was
derived was 72-95% *.
At a resident level, being beyond 95%ile was
associated with 3/4 chance of research surveyor
validation of a problem.
120
211
10 Essential Health Information and Tools
MDS
Reliability of Items
Indicator
Cognitive
skill/decision
making
Hearing
MDS
Reliability of Items
MDS+
Item
B4
NYS 1997 Five State
Reliability Reliability
.96
.88
C1
.75
.89
H1(a-g) .89
.92
ADL supported
H2(a-g) .83
.87
Disease Dx’s
K1(a-ff) .73
.74
Memory/orient.
B2(a,b); .74
B3(a-d)
.69
ADL self perf.
Indicator
121
MDS+
Item
Communication / C4, C6
understanding
Vision pattern
D1,
D2(a,b),
D3
Body control prob H4(a-k)
.59
.62
.73
.69
Behavior prob
E3(a-d)
.60
.63
Nutritional Status L2c;
L3(a-e)
.51
.69
Quality Indicators




Accuracy
Validity

Based solely from responses on the
MDS 2.0.

Reflective of current MDS assessment
data.
Indicators only; an investigation of flags
is required.
Tool for quality assurance.



MDS accuracy is needed.
123
124
Types of Quality Indicators


Quality Indicators
General Indicators


13 Domains

Based on Quarterly and Annual
assessments.

Expect some occurrence
Sentinel Events

122
Quality Indicators
20 studies in 5 demonstration states
700-800 residents included in the study
Each QI was assessed:

NYS 1997 Five State
Reliability Reliability
.88
.66

Should not occur

125
34 Indicators
Without section U- Medications
Does not incorporate the multiple
assessments of the Medicare-PPS.
126
212
10 Essential Health Information and Tools
Quality Indicators
Quality Indicators

Percentile Ranking – “Flagging”



Measures how the facility compares to
other facilities.
Reflects percentage of peer group facilities
that have a lower percentage of residents
flagging on the QI.
Percentile Ranking – “Flagging”


Does not equate to “automatic” assumption
of a problem.
Rather, suggests a concern to be reviewed
and evaluated to determine if a problem
exists and how it is being addressed.
127
128
Quality Indicators
Domains
Quality Indicators

Percentile Ranking – “Flagging”




Absence of a flag does not eliminate
possibility of a problem.
Need to consider all information provided.
QI – Only one tool for surveyors and staff
to use.





Accidents
Behavior / emotional
problems
Clinical management
Cognitive patterns
Elimination /
incontinence
Infection control







Nutrition / eating
Pain management
Physical functioning
Psychotropic drug use
Quality of life
Skin care
Post-acute measures
129
130
Quality Measure/Indicator
Accidents


Quality Measure/Indicator
Behavior/Emotional Problems

1.1 Incidence of new fractures
1.2 Prevalence of falls




131
2.1 Residents who have become more
depressed or anxious
2.2 Prevalence of behavior symptoms affecting
others - Overall
2.2-HI Prevalence of behavior symptoms
affecting others: High risk
2.2-LO Prevalence of behavior symptoms
affecting others: Low risk
2.3 Prevalence of symptoms of depression
without antidepressant drugs
132
213
10 Essential Health Information and Tools
Quality Measure/Indicator
Clinical Management

Quality Measure/Indicator
Cognitive Patterns
Use of 9 or more different medications.

4.1 Incidence of Cognitive Impairment
133
134
Quality Measure/Indicator
Elimination/Incontinence




Quality Measure/Indicator
Infection Control
5.1 Low risk residents that lost control of
their bowel or bladder
5.2 Residents who have/had a catheter
inserted and left in their bladder
5.3 Prevalence of occasional or frequent
bladder or bowel incontinence without
a toileting plan
5.4 Prevalence of fecal impaction

6.1 Residents with a urinary tract infection
135
136
Quality Measure/Indicator
Nutrition/Eating



Quality Measure/Indicator
Pain Management
7.1 Residents who lose too much weight
7.2 Prevalence of tube feeding
7.3 Prevalence of dehydration
137

8.1 Residents who have moderate to
severe pain
138
214
10 Essential Health Information and Tools
Quality Measure/Indicator
Physical Functioning




Quality Measure/Indicator
Psychotropic Drug Use
9.1 Residents whose need for help with
daily activities has increased
9.2 Residents who spend most of their
time in a bed or chair
9.3 Residents whose ability to move in
and around their room got worse
9.4 Incidence of decline in ROM





10.1 Prevalence of antipsychotic use in the
absence of psychotic or related conditions - Overall
10.1-HI Prevalence of antipsychotic use in the
absence of psychotic or related conditions -High
Risk
10.1-LO Prevalence of antipsychotic use in the
absence of psychotic or related conditions - Low
Risk
10.2 Prevalence of antianxiety/hypnotic use
10.3 Prevalence of hypnotic use more than twice in
last week
139


140
Quality Measure/Indicator
Quality of Life
Quality Measure/Indicator
Skin Care
11.1 Residents who were physically
restrained
11.2 Prevalence of little or no activity


12.1 High risk residents with pressure
sores
12.2 Low risk residents with pressure
sores
141
142
Quality Measure/Indicator
Post Acute Measures



13.1 Short stay residents with delirium
13.2 Short stay residents who had
moderate to severe pain
13.3 Short stay residents with pressure
ulcers
10.11-10.12
143
144
215
10 Essential Health Information and Tools
Quality Indicators
Reports



Facility Characteristics
Facility Level Summary
Resident Level Summary
New fields for this report
145
Facility Characteristics Report (New System)
146
Quality Measure/Indicator Report
Facility Level Summary







Numerator - Number in facility with QI condition.
Denominator - Number in facility that could have
the QI condition.
Observed percent
Adjusted percent (For indicators that are risk
adjusted.)
State average
National average
State percentile (How facility compares to others
in the state.)
147
Facility Quality Indicator Profile Report (Old System)
148
New fields for this report
New fields for this report
Facility Quality Measure/Indicator Report (New System)
Facility Quality Measure/Indicator Report (New System)
149
150
216
10 Essential Health Information and Tools
Quality Indicators
Resident Level Summary
The Monthly Trend Report
shows a facility's monthly scores
on any single QI/QM measure.
The months that are displayed
are based upon the time period
selected by the user. For each
month, the report displays the
facility's score as well as the
average score for the facility's
state and for the nation. The
data are displayed in both
tabular and graphical form,
allowing the user to determine
whether the facility's scores are
increasing or decreasing over
time and how those scores
compare with state and national
averages.




Uses most current MDS.
Alphabetical list of each resident.
Date and type of last assessment.
Check mark indicating any QI for which
resident is in the numerator.
Quality Measure/Indicator Monthly Trend Report (New System)
151
152
New fields for
this report
Resident Level Quality Indicator Summary Report
(Old System)
Resident Level Quality Measure/Indicator Report: Chronic Care Sample (New System)
153
154
Quality Measure/Indicator
Reports





Quality Measure/Indicator
Reports
Who gets the reports?
Who uses the reports
Who decides what to investigate?
Who decides what needs to be done?
Who follows up?

As an individual practitioner:



Whether they flag for any conditions.
As Medical Director:

155
For information about your personal
experience and the residents you care for.
To learn more about care being provided by
others.
156
217
10 Essential Health Information and Tools
Quality Measure/Indicator
Reports


Quality Measure/Indicator
Reports
Provides valuable insight to assist
Medical Director in improving care,
evaluation of new protocols, and identify
potential problems.

Role QA committee?



Team of investigators
Comprehensive solutions
Physician best able to analyze data?
Not just for survey.
157
158
Quality Measure/Indicators
Analysis Overview - 2
Quality Measure/Indicators
Analysis Overview - 1




Review Facility and Resident level reports.
Choose QI domains/individual QIs most likely to
represent a problem.
Select a sample of residents that flag on the
chosen QIs.
Check accuracy of each resident’s MDS
 Correct coding
 Actual Status




Decide if selected QI represents a
problem with the care of each resident.
Decide if problem is a part of the care
process.
Identify areas of concern outside the QI
area or with other residents not in
sample.
Decide if problem is widespread and/or
serious for the facility as a whole.
159
Quality Measure/Indicators
Analysis Overview - 3





160
Quality Measure/Indicators
Analysis Overview - 4
Review the QI sample as a whole; check for
accuracy.
Decide if there is a facility wide problem with
the issue related to the QI.
Decide if there is a facility wide problem with
one or more processes of care.
Prioritize the selected QIs according the most
serious and extensive problems.
Within the selected QI, prioritize the problems
and their causes.
161



Develop plans of improvement.
Implement plan of improvement.
Use subsequent QI reports to evaluate
the effectiveness of the plan.
162
218
10 Essential Health Information and Tools
Quality Measure/Indicators
Reports
Use of Quality Measure/Indicators in
Pre-Survey Preparation
Analysis – Summary
 Accuracy of MDS
 Clinical evaluation
 Does problem exist?
 Do other related problems exist?
 Primary root cause vs. secondary causes
 Widespread vs. isolated
 Need a plan to fix
 Monitor achievement of goals

163


Residents are chosen for Phase 1 sample (60%
of total) based on Resident Level Summary.
 Traditional Survey
Areas of focus chosen based on:
 Any Facility level QI > 75%ile
 Weight loss if > 50%ile
 Sentinel events regardless of %ile
 Fecal Impaction
 Dehydration
 Pressure ulcer in “low risk” individual
164
QM/I 3.1
Clinical Management
9 or More Medications


Quality Indicators
Numerator: Residents who received 9 or
more medications on most recent assessment.


Denominator: All residents on most recent

assessment.

MDS 2.0 Quarterly definition: (O1) number

Risk adjusted: No
Opportunity to be proactive
Monitor facility data quarterly
Utilize CQI Process


of medications > 9
PDSA (Plan, do, study, act)
PMPI (Process management and process
improvement)
165
166
Quality Improvement Process
Quality Improvement Process
# QIs Abov e Peer group (Total 34)
Three fundamental questions
18
16



What are we trying to accomplish?
How will we know that change is an
improvement?
What changes can we make that will result
in improvement?
14
12
10
# QIs

# QI Above Peer group
8
6
4
2
0
Q202
Q302
Q402
Q1 03
Q2 03
Q3 03
Q4 03
Q104
Quarter
167
168
219
10 Essential Health Information and Tools
Quality Improvement Process
Quality Improvement Process
"Falls" QIs
"Nutrition" QIs
300%
140.0%
120.0%
250%
% o f C o m p a ris o n
80.0%
Weight loss
Tube feeding
60.0%
200%
Falls
150%
Daily Physical restraints
100%
40.0%
50%
20.0%
0.0%
0%
Q202
Q302
Q402
Q1 03
Q2 03
Q3 03
Q4 03
Q104
Q202
Quarter
Q302
Q402
Q1 03
Q2 03
Q3 03
Q4 03
Q104
Quarter
169
170
What happened?
"Behavior" QIs
400%
350%
Small Group
Sessions
300%
% o f C o m p a ris o n
% o f C o m p a ri s o n
100.0%
250%
Behavior
200%
Behavior high
Behavior low
150%
100%
50%
0%
Q202
Q302
Q402
Q1 03
Q2 03
Q3 03
Q4 03
Q104
Quarter
171
172
Nursing Home Quality Initiative
NHQI

Quality Measures
10.13-10.15
173
174
220
10 Essential Health Information and Tools
Quality Measure Initiative


Public reporting – Web Site
 Nursing Home Compare
 Internet access of information
 Eventual payment penalties for poor care
trends?
From MDS
 Numerators
 Denominators
 Exclusion criteria
 Facility admission profile (FAP)
 Covariates
Quality Measure Initiative





2003: Looked at 6 chronic and 3 post acute
measures.
2004: “Enhanced” - 11 chronic and 3 post acute
Calculated quarterly
QI Organizations given money to increase
scrutiny of long term care.
Requires ongoing facility level monitoring of
care trends to proactively identify problems and
implement corrections immediately.
175
176
Quality Measures

Quality Measures
“These measures will help consumers
better understand and compare quality
of care when selecting nursing homes
and will help to monitor care once they
or a family member is in the nursing
home”

“Nursing homes can also use these
measures to benchmark how they are
doing compared to others in addressing
important nursing home quality of care
issues.”
David Gifford, MD, Co Chair NQF Steering
Committee on Nursing Homes
177
178
NQF Endorsed Measures
(Long Stay)






NQF Endorsed Measures
(Long Stay)
Physical therapy/restorative therapy for long
stay residents with new balance problems .
Percent of residents experiencing falls with
serious injuries.
Percent of residents who report moderate to
severe pain.
Percent of residents given influenza vaccine.
Percent of residents given pneumo vaccine.
Percent of residents with urinary tract
infections.
179






Percent of residents with new incontinence.
Percent of residents with a urinary catheter
inserted.
Percent of residents who are physically
restrained.
Percent of residents needing more assistance
with ADL.
Percent of residents loosing weight.
Percent of residents with depressive sym.
180
221
10 Essential Health Information and Tools
NQF Endorsed Measures
(Short Stay)





Quality Initiative - August 2005
Percent of resident on pain medication
regimen who experience a decrease in pain
Percent of residents who report moderate to
severe pain
Percent of residents with pressure ulcers that
are new or worsened
Percent of residents given influenza vaccine
Percent of residents given pneumo vaccine

QIS-Quality Indicator Survey

QI/QM combined Quality Indicator and
Quality Measure report
181
182
Increased Scrutiny of MDS
MDS Considerations

MDS repeatedly tested for accuracy and the
variances differ from whatever organization is
conducting the study.




CMS training of regional offices.
Increased software edits and monitoring.
Data Assessment Verification E project
(DAVE).
 On site federal teams review accuracy of
MDS information.
 Financial
 Clinical
 Intermediary targeting of problem trends.
 National rollout was Fall 2003.



OIG expected exact matches and that may be
unreasonable (Statistically Equal up coding to down
coding).
GAO identified MDS errors based on discrepancies in
documentation.
MDS “authors” using Kappa reliability 89% reliability
Individual States who utilize for Medicaid payment
report high confidence levels.
183
184
MDS Errors - GAO Report



MDS Errors - GAO Report

MDS errors exist because federal/state
safeguards are inadequate.
The GAO recommended that CMS take
the following steps:

Require facilities to provide documentation to
back up MDS info (CMS now considers the
MDS a primary document).

Monitor states' efforts to ensure MDS
accuracy instead of conducting broad federal
MDS reviews that examine only a small
sample of assessments.
1998 study: 67% of MDSs contained errors
that impacted reimbursement.
Claims Government does not monitor MDS
accuracy.
185
186
222
10 Essential Health Information and Tools
MDS Summary:
MDS Errors - GAO Report


CMS claims current oversight system is
adequate and that requiring backup
documentation for the MDS would
create a burden for SNFs.




Used clinically for care planning.
Used for billing.
Used for quality assurance.
? To be used for medical review.
Nursing homes that increase their
spending do not necessarily enhance
quality of care.
187
188
MDS Changes
MDS


Strengths





Universal set of information permitting
tracking and comparisons across NHs.
Focuses mostly on relevant clinical
characteristics.
Systematic and structured approach to
assess residents.
Field tested

MDS 3.0 implemented October 2010
Residents are interviewed directly about care.
Improved accuracy





Modifications of response options.
Revised instructions for diagnoses providing detailed
algorithms in order to assist in defining active
disease.
Adoption of the PUSH tool for pressure ulcers.
New ADL items separate toilet transfer from toileting
and upper body dressing from lower body dressing.
New delirium section
189
MDS 3.0 Changes

190
MDS 3.0 Changes
Brief Interview for Mental Status (BIMS)
(direct measure of short term memory
and temporal orientation) replaces the
Cognitive Performance Index (which
was based on subjective staff
assessments of patients memory and
daily decision making.
191



Delirium assessment incorporates the
CAM (Confusion Assessment Method)
Mood - Direct resident interview
(Resident Mood Interview) added to a
revised subjective staff observations of
resident mood.
Behaviors - Impact of behaviors
addressed (in addition to presence).
192
223
10 Essential Health Information and Tools
MDS 3.0 Changes


MDS 3.0 Changes
Interview for daily preferences directly
assesses the importance the resident
places on various aspects of daily life
(e.g. “How important is it to you to
choose what clothes you wear?”) used
to assess quality of life.
Pre-admission mobility assessment
added.


ADL scoring is modified to provide more
detail regarding levels of assistance.
Scale combines Self-Performance and
Support Provided

Moderate assistance added


With less than two person assist.
With more than two person assist.
194
193
MDS 3.0 Changes



MDS 3.0 Changes
Bowel and bladder assessment lookback
shortened to last 5 days (used to be 14 days),
and facility can indicate if patient has had a trial
of a toileting program.
Expanded list of Disease Diagnoses (Section I).
Pain assessment expanded to include
assessment of impact of pain on function and
use of analgesics.



Falls history / assessment added.
More detailed dental assessment added.
Expanded pressure ulcer assessment
that allows calculation of PUSH score.
195



196
MDS 3.0
MDS 3.0
Increased use of dropdown boxes.
Preliminary testing suggests it takes less
time and is more reliable than MDS 2.0.
Target implementation date October 2010.

197
http://www.cms.hhs.gov/NursingHomeQ
ualityInits/25_NHQIMDS30.asp
198
224
11 Medical Director's Contract
11 Medical Director’s
Report and Contract
Core Curriculum on
Medical Direction
2
1
Learning Objectives




Risk Management
Define the content and purpose of the
Medical Director’s report.
Describe the elements and content of the
Medical Director’s contract.
Ensure that all of the essential elements
are in the participants contract.
Discuss elements of risk management
including liability insurance and antikickback provisions.
3




The process of care has changed dramatically over
the past few years.
Medical Director's accountability and responsibility
to the overall quality of care has likewise increased.
Governmental agencies, insurers and payers,
facilities and even families are holding us to a
higher standard as well as holding us more
responsible for overall outcomes.
Besides improving quality we need to be proactive
in risk management reduction.
4
Risk Management Reduction
Techniques





Implement a Medical Director report.
AMDA contract
Administrative liability insurance
Proactively review facility’s policies and
procedures.
Participate in QA meetings, review of QIs.
11.1 – 11.2
5
6
225
11 Medical Director's Contract
Medical Director’s Report:
Role
Medical Director’s Report





Role
Purpose
Contents
Frequency
How to operationalize

Advisor and update to:
 Ownership
 Administration
 Other professional staff
7
8
Medical Director’s Report:
Purpose

Medical Director’s Report:
Contents

Demonstrate performance of
contractual and regulatory obligations.

Report of duties and tasks performed .
Review of clinical care in the facility (QI
viewpoint). May include:


Provide education and information.






9
Medical Director’s Report:
Frequency


Admissions, discharges, deaths
ED transfers, hospitalizations
Medical staff issues
Quality Indicators and Surveillance
Review and analysis of the overall quality of care in
the facility.
Relevant outcomes data
Emerging long term/geriatrics information
10
Medical Director’s Report:
How to Operationalize
Needs to be negotiated with administration and
board. At a minimum every 3 months, but you
may want to consider monthly for larger facilities
with sub acute care units or ongoing issues with
quality, infection control, quality indicator outliers
or physician issues.
Shorter reports addressing above issues will be
helpful for state surveys.
11

Create a medical directors log by tracking
all of the time spent for the facility.

Establish a process for keeping track of
what you are doing and when.

Periodically review of Medical Director’s
log.
12
226
11 Medical Director's Contract
Medical Director’s Report
How to Operationalize

Establish data collection and reporting
systems.



Medical Director’s Report:
How to Operationalize
Clinical data
Minutes of meetings, etc.



Meet with Administrator and DON to
review and discuss issues (don’t
surprise them with what you put in your
report).
Schedule and allow adequate time to prepare a wellthought out, incisive, and comprehensive report.
Time to complete report should be part of time spent
performing director activities.
Determine protocol for distribution of your report. Need to
allow appropriate individual(s) to review initially.
 Board, CEO
 Others
 Finance
 Compliance, etc.
13
Medical Director’s Report:
The Reality


14
Medical Director’s Report
Actual contents and frequency are determined by
the facility context.
 Administrative and reporting structures.
 Tasks and responsibilities of various
committees.
Nevertheless: Even if part of the suggested
components of the Medical Director’s Report are
done by others, the organization still benefits from
the Medical Director’s review and analysis of the
information!!!!!
One Physician’s Sample
15
16
Medical Director’s Report
Medical Director’s Report
Overlook Masonic Nursing Home
Medical Director’s Report
Jeffrey B. Burl, MD, CMD
1. Immunization Review:
Date: September-October 2010
Contents:
1. Immunization Review
2. Annual QI discussion
3. GI outbreak
4. Navicare

17
Review of charts of those that have been
here since last October, reviewed the %
without flu vaccine and reasons why refusal.
11% did not receive the vaccine. Found that
40% was the family’s desire to avoid the
vaccine. Called 5 families and all expressed
the same fear of avoiding possible side
effects. Awareness program started.
18
227
11 Medical Director's Contract
Immunization Review



Medical Director’s Report
* Review of pneumococcal vaccine:
92%. Those that hadn’t received it had
been admitted within past 3 months.
Found that though the staff queried
about the vaccine, there wasn’t always
follow up to insure it was given.
Created a policy to insure all eligible
residents were given the vaccine.
2. QI:
Given that we would no be having any QI
reports for the next 12 months, the QI team
used PSDA to decide on QI projects for the
coming 6 months. After multi-voting, we
choose 3 topics; created fishbone diagram for
each identifying possible opportunities; did
flow charting and then ad hoc committees
established with participants and chairs.
 Process took two separate sessions to
complete.

19
Medical Director’s Report
20
Medical Director’s Report
3. GI Outbreak:

Onset of GI sx’s started in the post acute care
unit. Sx’s of nausea and vomiting followed by
diarrhea lasting 24-36 hrs. Despite isolation
precautions, it spread to the rest home then
to the 3 nursing floors. Total of 58 residents
with the illness, no hospitalizations, 10
required IV fluids. Met with DON\IF control
daily, reviewed numbers and units and
process. State notified.

4. Navicare
Met with representatives of Navicare. This is
a dually eligible Medicare-Medicaid insurance
program for those over 65. Besides the usual
past A and B benefits, they offer a greater
benefit package for seniors especially for
nursing home residents. I arranged a meeting
with admin and Navicare to discuss possibility
of having Overlook as a preferred facility.
21
Medical Director’s Report
22
Medical Director’s Report
Time Log (see detailed log):
Time Log:
September: Daily meetings with DON\IF
from mid Sept to early October re GI
infection. Weekly UM meeting; quarterly
QI meeting; semi-annual meeting on
SNF admissions\LOS, hospitalizations;
Several calls to Dr L re tardy visits;
routine visits on 3-W,2-E and 4th floor. In
service on DM.
October: Attendance at monthly QA;
weekly utilization meetings; quarterly
rehab meeting; regulatory visits 2-W,3E
snf; daily discussions with DON until
October 8th re GI sx’s; CPR renewal;
visit with CM’s at Harrington Hospital re
referrals to SNF unit.
23
24
228
11 Medical Director's Contract
Time Log

Medical Director’s Report
Week September 14 th:
Monday: meeting with staff on sub-acute unit re new diarrhea.
Routine rounds and rounds on post acute;
Tuesday: meeting with DON\IC re diarrhea; weekly Medicare
utilization meeting 11-12; rounds on post acute care unit;
Wednesday: several meetings with staff, DON\IC re GI
outbreak; routine rounds on 3-W; call to Dr L re tardy visit;
Thursday: QA meeting; post acute care rounds; meeting to
discuss GI Sx’s. Meeting with Navicare insurance program.
Friday: rounds with medical residents; GI meeting. Rounds
on 2-E.
Practical Time
Create a report now
25
26
Medical Director’s Report
11.3 – 11.4
27
Regulation F-501


28
Medical Director’s Role
The facility must designate a physician to
serve as Medical Director.
The Medical Director is responsible for—
 Implementation of resident care
policies; and
 The coordination of medical care in the
facility.
29

Implementation of resident care policies.

Coordination of medical care in the
facility.
30
229
11 Medical Director's Contract
Medical Director’s Functions




Medical Director’s Functions
Provides leadership to meet medical care
goals.
Development and implementation of
policies and procedures.
Participates in QA, infection control,
pharmacy, safety.
Stays abreast of factors that may impact
long term care.




Interacts with regulatory agencies.
Negotiates contract and writes a periodic
report.
Keeps staff informed of changes in
policies and procedures.
Participates in the disciplinary action of
the organization when appropriate.
31

32
Priorities of Medical Director
Contract Provisions
By the end of the session each medical director
will create an individualized action plan for
his/her facility.




Yet each of your organizations may have
specific needs that you want to incorporate into
the contractual language. Eg, dedicated time for
in-services, having a computer available, hiring
infection control nurse…



Successors & Assigns
Notices
Waiver
Dispute resolution
Validity
State law
33
34
Specifications




Successors: Someone who comes after,
who will replace you.
Notices: A requirement that a party be
aware of the legal process affecting their
rights and obligations.
Waiver: Voluntary surrender of a right or
privilege.
Dispute resolution: Process for resolving a
dispute.
35

General qualifications

Services of the physician

Facility provisions
36
230
11 Medical Director's Contract
Specifications

Specifications
Compensation

Confidential information



Insurance
 Administrative liability
 Malpractice

Patient
Facility
Termination




Mutual
Death
Incapacity
Disciplinary
37
38
Termination


Minimum Qualifications
Mutual: Usually a 60 day notice to either party.

Incapacity, coverage: Arrangements should be
made on the contract that spell out the coverage
issues for medical director, who to call and
expectations of covering physician.




Remember that, if you resign, you may not be
able to re-sign a contract until the 12 month time
frame has elapsed per safe harbors.


Valid medical degree
License
Work experience, professional
accomplishments and honors
Freedom from illegal substances.
No healthcare felony convictions.
Not on OIG’s list of fraudulent providers.
39
40
Performance Requirements





Facility Provisions
Be prepared to be a leader.
Current geriatric and long term care
knowledge.
Current regulatory knowledge.
Current rights, dignity, individuality
knowledge.
Compliance with federal & state
regulations.



41
Correct legal entity: Correct address and
signatures. Specify time commitment and
when services will be provided.
Contracts with group practices should
designate specific individual.
Engagement: Full time vs. part time,
independent vs. employee
42
231
11 Medical Director's Contract
Service Agreement
Facility Provisions

Insurance for administrative decisions

Term of contract: Minimum 12 months
with annual renewal

Basic comforts: Desk, phone, (?)
computer, staff
43
44
Service Agreement






Service Agreement
Obligations
Management and Oversight
Licensure
Confidential Information
Time Records
Payment for Services







Basis for Compensation
Inspection of Records
Termination
Notices
Amendments
Miscellaneous
Appendix
45
46
Insurance




11.5 – 11.6
47
Malpractice insurance does not cover your
administrative decisions at the nursing home.
You need to have administrative liability
insurance coverage.
Best option is to be included on the home’s policy
that covers administrative decision making. No
additional cost to the facility.
If facility does not provide medical director liability
coverage, then negotiate compensation to cover
cost for additional insurance.
48
232
11 Medical Director's Contract
Avoiding Fraud

Anti-kickback provisions and safe
harbors

Stark I and II
Anti-kick Back
On the books since 1972. Designed to protect
patients and health care system from fraud and
abuse.
Anyone that knowingly and willfully receives or
pays anything of value to influence the referral
of federal health care program business.
Designed to avoid the inference that
acceptance of the position is wholly or in part
influenced by the number of referrals.



49
50
Anti-Kick Back Regulation
Safe Harbors



Safe Harbors
Because the law is broad on it’s face, concern
that innocuous arrangements could have been
construed to violate the law.
Safe harbors, though on the surface seem to
violate the intent, are created to protect
individuals and organizations in defined specific
circumstances
1987 issues regulations designating ‘safe
harbors’ for various practices.




Protects investments of physicians who
are in a group practice.
Will protect referrals when there is
knowledge that the patient will be
‘referred’ back for ongoing care.
Underserved areas.
Investments in ambulatory surgical
centers.
51
52
Anti-Kickback Provisions






Stark
Be in writing & signed by parties.
Specify services to be provided.
Specify schedule if not full-time.
Term not less than one year.
Compensation not based on volume or
value.
Not involve promotion or business
violating state law.
53



Stark I enacted in 1989 as method of
prevention of influence of referrals based
solely on volume in the laboratory arena.
In 1993 congress broadened the law
(Stark II) to include referrals of a broad
array of ‘designated health services’:
DHS.
Final Stark II, 2002, in two phases, only
phase I published.
54
233
11 Medical Director's Contract
Stark II
Exceptions
Stark II

A physician cannot refer patients to an
entity for DHS if there is a financial
relationship between the referring
physician (or immediate family member)
and the entity unless it fits into one of
the specific exceptions.




Provided contracting parties more
flexibility in their contracting.
If work within a group practice and use
their services.
Ambulatory surgical centers.
Dialysis related outpatient prescription
medications that are administered by
staff at dialysis.
55
56
Stark II Provisions







Be in writing & signed by parties.
Cover all of the furnished services.
Cover all separate agreements.
Cover aggregate services.
Term at least one year.
Compensation set in advance & fair market
value.
Not involve promotion violating state or federal
law.
11.7 – 11.9
57
58
Compensation For Administrative
Activities




59
Needs to be individualized per facility and overall
financial health of the institution and corporation.
Be willing to be flexible and use time as director
to demonstrate your value to the organization.
Have defined objectives for annual review, such
as periodic reports, in-services, policy reviews…
Remind administration that there is both direct
and indirect time element and which may be in
equal portions.
60
234
11 Medical Director's Contract
Compensation






Compensation
Scope of required duties
Facility size
Location
Case mix/acuity
Length of stay
Specialized care units

Support services available

Managed care contracts: Are you
capitated for your services?

Risk/gain contracts
61
62
Compensation





Compensation

May vary year-to-year
Consider committee time
Consider “on-call” commitment
Inservice
Employee health





Consider fair market value of services.
Varies with time commitment.
Never linked to occupancy rate, bed
rate/month.
Consider negotiating for CME activities, AMDA
membership.
Compensation not dependent on volume of
patient referrals or other business generated.
Cannot promote or counsel business
arrangements that violate law.
63
AMDA Survey
Services Performed
AMDA Survey
Board
Certified
2004
2008
2010
84%
80
7
CAQ
49%
Geriatrics
43
Office
Practice
50
59%
64
35
45
65
2004
2008
2010
SNF
96%
78
80
Hospital
SNF
0%
20
15
Hospice
48%
40
37
ALF
54%
50
49
LTAC
0%
23
19
66
235
11 Medical Director's Contract
National Average = $155.73
State – Hourly Pay
State
Compensation


AMDA membership survey 2010:
 Average: $ 155\hour
Minimum
Maximum
5
$289.00
$120.00
$500.00
AR
3
$70.00
$50.00
$85.00
AZ
13
$131.62
$57.00
$200.00
CA
27
$177.41
$33.00
$750.00
CO
5
$137.00
$60.00
$200.00
4
$156.25
$125.00
$200.00
DC
4
$177.50
$150.00
$200.00
FL
19
$166.68
$100.00
$400.00
GA
18
$174.03
$50.00
$560.00
State
Average
Minimum
Maximum
MT
1
$100.00
$100.00
$100.00
NC
19
$162.81
$64.00
$500.00
ND
3
$166.67
$50.00
$250.00
NE
6
$182.92
$60.00
$300.00
NH
3
$133.33
$100.00
$150.00
NJ
13
$166.03
$100.00
$275.00
NM
# of Responses
$175.00
$100.00
NV
1
$200.00
$200.00
$200.00
NY
29
$142.52
$50.00
$400.00
OH
4
23
$225.00
HI
2
$140.00
$100.00
$180.00
$154.37
$85.00
$200.00
IA
10
$143.70
$67.00
$200.00
OR
4
$143.75
$130.00
$150.00
30
$139.33
$50.00
$275.00
$100.00
ID
4
$186.25
$100.00
$400.00
PA
IL
15
$131.07
$35.00
$250.00
RI
5
$140.00
IN
15
$156.33
$30.00
$375.00
SC
4
$177.50
$35.00
$375.00
KS
2
$175.00
$150.00
$200.00
SD
3
$166.67
$150.00
$200.00
$200.00
TN
8
$161.25
$50.00
LA
3
$187.67
$125.00
$300.00
TX
16
$116.56
$35.00
$195.00
MA
13
$175.31
$120.00
$280.00
VA
17
$149.12
$0.00
$340.00
MD
21
KY
67
Average
AL
CT
Wide variation
# of Responses
3
$141.67
$125.00
$150.00
$275.00
$156.62
$45.00
$500.00
VT
2
$150.00
$150.00
$150.00
ME
4
$181.25
$125.00
$325.00
WA
7
$141.86
$50.00
$193.00
MI
17
$134.69
$68.75
$210.00
WI
13
$120.77
$50.00
$200.00
MN
15
$127.93
$50.00
$200.00
MO
9
$169.44
$100.00
$300.00
MS
3
$183.33
$150.00
$200.00
WV
4
$146.25
$120.00
$180.00
WY
1
$100.00
$100.00
$100.00
Canada
4
$168.75
$100.00
$200.00
Contract

AMDA’s model contract

Pre-2006 model on resource disk

Visit registration for product information or
AMDA’s web site to purchase 2006
updated contract
http://www.amda.com/resources/print.cfm
69
70
236
12 Personality Profiles
Personality Profile
Many attempts over the years to help us gain
a better understanding of ourselves by
appreciating our inner thought process and
how they influence our actions.
By age of 3 most personalities established but
there is some adjustment possibly to age 12.
Personality tests have been created to help us
gain an better understanding of our ourselves
and how we relate with the world.

12 Personality Profile
Know Thyself

Core Curriculum on
Medical Direction

1
2
Myers-Briggs Type Inventory

Myers-Briggs
The essence of the theory is that much
seemingly random variation in the
behavior is actually quite orderly and
consistent, being due to basic
differences in the ways individuals
prefer to use their perception and
judgment.

“Whatever the circumstances of your
life, the understanding of type can make
your perceptions clearer, your
judgments sounder and your life closer
to your heart’s desire.”
Isabelle Briggs Myers
3
Personal Characteristics and
Participation: The Challenge for
the Chair
Personality Profile


4
Knowing thyself facilitates our contributions
to the team structure.



Appreciating how others are focused on the
external and internal helps us to deal more
effectively with others. By having a greater
understanding on how people will react in
situations provides us the opportunity to help
the team process.

5
Personality type preference.
Manifest behavior.
Facilitating a meeting so that
maximum benefit is derived from all
present.
Optimizing productivity and outcomes.
6
237
12 Personality Profiles


Myers-Briggs Type Indicator
Four Domains of Myers- Briggs
A self report questionnaire that defines
the predictable differences in the way
individuals take in information
(processing) and the way they organize
that information(judgement).
Myers Briggs adopted Jung’s work to
create 4 domains on how we live in the
world.




Focus Attention
Take in Information
Make Decisions
Orientation to the World
7
Myers-Briggs
Look at the World
Myers-Briggs



8
Important to appreciate that it doesn’t
typecast or label. It doesn’t measure
character or ability.
Depending on circumstances each of us will
react the same manner. Eg if fire bell goes
off, we will all leave the building.
Yet if we are asked to perform a task, some
may take time to think about the approach
while others will start to outline the process.

Focus attention:

Extravert vs. Introvert
9
10
Where Do You Focus Your
Attention?






Extravert
Tuned to external
Prefer talking
Learn by doing
Takes initiative
Speak, reflect
Sociable
Myers Briggs
Introvert
Drawn to inner
Prefer writing
By reflection
Readily focused
Reflect, act
Private
11

Take in information:

Sensing vs. Intuition
12
238
12 Personality Profiles
How Do You Take in Information?






Sensing
Focus on real
Practical application
Factual, concrete
Observe, remember
Present-oriented
Trust experience
Intuition
On big picture
Imaginative
Abstract, theory
See patterns
Future-oriented
Inspiration
Sensing vs. Intuition

Sensing: Experience world as is, uses 5 senses,
being here and now; aware of the tangible
impressions of the moment; being literal,
concrete and practical; what is as opposed to
what would be; remembers and catalogues.

Intuition: Exploring, understanding, creating
patterns; imagines new possibilities, produces
insights on complex issues; links past and
present to forecast future;
13
Myers-Briggs
How We Make Our Decisions?

14
How Do You Make Decisions?
Decisions made:



Thinking vs. Feeling




Thinking
Analytical
Logical solving
Cause and effect
Objective truth
Reasonable
Fair
Feeling
Sympathetic
Assess impact
Personal values
Individual validations
Compassionate
Accepting
15
Myers-Briggs
Our Actions in the World
Thinking vs. Feeling


16
Thinking: Order and organization, being
objective, detached; uses logic and tries to
understand cause and effect. Seeks structure.
Usually orderly uses chain of reasoning to
establish relationships.

Orientation to the world:

Judging vs. Perceiving
Feeling: Values beliefs, open to emotions,
needs and thoughts; subjective, value
conclusions arise within; desires harmony;
sensitive to inner self.
17
18
239
12 Personality Profiles
How Do You Orient to the World?






Judging
Scheduled
Systematic
Methodical
Plan
Like closure
Avoid stress
MBTI
Perceiving
Spontaneous
Casual
Flexible
Adapt
Open to change
Energized by it

Four domains:
Extraversion vs. Introversion
Sensing vs. Intuition
Thinking vs. Feeling
Judging vs. Perceiving

Creates possibility of 16 different
personality types.
19
20
Myers-Briggs Inventory
Attitudes
Myers-Briggs Inventory


The first and last letters in your type are
called attitudes or orientations because
they have to do with how you interact with
the world.
The middle two letters are called your
mental functions because they are the
basis for much of your brain’s work. The
two letters together are called your
function pair.

Those who prefer Extraversion, direct
energy outwardly and are energized by
the outside world.

Those who prefer Introversion, direct
energy inwardly and are energized by
reflecting on their inner world.
Myers-Briggs Inventory
Attitudes
Myers-Briggs Inventory
Mental Functions
21


People who prefer the Judging attitude
are likely to come to conclusions quickly
and enjoy the structure provided by
reaching closure.
People who prefer the Perceiving attitude
are likely to take more time to gather
information before comfortably coming to
closure, enjoy the process, and are more
comfortable being open-ended.
23
22

Sensing (S) perception pays attention to
details and current realities; Intuition (N)
perception pays attention to meanings,
patterns, and future possibilities.

Thinking (T) chooses decisions based on
principles and logical consequences.
Feeling (F) chooses decisions based on
values and consequences for people.
24
240
12 Personality Profiles
MBTI
Four Primary Personalities




MBTI
Interesting Facts
Dominant Intuitive:
INFJ,INTJ,ENFP,ENTP
Dominant Sensing:
ISFJ,ISTJ,ESFP,ESTP
Dominant Thinking:
ISTP,INTP,ESTJ,ENTJ
Dominant Feeling:
ISFP,INFP,ESFJ,ENFJ

75% of the American population that
complete the inventory are ‘E’.
Profile Results
25
Personality Sub-types
26
ISTJ

Will make a great Medical Director.
27

28
ISTJ
ISFJ
Quiet, serious, earn success by
thoroughness and dependability. Practical,
matter-of-fact, realistic, and responsible.
Decide logically what should be done and
work toward it steadily, regardless of
distractions. Take pleasure in making
everything orderly and organized – their
work, their home, their life. Value
traditions and loyalty.

29
You will become a great Medical
Director.
30
241
12 Personality Profiles
ISFJ

ISTP
Quiet, friendly, responsible, and
conscientious. Committed and steady in
meeting their obligations. Thorough,
painstaking, and accurate. Loyal,
considerate, notice and remember
specifics about people who are important
to them, concerned with how others feel.
Strive to create an orderly and harmonious
environment at work and at home.

You will be a great Medical Director.
31
ISTP

32
ESTJ
Have original minds and great drive for
implementing their ideas and achieving
their goals. Quickly see patterns in
external events and develop long-range
explanatory perspectives. When
committed, organize a job and carry it
through. Skeptical and independent, have
high standards of competence and
performance – for themselves and others.

Working hard, you will become a very
good Medical Director.
33
34
ESTJ

INFP
Practical, realistic, matter-of-fact. Decisive,
quickly move to implement decisions.
Organize projects and people to get things
done, focus on getting results in the most
efficient way possible. Take care of routine
details. Have a clear set of logical
standards, systematically follow them and
want others to also. Forceful in
implementing their plans.

35
You will probably make a good Medical
Director.
36
242
12 Personality Profiles
INFP

INFJ
Idealistic, loyal to their values and to
people who are important to them. Want
an external life that is congruent with their
values. Curious, quick to see possibilities,
can be catalysts for implementing ideas.
Seek to understand people and to help
them fulfill their potential. Adaptable,
flexible, and accepting unless a value is
threatened.

You have a very good chance of
becoming a good Medical Director.
37

38
INFJ
ESFP
Seek meaning and connection in ideas,
relationships, and material possessions.
Want to understand what motivates
people and are insightful about others.
Conscientious and committed to their firm
values. Develop a clear vision about how
best to serve the common good.
Organized and decisive in implementing
their vision.

You have the potential to become a
good Medial Director.
39

40
ESFP
ISFP
Outgoing, friendly, and accepting.
Exuberant lovers of life, people, and
material comforts. Enjoy working with
others to make things happen. Bring
common sense and a realistic approach to
their work, and make work fun. Flexible
and spontaneous, adapt readily to new
people and environments. Learn best by
trying a new skill with other people.

41
Good thing you came to this course!
42
243
12 Personality Profiles
ISFP

ESFJ
Quiet, friendly, sensitive, and kind.
Enjoy the present moment, what’s going
on around them. Like to have their own
space and to work within their own time
frame. Loyal and committed to their
values and to people who are important
to them. Dislike disagreements and
conflicts, do not force their opinions or
values on others.

Warmhearted, conscientious, and cooperative.
Want harmony in their environment, work with
determination to establish it. Like to work with
others to complete tasks accurately and on
time. Loyal, follow through even in small
matters. Notice what others need in their dayby-day lives and try to provide it. Want to be
appreciated for who they are and for what they
contribute.
43
44
ENFJ

INTJ
Warm, empathetic, responsive, and
responsible. Highly attuned to the
emotions, needs, and motivations of
others. Find potential in everyone, want to
help others fulfill their potential. May act as
catalysts for individual and group growth.
Loyal, responsive to praise and criticism.
Sociable, facilitate others in a group, and
provide inspiring leadership.

Have original minds and great drive for
implementing their ideas and achieving
their goals. Quickly see patterns in external
events and develop long-range explanatory
perspectives. When committed, organize a
job and carry it through. Skeptical and
independent, have high standards of
competence and performance – for
themselves and others.
45
46
ESTP

INTP
Flexible and tolerant, they take a pragmatic
approach focused on immediate results.
Theories and conceptual explanations bore
them – they want to act energetically to
solve the problem. Focus on the here-andnow, spontaneous, enjoy each moment that
they can be active with others. Enjoy
material comforts and style. Learn best
through doing.
47

Idealistic, loyal to their values and to
people who are important to them. Want
an external life that is congruent with their
values. Curious, quick to see possibilities,
can be catalysts for implementing ideas.
Seek to understand people and to help
them fulfill their potential. Adaptable,
flexible, and accepting unless a value is
threatened.
48
244
12 Personality Profiles
ENFP

ENTP
Warmly enthusiastic and imaginative. See
life as full of possibilities. Make connections
between events and information very
quickly, and confidently proceed based on
the patterns they see. Want a lot of
affirmation from others, and readily give
appreciation and support. Spontaneous and
flexible, often rely on their ability to
improvise and their verbal fluency.

Quick, ingenious, stimulating, alert, and
outspoken. Resourceful in solving new and
challenging problems. Adept at generating
conceptual possibilities and then analyzing
them strategically. Good at reading other
people. Bored by routine, will seldom do
the same thing the same way, apt to turn
to one new interest after another.
49
50
ENTJ

In Summary
Frank, decisive, assume leadership readily.
Quickly see illogical and inefficient
procedures and policies, develop and
implement comprehensive systems to solve
organizational problems. Enjoy long-term
planning and goal setting. Usually well
informed, well read, enjoy expanding their
knowledge and passing it on to others.
Forceful in presenting their ideas.

Effective Physician leader and manager:
 Will get to know the lay of the land:
political, health care.
 Understand what we are trying to
accomplish: Values, mission, goals.
 Orchestrate many people’s efforts using
our leadership, managerial and power
attributes.
51
52
Personality Profiles

www.RebelEagle.com

www.teamtechnology.com/mb-intro
12.1 – 12.3
53
54
245
12 Personality Profiles
Personality Preference on the
Web

http://www.humanmetrics.com/cgiwin/JTypes1.htm


Full 72 question Myers-Briggs with scoring
http://www.haleonline.com/psychtest/

The brief, 4-question test you took in this
course
55
246
13 Influencing Employee Behavior
Objectives

13 Why Nursing Home Employees Don’t
Do What They Are Supposed to Do

An Adaptation of Fournies
“Why Employees Don’t Do What They Are
Supposed to Do”

Core Curriculum on
Medical Direction
Describe situations in which employees may
not know why and what they should be doing.
Explain why no positive consequences for the
right thing could negatively influence
employees’ behaviors.
Apply concept of Fourniers differential
diagnosis to help correct negative behaviors.
1
2
Importance to the Medical
Director
Sources



3
Influence important employee behaviors such as:
 Acceptance of flu vaccine.
 Use of ergonomic protections.
 Otherwise implementing facility policies day to
day.
Understand & assist other managers (DON,
Administrator).
 Further your value to the facility.
The same principles relate to your management
4
of the medical staff.
Managing the Medical Staff


Medical Staff Behaviors
Are not “employees.”
However, specific behaviors are
expected of attendings & other cliniciansNPs, PAs, consultants.
 As Medical Director, you are
responsible for ensuring these
behaviors take place.











Accepting initial responsibility for patient care.
Facilitating patient discharges and transfers.
Making periodic, on-time pertinent visits in the facility.
Providing appropriate patient care.
Providing adequate ongoing coverage.
Providing appropriate, timely medical orders.
Providing appropriate, timely, pertinent documentation.
Return calls promptly.
Maintain CME.
Be courteous.
Adhere to facility policies.
Levenson S. JAMDA March/April 2002:S61-S69
5
6
247
13 Influencing Employee Behavior
Management Duties





Management, Defined
Communicate roles & responsibilities.
Provide criteria for adequate performance.
Identify explicit process responsibilities.
(Not specific tests or meds however.)
Review performance.
Feedback



“Management is the art of getting things
done by other people.”
-F. Fournies

Sounds manipulative but is not.

“Directive” feedback won’t work.
1 minute manager instead (to follow).

Set of sequential activities that lead to
desired organizational outcomes.
If “well-done”, enhances others.
7
8
Examples of Medical Director
Managerial Activities












Management =/= Leadership
Planning
Budgeting
Organizing
Prioritizing
Delegating
Coordinating
Directing
Educating
Holding individuals accountable.
Analyzing and solving problems.
Providing feedback to improve individual performance.
Reward performance/celebrate success.

Leadership “…the art of getting others to
do something you are convinced should be
done.”





Vision, inspire etc.
More in Jeff’s talk (#22)
Management-concrete
Leadership-big picture
Management-details

The devil is in the details.
9
10
So Who is this Fournies Guy
Anyway?
LEADER

MANAGER

Professor at Columbia University’s Graduate
School of Business
15-year study of reasons for poor performance
with more than 20,000 managers, Fournies and
colleagues asked: Why do people not do what
they are supposed to do?


11
The answers don’t change whether talking to corporate
presidents or first-line supervisors.
Ultimately, employee nonperformance most commonly
occurs because of poor management.
12
248
13 Influencing Employee Behavior
Fournies Premises
Premises, Continued
Most people at work…
 Do most of what they are
supposed to do.
 Work hard.
 Some even do more than
expected.
Motivation for performance is
complex.
 Psychologists don’t agree
on what motivation is, or
how it operates.



“Management is an intervention more
like bridge building than rain-dancing…”
13
14
In Other Words


A Different Approach
”Effective management applies specific
principles—rather than guesswork and
hope—in targeted situations to achieve
predictable results.”
There is a direct cause-effect
relationship between manager’s actions
and employee’s performance.

Fournies suggests an alternative
approach.

If you can figure out why the
employee is not doing what they
are supposed to do, you may be
able to have a positive impact on
behavior.

Found common answers as to the
why.
15
A Differential Diagnosis of Sorts


16
Taxonomy
1. Don’t know why.
2. Don’t know how.
3. Don’t know what they are supposed to
do.
4. Don’t think your way will work.
5. Think their way is better.
6. Think something else is more important.
7. Think they are doing it.
Managerial
misdiagnosis =>
treating symptoms, not
causes of performance
problems.
A systematic,
differential approach (to
follow) is more likely to
be effective.
17
18
249
13 Influencing Employee Behavior
They Don’t Know Why They
Should Do It
Taxonomy, Continued
8. No positive consequences for doing the right
thing.
9. They are rewarded for not doing it.
10.Negative consequences for doing the right
thing.
11.Lack of consequences for poor performance.
12.Obstacles beyond their control.
13.Personal limits.
14.No one could do it.
19


Benefit of employee action may
be evident to management, less
so to employee.
Enlightened managers allow
employees to ask “why?”
 Why should the task be
done?
 Why should the employee do
the task ?

People are more interested in
consequences to themselves.
20
Don’t Know How
Don’t Know Why: Examples



Why should I have to
date orders and
certification forms, I
signed them didn’t I?
Why can’t I use any
medications I want to?
Why do I have to
participate in ethics
discussions /
documentation?
22
21
Don’t Know How-Reasons


Don’t Know How: Training
Managers assume employees already
know how.

Managers believe they are teaching
when in fact they are just telling.



Common approach: Assign experienced
employee to teach new one.
Mistakes on the job cost > mistakes cost
during practice.
The right way:


Hazard of in-services, why they are often
not the solution.


Learning requires practice.
Confirm learning has occurred.


No time to teach employees how.

23
Manuals – Standardization
Trained instructor - Guidance
Written test
Performance test
24
250
13 Influencing Employee Behavior
Don’t Know What
They Don’t Know What They Are
Supposed to Do
26
25
Don’t Know What: Examples

Job Descriptions
Need clear communication, Not vague
advice.







Make sure to check the patient.
Turn the patient often enough.
Use your judgment as to when to notify the
physician.
Use “nursing judgment” to decide when to
send someone to the hospital.
“As soon as possible.”
Behavior rental agreement
Should




Describe what behavior is being rented.
Be referred to
Written together by manager and subordinate.
Shouldn't



Be short.
List Responsibilities.
Describe what job is worth.
27
28
They Think Their Way Is Better
Don’t Think That Your Way
Will Work
29
30
251
13 Influencing Employee Behavior
They Think Their Way Is Better:
Preventive Solutions
They Think Their Way Is Better


Management

Must reexamine “their way.”


Evidence-based
Without habit or preference bias.
Before work begins…
 Do they think their way is better?
 Why might they do things differently?
 Give convincing information.


Know about possible alternatives.
 Alternatives that don’t disrupt system
are allowed if feasible.


Front line employees should help re-design the
work process.
 Insights are valuable.


31

Integral to Deming’s Quality Improvement
32
The Wrong Way



How actually done?
Barriers to completion.
They Think Something Else Is
More Important
They Think Their Way Is Better:
The Wrong Way

Telling is not enough, needs explained.
Compare outcome/results between methods.
Don’t let anyone use the
wrong way to prove you
are right.
Harmful and wasteful
Last Resort:


“Is there anything I can do
to convince you that your
way is not better?”
If not, tell them it must be
done your way.
33
34
They Think They Are Doing It
They Think They Are Doing It
Why? - Inadequate feedback

Annual feedback




Frequent feedback


35
Not specific
Late
Too infrequent
What they are doing right?
What must be corrected and how?
36
252
13 Influencing Employee Behavior
Feedback, Defined
Types of Feedback
Use of information about previous
performance to promote performance
improvement.

Archer. Med Ed 2010; 44:101–8


Minimal:
 Good job/bad job, no explanation.

Specific:
 You did good hand washing after
wound care on patient A but not on
patient B.
Salero et al. J Gen IM 2002; 17:779-87.
37
38
Interactive Feedback
Types of Feedback

Hierarchical


(Adapted from 1-Minute Preceptor)
Supervisor-up/employee down, directive
process
Interactive


Elicits employee’s learner's self-evaluation of
his/her performance with interactive
discussion based on the self-evaluation.
Facilitative approach that enhances learning.
1. Ask the employee to articulate his/her
understanding of what he/she is being asked to do.
2. Probe for employee’s knowledge of procedures &
reasoning for what was done or not done.
3. Provide general guidance that can be used in future
cases, aimed preferably at an area of weakness for
the employee.
4. Reinforce what was done well—provide positive
feedback.
5. Correct errors—provide constructive feedback with
recommendations for improvement.
Furney et al .J Gen IM 2001; 16:620-4
39
40
“Houston We have a Problem…”

1st talk with person about perceived
problem.






Not admonishment or warning.
Instead note concerns, employee response.


Acknowledgment-work on solutions.

Giving Negative Feedback
May reflect personal stressors.
May reflect lack of information.

Resistance-next slides

41
10 reasons why we don’t.
5 step process based on Kluber-Ross’s 5
stages of grief.
Pitfalls
Developed by Frank Medio, PhD
http://www.iamse.org/development/2007/b
io_medio.htm
42
253
13 Influencing Employee Behavior
Top 10 Reasons We Avoid Talking to
Someone About a Problem
Top 10, Concluded
1. “I don't want to be the bad guy.”
6. “I am not sure how he will react.”
2. “I don't want to upset him/her.”
7. “I may have contributed to the problem.”
3. “I don't want to make a big deal out of this.”
8. “I know she/he realizes it was wrong and
will not do it again.”
4. “I don't want to ruin the person's career.”
9. “I think it's too late to do anything...”
5. “I don't want to end up in court.”
10.“I don't like confrontation.”
43
44
1. Denial


2. Anger
Expect it  it's a normal response to pain.
Strategy:
1. Describe the mistake in clear, succinct
and specific terms.
2. Describe what needs to be done to
correct the mistake.
3. Describe what will happen if the
mistake is corrected and what will
happen if the mistake is not corrected.

Once Denial breaks down, anger begins.
 Remember, these feelings are inner-focused
but outer-directed.

Strategy:
1. Don’t take the anger personally.
2. Acknowledge that anger is understandable
but must focus on correction.
3. Don’t feel you have to justify your position
or actions –– repeat 1-2-3 in Step 1.
45
46
3. Understanding
4. Bargaining

The key: Correcting requires person to "own
up" and take responsibility.

Strategy:
1. Watch for verbal and nonverbal signs of
understanding & readiness to move on.
2. Ask the person to tell you in his/her own
words problem, needed corrections, &
consequences of non-correction.
47

Some individuals will try to "negotiate" different
corrective steps or consequences.

Strategy:
1. Decide whether there is room for negotiation
and what you are willing (or unwilling) to
negotiate.

Only negotiate changes within your
authority.
2. Don't be afraid to say, “Sorry, this is not
negotiable.”
48
254
13 Influencing Employee Behavior
5. Acceptance/Agreement
Other Feedback Traps

Reaffirm the person’s responsibility to correct
the mistake or problem and your willingness
to help.


Strategy:
1. Conclude by recognizing effort involved in
reaching this point.
2. Agree on corrective steps to be taken and
the consequences for achieving (or failing
to achieve) them.

Best written



Reviewing another person’s
performance from our experience.
Being the target of “responsibility
ricochet.”
Basing judgment on “extraneous”
factors.
Introducing “halo” (or “horns”) effect
bias.
49
Levels of Corrective
Documentation


Levels of Corrective
Documentation
Verbal counseling
Informal warning

Final written warning
Problem
Corrective actions
Consequences

Suspension

Termination




50
Formal written warning

Above plus summary of warnings, timetable,
potential for more draconian action.
51
No Positive Consequences for Doing
the Right Thing
Suggestions for Correcting
Performance Issues



52
Nip in the bud.
The best solution is a collaborative
solution.
Don’t be intimidated.
 Documentation
 Fairness
53
54
255
13 Influencing Employee Behavior
No Positive Consequences
for Doing the Right Thing
The ABC Cycle


Variation:
“That’s what you are paid to do.”
Managers often don’t understand.


55
B.F. Skinner: “People don’t come to
work to get paid, they come to work
so the pay doesn’t stop.”



Don’t take them for granted.
 They’ll go elsewhere.
Recognition
 Informal
 Formal
Monetary rewards.
Career development.


Managers reward
non-performance
frequently without
realizing it.
When employees
make errors, help
them to correct the
errors.
57

58
No Negative
Consequence for Poor
Performance
Negative Consequences for
Doing the Right Thing

56
They Are Rewarded for
Not Doing It
Rewarding the Good Employee

Positive consequences for employees.
How rewards affect performance.
Punishment inhibits
behavior, whether desirable
or undesirable.
Variations:
 Employee who does
difficult work well gets all
of the difficult work.
 Employee who follows
instructions is criticized for
doing so.
59
60
256
13 Influencing Employee Behavior
Obstacles Beyond Their Control
Obstacles Beyond Their Control
1. Authority
undermined.
2. Resources not
available.
3. Poor quality of
resources.
4. Conflicting
instructions.
61
62
Personal Limits



Personal Problems
Rarely as frequently as managers claim.
Individual physical limits that are
unchangeable, and prevent job
performance.
Two categories:
 Temporary
 Permanent
 Limited





Puzzling to most managers.
Handling the problem varies greatly and
consumes a lot of time.
Sometimes nothing works.
Permitting nonperformance.
Plan ahead.
Intelligence
63
64
No One Could Do It
No One Could Do It
65
66
257
13 Influencing Employee Behavior
Preventive Management =
Preventive Maintenance
Manipulation
Elements
Predictable
Outcome
67
68
Typical Manager in
Long Term Care

Typical Manager in
Long Term Care
Lacking knowledge

Basic management techniques
 Employee non-performance
assessment
 How to write policy and procedures
 How to teach
Background
Clinician without management
training.
 Manager with no LTC experience.



Lacking knowledge

Articulate behaviors required
 Document behaviors required

Management responsibilities


Not understood.
Accountability is often secondary.
69
70
Problem Solvers Or Creators?
Prerequisites for Managers


Know the business and its goals and
objectives.
Know the functions and tasks associated
with achieving those goals and objectives.



Job descriptions & activities
Observe, listen & learn
Know accountability.


What others are accountable for
How to hold them accountable
72
258
13 Influencing Employee Behavior
Management as Intervention
Management as Intervention

“Managers must do
specific things at
specific times to
influence eventual
outcome of people’s
performance.”
Preventive management strategy is to
counteract the reasons why employees
don’t do what they’re supposed to do:



Before the work begins
After work begins
At any time - personal problems
74
73
Preventive Solutions:
Before Work Starts

Explain why things need to be
done a certain way.



Preventive Solutions:
After the Work Begins

“Follow up”

Benefit to the organization
Harm to organization

Describe relationships
between…




Individual tasks employees
perform.
Tasks in various departments.
Tasks and organization’s
75
mission.
76
How do you Make People
Change?
When Change is Desired

Employee understanding is especially
important when:






How do people change?

Task is undesirable or difficult to do.
Immediate consequences of task are not
rewarding.


Why Change?

Not reactive
management.
The delivery system
for assistance and
consequences.
Needed periodically
as performance
maintenance.

Solving problems
Improving quality
Improving productivity

77
Explain problems in detail.
Explain goals in detail.
Discuss solutions in detail.
Explain expected benefit of success and
agony of defeat.
Discuss consequences of nonperformance.
78
259
13 Influencing Employee Behavior
Other Skills
Delegation



Define goal.
Communicate with delegatees, get buy-in.
Collaboratively determine tasks.





What?
When?
Monitor progress.
Revise as indicated.
Celebrate success.
79
Facilitating Conflict Resolution




80
Avoiding Manager Traps
Parties must listen to each other without
interruption.
Each must commit to seeking a
resolution.
“I wish” or “I want”, not “you must” or
“you should”
Confidentiality
81








Public criticism of others.
Trying to be everyone’s buddy.
Over-ambitious.
Arrogant.
Arbitrary use of authority.
Inconsistency.
Avoiding direct communication.
 Over use of e-mail.
 Stay in office/out of sight.
 Disinterest in personal lives/wellbeing of
employees.
Perfectionism
82
References

Why Employees Don’t Do What They’re Supposed to Do,
and What to Do About It
 Ferdinand Fournies / 1999

Coaching for Improved Work Performance
 Ferdinand Fournies / 2000

Levenson S. Bridge Building, Not Rain Dancing: A Medical
Director’s Core Management Responsibilities. JAMDA
March/April 2002:S61-S69

Avakian L. Helping Physicians become great Managers
and Leaders. Health Forum Inc. Chicago IL. 2011
83
260
14 Medical Staff Oversight
Objectives

14 Medical Staff Oversight


Core Curriculum on
Medical Direction


Explain the rationale of why medical directors
have oversight responsibilities.
Discuss the two basic Medical Director
responsibilities for oversight in LTCFs.
Develop strategies to address medical staff
issues.
Describe different models for organizing the
medical staff.
Understand the precepts to credentialing and
privileging the medical staff.
2
1
Historical Context



Many medical directors didn’t feel that
they had any authority for oversight.
Many homes discouraged medical
directors from participating in home
affairs.
Some medical directors didn’t care.
14.1 – 14.3
3
4
Historical Context



Historical Context
1973 – AMA publishes “Guidelines for a
Medical Director in a LTCF”.
1974 – HCFA mandates that each SNF
must have a medical director and must be
a physician.
1987 – OBRA requires that all nursing
facilities must have a medical director, who
must be a physician.
5



1992: Roles and functions of being
medical director developed by James
Pattee et al.
2000: AMDA white paper reaffirms medical
director is responsible for the care
provided in the nursing facility.
2001 – IOM Report: “Improving the
Quality of LTC”. Medical director needs to
be part of the care process.
6
261
14 Medical Staff Oversight
In the Beginning:
CFR 483.75 (i) Medical Director
Oversight Medical Staff



2005: OIG survey. Medical directors
provide input into their roles, confirming
AMDA’s expectations.
2005 – CMS listens and creates
“interpretive guidelines” and “investigative
protocol” for F 501.
F 501 is the guideline delineating the
medical director’s functions and the
facility’s responsibilities.
7
IGs’ Intent:
The Medical Director is to:
Provide clinical guidance and oversight regarding
the implementation of resident care policies.

Coordinate medical care in the facility.

Help the facility identify, evaluate, and
address/resolve residents’ medical and clinical
concerns and issues that:

2.
8
Resident Care


The facility must designate a (licensed)
physician to serve as Medical Director Who is responsible for:
(i) Implementation of resident care
policies; and
(ii) The coordination of medical care in
the facility.
1.

Should be consistent with:

Current “standards of practice.”

Facility policy and procedures.
Affect resident care, medical care or quality of life;
Are related to the provision of services by physicians
and other licensed healthcare practitioners.
10
9
Coordination of Medical Care

Refers to the “practice of medicine” as
consistent with State law and
regulations.



Coordination of Medical Care
Credential
Monitor
Ensures medical care is timely and
appropriate.
11

Reviews/evaluates physician and
practitioner care/services.

Addresses. . . quality of care…quality of
life, identified through the facility’s
quality assurance program.
12
262
14 Medical Staff Oversight
Coordination of Medical Care:
Components


Coordination of Medical Care:
Components
Physician services: 24 hour coverage,
emergencies, timeliness.
Non-Physician Practitioners (NP/PA):
 Scope of practice, within state law
and regulatory requirements.

Staff knows when the medical director
should be contacted.

Obtaining/facilitating needed consultations
and other medical services.
Address concerns between attending
physicians and the facility.


Including medical staff.
13
14
Coordination of Medical Care:
Components

Medical Staff Oversight
Communication:




Inform the attending physicians (and
consultants) of facility expectations and
policies.
Review practitioner performance and provide
guidance and feedback.
Disseminate QA information relevant to
medical care.
 Infection control data, e.g.


We have the responsibility: from the initial
OBRA to the revised F tag.
We will be held accountable.
In order to fulfill our functions as Medical
Director, we will need to ensure that our
medical staff fulfill their obligations.
15
16
Medical Staff Organization:
Goals

Ensure adequate, comprehensive services.



Mechanism for resolving conflict.

Granting credentials & privileges.
Regulatory compliance

14.4

17
Clear communication of expectations and
responsibilities for facility clinical care.
Review and implement NF clinical policies.
Impartial review of care.
18
263
14 Medical Staff Oversight
Medical Staff Organization
Medical Staff Organization
The problem: Urban, rural, state-owned, countyowned, VA run, private pay, for-profit, not-forprofit, religious sect owned, ethnic, fraternal
organization run, skilled, post-acute, hospitalbased, stand alone, pediatric, salaried
physician, fee for service physician, capitated
physician, etc.

Where we’ve been.






Medical Director role poorly understood.
Custodial care facilities.
Nursing home care as a public service.
Open, unorganized medical staffs.
Minimal additional services and even less
accountability.
There is no typical facility or staff.
19
20
Medical Staff Organization

The Role of the Medical Staff
Where we’re going.

Expansion & professionalism of the
Medical Director role.
 Broader spectrum of care.
 More appropriate reimbursement.
 Closed and/or organized staffs.
 Expansion of services, with accountability
for outcomes and costs.



Provide medical care to residents:
admission assessment, regulatory
episodic.
Ensure appropriate coverage and follow
through for clinical issues.
Meet regulatory requirements.


Pharmacy recommendations
Certification & recertifications
21
22
Medical Staff:
It’s not just clinical. . .




Medical Staff Models
Listen to patients, staff, medical director.
Communicate well.
Work in an interdisciplinary environment.
Have a basic understanding of ethics, law
and regulations.
23


Open vs. Closed
Essentials
 Physician responsibilities and duties.
 Establish criteria for membership.
 Methods to correct failure to meet
care obligations.
24
264
14 Medical Staff Oversight
Medical Staff Models
Closed Staff:






Organizing the Medical Staff:
By-Laws
Usually requires by-laws.
Dedicated providers, with similar practice styles
and knowledge.
Coverage for regulatory, episodic and afterhours calls basically assured.
Protocol development facilitated.
Feed back and corrective action plans more
accepted.
Potentially financially rewarding.

Basics:

Define the organization and mission.

Define the governance structure.

Define the qualifications for staff; qualified
physicians must be allowed to have their
credentials reviewed.
25
26
Staff Expectations
Organizing the Medical Staff:
By-Laws

Basics:



Provisions for adopting and amending
policies, agreements.
Expectations for staff.
Conditions for appointment, reappointment
and duration of membership.
 Education
 Training/experience
 Certification
 CME activity
27
Organizing the Medical Staff:
By-Laws

Medical Staff Models
Open Staff:
Basics:






28

Immunity from liability for imparting
information in good faith.
Mechanism for corrective action.
Suspension of privileges.
Due process
Appeals
AMDA: Sample by-laws




29
Greater Diversity
Attract community physicians
Facility image
Small facility
Medical Director’s role minimal
30
265
14 Medical Staff Oversight
Organizing the Medical Staff
Organizing the Medical Staff

Practice Agreements:






Less rigid/formal than by-laws.
Defines the relationship, scope of care
and services, emergency coverage.
Defines the terms of the relationship.
Contains due process.
Credentialing is addressed.
Practice Agreements:



The medical director sets up the rules.
The practitioner agrees to abide by them.
Can be simple or complex, but however
they read, they should contain this
phrase:
“I have received, read and understand
the rules and I agree to abide by them.”
31
Additions to By-Laws or Practice
Agreements:





Staff categories
Meetings
Delineation of privileges
Committees
Officers
32
Additions

Practical considerations:
 Emergency coverage
 Transfer procedures
 Scope of services
33
Organizing the Medical Staff:
Due Process




34
Due Process
Complaint: Who may make it?
Confidentiality of statements
Review committee: Medical Director,
administrator
Consider creating a medical care
committee, that would include 1-2
additional physicians.





35
Decisions made and action plans
created.
Notification
Hearing if applicable.
Appeals: Who will be at the appeals?
Consider inviting those without biases.
Decision
36
266
14 Medical Staff Oversight
Organizing the Medical Staff:
Getting Started
14.5 – 14.7
37
Organizing the Medical Staff:
Getting Started. . .



38
Organizing the Medical Staff:
Credentialing
Buy in from administration. Be aware of
potential conflict of greater control vs.
referrals.
Create your practice guidelines, by
laws. Share them with your staff. Then
offer to meet with them.
Start the credentialing process.

Primary source verification


Costly, time consuming
Delegation: Use local hospital, health
care organizations.

May not be aware of nursing home-specific
issues.
39
Credentialing Data








Education
Training and experience
Board Certification(s)
Scope of practice
Licensure
Malpractice or disciplinary issues
References
Impairments
40
Credentialing




41
Primary attending
Do you credential coverage if they do
not provide care in the facility?
Consultants problematic especially if in
group practice.
Non-Physician Practitioners (NPPs)
42
267
14 Medical Staff Oversight
Credentialing
Privileges
Review credentials/make
recommendations.


Notification of applicant via letter.


Signature of practice agreement/bylaws needed before patient care.



Added dimension
JCAHO mandate
Difficult to ensure that practitioners
actually have the qualifications relevant
to long term care.
Onus on us to sign off.
43
44
Credentialing:
Allied Health Providers







Allied Health Care Staff
Audiology
Podiatry
Optometrists
Dentistry
Mental Health
PT, OT, Speech
Alternative therapy

Medical Director is not usually involved in the
credentialing of these providers.

Many of the non-physician staff are from
consultant practices who perform the
credentialing and background.

Should insist that the vendor make available
pertinent information, e.g. license, training. In
addition it would be worthwhile to ask for any
recent sanctions from insurers, hospitals, etc.
45
Credentialing:
Non-Physician Practitioners
Allied Health Care Staff

46
The facility should have a job
description/agreement that delineates the
specific responsibilities and scope of practice of
the consultant or provider.

Nurse Practitioners and Physician
Assistants:



The facility should be aware of any reporting
process that involves poor patient outcomes.



47
To whom do they report, physician
responsibility
Collaborative agreements
Legal and regulatory status
Relationship to facility
Discipline
48
268
14 Medical Staff Oversight
Nurse Practitioner
Physician Assistant
RN, MSN or certificate
Certified programs: BS, MS
National Specialty Certifying Exam
(State Specific)
National Specialty Certifying Exam
(State Specific)
Independent or collaborative practice
Physician supervision required
Non-Physician Practitioners:
NPs, PAs



State regulations vary considerably

Prescriptive authority varies

Independent licensing is state-specific

Roles and responsibilities have increased.
HMOs: Use of NPs/PAs to work in facilities as
agents of the insurer. Physicians may or may
not have direct connection to NPPs
Direct employment
Recruitment to place NPs in facilities, by region,
by chain.
DONs
Sub-specialty consultative services.
49
50
Non-Physician Practitioners
Non-Physician Practitioners
Advantages:






Facilitate communication with the team.
Facilitate communication with families.
Improve physician efficiency and throughput.
Possibly increase overall quality of care
delivery.
Physicians may able to increase their census
at the facility.
May assist the Medical Director in
facility wide functions:





Employee health
In-service training
Policy development
Incident reviews
Quality indicators
51
52
Non-Physician Practitioners
Non-Physician Practitioners
Disadvantages:





Needs supervision.
Billing process could be complex.
Potential drug prescribing limitations.
Medical Director may need to ensure that
supervising physician is not over-delegating.
53


CMS mandates collaboration when
providing services in a NF .
Medicare allowable minus 15%.
The physician must perform the initial
comprehensive assessment; NPs may
make a medically necessary visit, before
or after that initial comprehensive
assessment.
54
269
14 Medical Staff Oversight
Non-Physician Practitioners
Practical Concerns






Non-Physician Practitioners:
Start Up
What is the relationship to the facility?
Scope of practice?
To whom do they report, who is the
supervising physician?
What are the practice, collaborative
agreements?
Prescriptive authority?
What is the discipline process if any?






Orientation with staff.
Meet the families, residents.
Develop system for NP/PA and
physician visits.
Agree to specific visit from other allied
health care providers.
Create communication systems.
Foster team building.
55
56
Physician/Non-Physician
Practitioner Orientation








Meet NHA/DON
Tour Facility
Meet Department Heads
Review Formulary
Review Wound Care Protocols
Review Lab/Radiology Services
Meet Consultant Pharmacist
Define Communication Methods
Medical Staff Oversight
Summary


Medical Staff accountability may be
enhanced/ensured via utilization of
Practice Agreements (Open Model).
The Medical Director should have an
integral role in the credentialing process
of Physicians and Non-Physician
Practitioners.
Medical Staff Oversight
Summary



Revision of FTag 501 Interpretive Guidelines in
2005 significantly enhanced Med. Dir. oversight
responsibilities.
The two basic Med. Dir. responsibilities for
oversight in LTC Facilities include
implementation of resident care policies, and
coordination of medical care.
Medical Staff organization in LTC Facilities
includes both Open and Closed models.
Medical Staff Oversight
Using the principles of medical
staff oversight to deal with difficult
issues and providers:
Breakout on Case Studies.
60
270
14 Medical Staff Oversight
Medical Staff Oversight Breakout
Take Home Points




Ensure patients receive appropriate
care.
Define expectations and responsibilities
via clear communication.
Solicit administrative support.
Create practice agreements.
271
15 Ethics
Overview
A.
B.
C.
D.
E.
F.
15 Healthcare Ethics
Core Curriculum on
Medical Direction
Foundation of Ethics in Healthcare
Case Study
Decision Making Capacity
Advance Directives
Substitute (Proxy) Decision Maker
Physician and Medical Director Role
Responsibilities and Duty
G. Ethics Committees/Consultation
2
1
A. Foundation of Ethics in
Healthcare
Learning Objectives:







Review basic principles and concepts relevant to
healthcare ethics.
Apply 4 key ethical principles to various clinical case
studies.
Delineate Medical Director role and responsibilities that
promotes facility-wide ethical/clinical decision-making.
Moral responsibility to “do right” by our patients.
To do good, protect from harm.
“Primum non nocere”
Hippocratic oath
From the Greek ethos
 Moral principles
 Rules of conduct
 Doing what is honorable, right and just.
3
4
Healthcare Ethics

Healthcare Ethics
As health care practitioners, we have
an ethical responsibility to:




Patients
Families
Facilities
Employers





Government
Payers
Society
Ourselves

5
There are times when our professional
responsibilities and personal ethics may
conflict and we are asked to subordinate
either our principles (personal ethics) or
our responsibilities.
Bioethics provides a framework to help
resolve conflict.
6
272
15 Ethics
Healthcare Ethical Principles




Autonomy
Autonomy
Beneficence
Nonmaleficence
Justice
The right of self-government, personal freedom
and freedom of will.

Ethical Principle: Having, acknowledging and

showing respect for a person’s right of selfdetermination regarding his/her life, body,
mind, and spirit (including medical care).
7
Beneficence


8
Non-maleficence
The act of doing good, being generous
and actively being kind.


Ethical Principle: The obligation to do
good and act in the best interest of
others.
Not being hurtful to others.
Ethical Principle: The obligation to
avoid harming others.
9
Justice

10
Fidelity
Just conduct, fairness.



Ethical Principle: The duty to treat
individuals fairly and without
discrimination and to distribute resources
in a non-arbitrary and fair manner.
11

Faithfulness, loyalty
Strict conformity to truth or fact.
Corollary Ethical Principle: The duty to
keep promises.
12
273
15 Ethics
Ethical Theory: Summary

Other Related Issues
Four key ethical principles for
healthcare decision making and conflict
resolution of ethical/clinical dilemmas.




Autonomy
Beneficence – “do good to others”
Nonmaleficence - “do no harm”
Justice - “treat others fairly”

Paternalism






“Do what I say even though you don’t want to,
because I know better than you and I have decided
that [this] is good for you and is what you should do.”
Counter to the principle of autonomy.
Not an ethical principle.
Confidentiality
Privacy, dignity
Truth, duty, responsibility
13
14
B. Case Study 1
Case: Severe PAD
Balancing Ethical Principles
To Solve
An
Ethical Dilemma

Mrs. Smith, an 88-year-old woman, able
to give informed consent, has severe
vascular disease and a painful ischemic
foot; she has refused surgery
(amputation), saying that she would
never want to be deformed. Her family
agrees, wishing to limit “unnecessary
care” (citing surgery as being “too
much”).
15
Case

16
Points of Case
A few weeks later she becomes
confused, her pain has increased, and
despite aggressive pain management, is
uncontrolled at times (she screams in
pain). The family, although distressed by
her suffering, still refuses surgery, stating
that this was the patient’s wish. The
attending physician is now asking you,
as the medical director, for help.
17
What points of this case need
to be taken into account?
18
274
15 Ethics
Points of Case



Case
Expressed wish for no amputation.
Uncontrolled pain (as opposed to
“uncontrollable”).
All parties unhappy with watching her
suffer.
What are the ethical conflicts?
19
Conflicts

20
Case
Desire to relieve pain and suffering (which
might be obtained by amputation versus
adhering to patient’s stated desire for
treatment).
What ethical principles are
applicable in this case?

Respect the patient’s previously stated wishes.

Keep one’s promise to the patient.

Avoid causing harm to the patient.
21
Principle of Autonomy


22
Principle of Beneficence
Resident’s wish for no amputation.

She has said that she would never want
to be deformed.
23

“Best interest” for the patient.
Does performing amputation in the hope
of alleviating pain fulfill this principle?
24
275
15 Ethics
Principle of Non-maleficence



Principle of Justice
Do we let resident have continued
pain? Risks of surgery.

What if she dies or has severe phantom
pain from the surgery?

Justice: Fair distribution of burdens and
benefits within a society.
Do we withhold surgery to save cost to
society?
Is this risk worth the potential benefit?
25
26
Corollary Principle of Fidelity


Honor her wishes for no amputation;
keep promise.
Her wishes for non-amputation had
been agreed to while she had decisional
capacity.
15.1
27


28
Ethical Determination / Solutions
Summary
Unethical to proceed with amputation.

Initiate other interventions to alleviate pain
and suffering.



Healthcare ethics (theory) provides a
construct to help patients, families and
practitioners resolve conflicts in
provision of care.
Aggressive pain management (consensus
that there are some cases wherein complete
control of pain cannot be achieved).
Increase sedation (i.e. palliative sedation).
Consider nerve block or epidural.
29
30
276
15 Ethics
C. Decision Making Capacity
(DMC)



Resident DMC
Describes an individual's ability to make
practical decisions in his or her own
interest.
Can be health-related and/or financially
related.
Not same as judicially defined status of
“competent” or “incompetent.”


Is the resident capable of making
decisions for him/herself?
If so, we have to abide by the resident’s
decisions.
31
Determination of DMC
32
Determination of DMC
Resident’s ability to:
How do we determine decisionmaking capacity?
33
Determination of DMC




Gather evidence:
 Prior and current cognitive function and
decision making capacity.
Observe:
 Mood, cognition, behavior, decision making
in daily situations.
Assess:
 Cognitive function and physical problems that
could affect DMC.
Confirm and certify scope of DMC.
35
1. Comprehend the facts presented.
2. Appreciate the consequences of the decision
he/she might make.
3. Reason—able to take information & develop
a rationale for the choice.
4. Communicate the choice.
5. Maintain some consistency.
. . . Congruent with resident’s values,
wishes, preferences . . .
34
“Partial” DMC




Characterize by individual’s highest
level of decision making.
Related to the risk of the decision.
May need to reevaluate just prior to
specific decisions.
Partial DMC may suffice for a specific
decision, despite periodic fluctuations in
cognition/decisional capacity.
36
277
15 Ethics
Lack of DMC
D. Advanced Directives
Options:
1. Advance directives (AD)
2. Substitute decision maker
3. Surrogate or proxy
4. Guardian
5. Other sources of information



Health care decisions
Financial decisions
Practical (day to day) decisions
37
38
Advance Directives for Health
Care
Advance Directives for Health
Care
Definition:
 Formal or informal statements of a
person's philosophy and instructions for
health care made in advance of
incapacity to make such decisions or to
effectively communicate choices.



Living Will: Primarily for wishes in event of
coma/terminal illness/advanced illness.
DPOA-HC: Assignment of another
decision maker regarding wishes for
health care in the event of incapacity.
Remember POA ≠ DPOA
39
40
Advance Directives for Health
Care

Advance Directives:
Legal and Regulatory Foundation
Components






Applicability
Treatment instructions
Designation of surrogate(s) on proxy
decision maker
Proxy instructions
Organ donation

Patient Self-Determination Act 1991
Autonomy principle


Premise for substitute decision maker (SDM)


Authorization of other individuals to act on behalf of
someone who can no longer act autonomously.
Providers and practitioners

41
Basic right to execute Advance Directives and have
them honored.
Duty to inform of rights and offer support for resident
decision making.
42
278
15 Ethics
Advance Directives:
Legal and Regulatory Foundation

Federal


Identify Any Existing Treatment
Instructions
Determine if any advance directives exist.

Several parts of OBRA '87 regulations
regarding resident rights are relevant.


State



All states support competent person’s rights
to make Ads.
States also support rights of others to make
health care decisions on behalf of
incapacitated individuals, to varying degrees.
43
Different procedural requirements.

Obtain existing documents.
Portable DNR (POLST, POST, MOLST)


44
Review the Advance Directive(s)

Evaluate existing information as to:
Review the Advance Directive(s)

Validity: Compatibility with relevant
state law and regulation.
 Scope: Issues that it does and does
not cover.
 Clarity: Specifics of the directives.
Formal
Other decisions; e.g., Made during recent
hospitalization.
Appreciate the patient’s cultural background.
Identify need to supplement or clarify
existing information.


Verify:
AD is in effect.
Circumstances when it becomes
effective (loss of DMC, terminal condition, etc.).


45
46
Problems in Interpreting and Applying
Any Advance Directive Include:





Absence of any written instructions for
care;
Insufficient clarity or specificity;
Inadequate patient or SDM; understanding
(of care options or implications of
choices);
Problems related to SDM;
And cultural differences.
47
Challenges to Advance Directives

Some family members or physicians may
dispute AD.


Try to contradict AD by stating that individual
didn’t understand, didn’t know what they
were doing, or would do something different
now.
Valid ADs are best available
representation of individual values and
wishes.
48
279
15 Ethics
Advance Directives:
Cultural Issues/Influences




Advance Directives:
Cultural Issues/Influences
Western biomedical model of autonomy.
Failure to recognize different decision
making process in other cultures.
Cultural, social, economic, educational,
and linguistic differences between
provider and patient/family.
Not acceptable to discuss death or
disability in some cultures.




Historical persecution or oppression by the
patient’s ethnic group leading to distrust of
providers.
Variation by ethnic group in the knowledge of
advance directives.
Multiple cultural influences during the lifetime
of the patient.
Respect cultural rituals and traditions at the
time of death.
49
50
Advance Directives:
Cultural Issues/Influences
Advance Directives:
Cultural Issues/Influences
African American
Skeptical of mainstream
medicine
Asian American
Family makes decisions
Protect the elder

Latin American
Well-being of the family
Respect for hierarchy
Emphasis on present

Native American
Life is circular pattern
Purification ceremonies
Must be positive-not
negative

Minimizing confusion and misunderstanding:


Self-assess provider's own values and culture
about death.
Use cultural guides for culturally appropriate
interaction.
Ask patient to describe his/her customs,
concerns, and beliefs about death, if
appropriate.
Ask patient to identify the family decision maker.
51
52
Substitute Decision Maker (SDM):
Criteria for Serving
E. Substitute Decision Makers



53
Usually, but does not have to be, next-ofkin.
Sometimes, no one named to make
decisions on behalf of incapacitated
individual.
Substitute decision maker may either be
appointed or assume role by default.
54
280
15 Ethics
Succession of SDMs
Succession of SDMs
Guardian or SDM specifically appointed in
an AD (often called a surrogate or agent)
take precedence over others.
When no one appointed by patient or
courts, most states specify succession of
SDMs.





Most states permit designation of an
alternate SDM if primary SDM
unavailable or unwilling to serve.
SDM’s authority may be limited,
depending on decision.

Spouse, adult child, parent, adult sibling,
close friend (e.g. hierarchy of decision
making)
e.g., withholding life-sustaining treatments,
DNR
55
Substitute Decision Maker Tasks



Should honor advance directives.
Where guidance inadequate, use “best
interest” criterion.
Qualifying conditions (end-stage,
terminal, or persistent vegetative state)
sometimes required to allow SDM to
withhold or withdraw life sustaining
treatments.
56
Potential Conflicts Among SDMs





Authorized individual may disregard input
from others.
Multiple decision makers.
Some states require all surrogates in a given
class to agree (or at least not to dissent).
Unresolved conflicts.
Cultural Differences: Some family members
may follow the ethnic traditions, while others
may be more Westernized in their views.
57
Guardianship


A person or entity appointed by the
courts
to exercise all of the powers and
duties necessary for the care of an
incapacitated person (some
limitations may exist).
Occurs when there is no legal substitute
decision maker and the person lacks
capacity.
59
58
F. Physician
Responsibilities/Duty

Practical Approach to Ethical Decisions
in Clinical Practice
60
281
15 Ethics
(1) Clarify Medical Condition and
Prognosis


Patient’s ability to participate in process.
Potential medical effectiveness and risks
of various treatment options.


Help staff identify ethical relevance of
treatment options.

15.2 – 15.4
Based on medical condition and prognosis.
Based on patient’s values and wishes.
61
62
(2) Summarize and Present Information
in Understandable Language



Written version may help organize and
reinforce concepts.
Answer as many questions about
condition and prognosis as possible.
Use those answers to help identify
relevance of treatment options.
(3) Define Treatment Options

What treatment options should be identified?




Short-term vs. long-term situations
Whether aggressive medical treatment is
desired for serious acute illnesses.
Whether diagnostic testing is desired to assess
condition changes.
Whether to hospitalize for more complex
situations.
63
64
Attending Physician Tasks

Medical Director Tasks
Direct Care Issues
 Establish and explain medical
condition, prognosis and treatment
options.
 Advance directives / care instructions
 Clarify decision making capacity.




65
Establish expectations for physicians and
staff.
Ensure physician compliance with relevant
laws, regulations, policies and procedures.
Ensure appropriate, timely medical
certifications and orders.
Provide background and case-specific
education (in services).
66
282
15 Ethics
Medical Director Tasks




G. Ethics Committees
Ensure adequate determination of
individual's decision making capacity.
Intervene where needed with patients
and families.
Participate in creating a facility-specific
process for review and implementation.
Obtain case-specific medical and ethical
input when needed.
67
Ethics Committees - Purpose

Ethics Committees - Purpose
Education




Of the committee about ethical principles, laws,
regulations, policies, procedures, and common
ethical dilemmas.
Review of clinical literature relevant to ethics
decision making.
 Example: Medical factors that predict
prognosis.
Of facility staff, residents and families, and the
greater community.
69
Ethics Committees - Composition






68
Administration
Clinical: physician (medical director) / nursing /
rehab / dietary
Support: Social work / nursing assistant
Clergy
Legal counsel
“Community”
 Be clear about what you wish community
member to bring to the committee.
71



Values clarification
Development of policies and procedures
concerning handling of ethical dilemmas.
Quality assurance activities to ensure
that policies and procedures are
implemented and followed.
Consultation
70
Ethics Committees - Process



Available to resident, family, staff,
facility.
Serves in advisory capacity, making
non-binding recommendations.
Documentation may not be protected
from discovery.


Avoid names and identification.
May be “shared” with other institutions.
72
283
15 Ethics
Ethics Committees
Case Review
Ethics Committees - Issues






Capacity for decision-making
End-of-life care
“Non-compliance”
Family conflict
Resident rights / autonomy
Sedation / restraints




Physician referral
Family or resident issues
Nursing/caregiver concerns and
“stresses”
Unexpected/undesired outcomes
73
74
Internal Resources to Help
Facilities With Decision Making
Successes and Pitfalls






Keeping clarity of purpose.
Maintaining involvement.
On-going committee evaluation.
Expense
Should support willingness of
physician/family to make decisions.
Potential for adversarial situations.

Ethics committee

Quality assurance committee
75
76
External Resources to Help
Facilities With Decision Making







Research in LTCFs
Ombudsman
Clergy
Bioethics literature/consultation
Alzheimer’s Association
Hospice
Community ethics committees
Pertinent state law and regulation



77
Clinical research may present ethical
conflicts.
Informed consent for an IRB-approved
protocol is basis for ethical inclusion of
nursing home residents in a clinical trial.
Ethical dilemmas arise when incapacitated
persons are enrolled in a research
protocol.
78
284
15 Ethics
Summary:
Medical Director Responsibilities



Help reconcile and balance interests of
facility, physicians, and patients and
families.
Help address family concerns, issues
related to advance care planning.
Help maximize resident autonomy.
Summary:
Medical Director Responsibilities



Ensure adequate physician participation
in key steps of decision-making
process.
Help attending physicians understand
factors involved in ethics and decision
making.
Clarify risks and benefits of life-saving
technologies and treatment options.
79
Summary:
Medical Director Responsibilities




Policies and procedures
Ensure adherence to laws and
regulations.
Advisor in actual cases.
Ethics committee
80
Questions and Answers
Conclude With Small Groups
81
82
285
16 Working with Families
Learning Objectives

16 Working with Families

Core Curriculum on
Medical Direction

Define basic concepts of family systems,
including boundary, structure and culture.
Relate chronic disease to patient, and
family relationships and interactions.
Identify common patterns of family
behavior that arise in the LTC setting.
2
1
Learning Objectives



Discuss effective strategies to enhance
physician communication with families.
Employ appropriate strategies to deal
with complex family situations.
Delineate Medical Director tasks that
address family issues.
16.1-16.8
3
4
Family Involvement

Pros
Quality of life improvement.
 Asset to both the resident
and the facility.


Cons


Destructive
Therefore having skill in working with families is
essential for medical directors and attending
physician.
5
Family Involvement


Caregiver stress and guilt continue.
Family members are involved:



Average visits - 12 times per month
Weekly visits - > 60%
Residents’ children - most common
Gerontologist 30(3):385,1990
Gerontologist 17: 500, 1977 Social
Bonds in Later Life. 389
6
286
16 Working with Families
A Guiding Principle

A Guiding Principle
Most of the time,
we are dealing with
families with difficult
problems…not
difficult families.

The concept of a
family being
“dysfunctional” is
not helpful.
7
8
A Guiding Principle

On the other hand…
9
10
Family Systems
11
12
287
16 Working with Families
The Family as a System

Families are…


Family Systems
More than a collection of individuals.
Families have rules…


Roles, responsibilities and patterns of
behavior.
Individuals’ symptoms may have a function
within the family.

Boundaries

Culture

Structure
13
The Family System and the
Health Care System
The Family “Culture” - Helman



14
Triadic Pattern
Families are small
scale societies.
Each family has
beliefs, habits that
are protective of
health, or pathologic.
“Language of
distress”
“Formal” Healthcare
System
Family
MD
“Informal”
Husband
MSW
Sister
RN
Son
Patient
Focal point
15
Family System and Health Care
System
The Nursing Home “Culture”




Formal and rigid
Hierarchy
Patient-centered vs.
Profit-centered
Diverse “family members”
 Honoring and
acknowledging
differences
 Empowerment
Family
Failure
NH
Admission
NH
Success
17
Physician
Place of Service
Change
18
288
16 Working with Families
Family System and Health Care
System
Family System in Long Term
Care
Questions
$
Stress

New roles
Integrate
Integrate
NH Admission
Dyadic Patterns - Family System and
Health Care System

Crossroads

Guilt
Anger
Relief
Less control
Disassociate

Rigid definitions of care provider and care
receiver.
If both parties don’t agree to premise, 
anger, refusal.
If both parties do agree, family may become
helpless.
19
20
Adjusting to the LTC Facility
Families must find their niche.
Establishing a stable relationship with the
various parts of the facility helps determine how
quickly the family system can recover from
“the crisis of placement.”


Chronic Illness
and
Families
21
The Transgenerational Development
of Chronic Illness Meanings

22
Roshoman
Chronically ill patients and families face
the challenge of giving meaning to the
illness experience.



Develops over generations.
Embedded in their stories.
The stories create a
framework for coping:
healing, if not cure.
23
24
289
16 Working with Families
How Do We Begin to Understand
Family Dynamics?
Behavior Patterns

Discussion




Family history
Genogram
Input
Observation
25
26
Genogram for Resident Mollie
Understanding the Family
System: The Family Genogram




Old age
?
Sister, Emma, very
close to Mollie.
Emma’s daughter
visits Mollie often.
(Sally Mueller)
Organizes the family pedigree.
Helps define the family system.
Physicians:
 Usually take a family history.
 Favor the genogram.
Effective if self or family administered.
d. 1979
?
d. 1991
Ca.
1st husband
Mike McGee
d. 3/1/66 - MI
Eddie McGee
b. 1930
d. 7/4/52
Auto accident
Frank McGee
b. 1932
(CAD, DM)
Mollie
b. 2/16/10
d. 1995
MI
2nd husband
Elwood Telling
d. 6/14/89 - Colon Ca.
Eunice
b. 1935
d. 1993
MI
*Therald McGee
b. 1937
(CAD, HTN)
**Betty
Fitzpatrick
b. 1940
27
How Chronic Illness Effects the
Family System



How the LTC System Effects the
Family System
Illness  disability  handicap
Abrupt change in function and quality of
life.
Much depends on level of interactions and
quality of relationships prior to illness.


Disruption of customary relationships and
activities.
Exacerbation of existing tensions and
dysfunctional relationships.

Expectations



Family caregivers issues



29
Navigating the system
Financial – stress?
Still function as informal caregivers.
Caregivers’ own lives are strained.
Coping with grieving and death.
30
290
16 Working with Families
Illness, Chronic Disease and the
Family System
Les
The Family “Role”
Hildegard


Disengaged
Consultants
31
The Family “Role”


32
Family Behaviors
Competitive
Collaborative
33
Collaborative Family
34
Supportive, Collaborative



DS



35
Engaged
Utilizes facility appropriately
Anxious to learn and participate
Seek help
Flexible expectations
Prepare for discharge
36
291
16 Working with Families
Unreasonable Family
Overly Involved
BW
?
?
?
?
out of
town
disabl
ed
RS
store
owner
37
38
Unreasonable, Demanding,
Overly Involved





Unreasonable, Demanding,
Overly Involved
Can’t “let go.”
Obsessive preoccupation with care details.
Overly critical.
“Entitlement” attitude.
Underlying causes:






Guilt
Denial
Previous patterns of control and manipulation.
Individual rights
versus others’
rights.
Manipulative and
divisive
Legitimate
concerns may
appear excessive.
39
40
Unrealistic Expectations /
Frequently Dissatisfied
Frequently Dissatisfied

Various causes

Stella S

Cultural and religious
beliefs
Not fully informed


Joan V
(out of town)

41
Condition and
prognosis
Financial issues
Entitlement attitude
42
292
16 Working with Families
Unrealistic Expectations /
Frequently Dissatisfied





Angry, Accusatory, Blaming,
Threatening
Unable to comprehend.
Explanations inconsistent.
Equate “cure” with long term care.
Catastrophic illness forced first long
term care system encounter.
Threats of legal action may result.
Reasons vary
Carryover
Indiscriminate
Alienate staff
Manipulative





43
44
Angry, Accusatory, Blaming,
Threatening


The Case of John W.
Personalizing attacks
may lead to staff
reprisals and abuse
against patient.
Possible Solutions:
 Allow them to express
reasons for their
anger.
 Assist staff in avoiding
attacks.
“Decision Making in the Incompetent
Elderly: The Daughter from California
Syndrome”

JAGS 1991
45
46
Rarely Involved or Uninvolved



Rarely Involved or Uninvolved
Why?
 Limited by distance or by their personal
situation.
 Distant relative or disengaged family member.
Difficult for essential care decisions.
 Advance care planning
Overreact to condition changes due to infrequent
monitoring of patient’s progress / decline.
The Daughter from California Syndrome. JAGS 1991
47

May show up suddenly and demand:




Medically ineffective care.
A change to existing approach.
Counteract decisions by family members
or patient.
Unable to deal with relative’s decline or
impending death.
48
293
16 Working with Families
Physician
Communication
Skills
Conflicts Among Family Members


May reflect
 Different philosophies.
 Existing weaknesses of family
structure.
 High risk situations.
 Substance abuse
 Criminal behavior
 Chronic mental illness
May try to involve in conflict.
 Patient
 Staff
49
50
Levels of MD Involvement with the
Family





The Family Meeting

Level I: Minimal
Level II: Ongoing medical information and advice
Level III: Feelings and support
Level IV: Systematic assessment and planned
intervention
Level V: Family therapy



Adapted from Doherty,
Baird. Fam Med. 1986
Really a medical meeting - to which the
family is invited.
The language - medical and problem
solving.
The family is often marginalized.
Can help the family find their niche in the
nursing home.
51
52
Concentrate on the Family






Listen Intently
Acknowledge the family’s presence.
Be courteous.
Avoid interruptions.
Practice positive non-verbal communications.
Keep the family informed, explain what you are
doing.
Check the family’s reaction after
 You’ve given information.
 Offered suggestions.
53






Don’t assume.
Prepare to listen.
Avoid pre-judging.
Without interrupting.
Give positive non-verbal feedback.
Focus on what the family is saying.
 Check non-verbal and emotional cues.
 Ask questions to clarify.
 Pick out the main point.
54
294
16 Working with Families
Support Self-Esteem






Assume Personal Accountability
Use the family’s name.
Avoid the use of jargon.
Show appreciation.
Compliment whenever
possible.
Share positives.
Uphold confidentiality.







Be flexible.
Be open to requests.
Offer assistance.
Look for ways to help.
Keep the family
informed.
Take ownership.
Keep promises.
55
The Family Meeting
Communicating Bad News

 Attending Physician







Psychologist
Resident
Administrator
AL Manager
AL Nurse
Social Worker
Family Member
56
When?


Eleanor


Advance directives
Prognosis
Delivering updates
How?


Lay out avenues of communication.
Discuss any obvious problems early.
57
Step 1:
Getting Started
Importance of Giving Bad News




58
Most people want
to know.
Strengthens
relationship.
Fosters
collaboration.
Permits
anticipatory grief.




59
Determine who should
be present.
Plan what you will say.
Create a conducive
environment.
Allot enough time prevent interruptions.
60
295
16 Working with Families
Step 2:
What Do They Know?
Step 3:
Do They Want to Know Bad News?
Crucial to establish!
- Saves time and
energy
How well do they
comprehend bad
news?
Reschedule if you
are unprepared.




Recognize patient preferences.



Decline to receive information.
Designate other.
Support patient preferences.


People handle information differently.
Pose as a hypothetical question…
61
Step 4:
Sharing Information
The Family Says “Don’t Tell”

What should you do?


62

Legal obligation - informed consent
Ask the family:
 Why not tell?
 What are you afraid I will say?
 What are your previous experiences?
 Is there a personal, cultural or religious
issue?






Step 5:
Responding to Feelings





Avoid monologue, promote dialogue.
Avoid jargon, euphemisms.
Pause frequently.

63

Say it, then stop.
Use silence.
Use body language.
Understanding?
Don’t minimize severity - avoid
vagueness.
64
Step 6:
Planning and Follow Up
Affective response
Cognitive response
Flight or fight
Be prepared for
emotion.
Give time to react.
Listen quietly.




Discuss the game plan.
Discuss sources of support and
education.
Give contact information.
Repeat bad news at future visits.
Buckman R How to Break Bad News: A
Guide for Health Care Professionals,
1992.
65
66
296
16 Working with Families
Communicating Prognosis





The Language Barrier
Inquire about reasons for asking.
Variability in patients and families.
 Want to know what to expect.
 Need reassurance.
Avoid precise answers.
Limits of prediction.
Reassure availability, whatever happens.
The Power of personal experience vs. Evaluation of Prognostic
Criteria for Determining Hospice Eligibility in Patients with
Advanced Lung, Heart, or Liver Disease: JAMA 1999.

Use a skilled translator if possible.

Avoid family as primary translator
because it may be:





Familiar with medical terminology.
Confusing
Inaccurate
Modified
Speak directly to the patient or family.
67
68
Working with Families
Summary




Recognize family dynamics -- patterns
of functioning.
Avoid/avert alliances and splits.
Use innovation to avoid replicating
“stuck” family patterns.
Use the ethics committee (or QA
committee) to address genuine
concerns related to families.
69
70
Working with Families
Summary

Medical Director’s Responsibilities
Functions
Remember: There is a triangle of care.





“System” with multiple players obligated to
interact with the family.
Family (  multiple players) obligated to
interact with the “System.”
Patient, whose outcomes everyone ought to
be concerned about.
We, as physicians, are in the middle and must
interact with all.
Function 2 - Professional Services


The Medical Director organizes and
coordinates physician services and services
provided by other professionals as they relate
to patient care.
Function 6 - Community

The Medical Director helps articulate the long
term care facility’s mission to the community.
71
297
16 Working with Families

Medical Director’s Responsibilities
Medical Director’s Responsibilities
Functions
Tasks
Function 7 – Rights of Individuals:

The Medical Director participates in
establishing policies and procedures for
assuring that the rights of individuals,
resident, staff members, and community
members are respected.

Task 16 (Professional Services): The Medical Director
participates, when necessary, in family meetings and similar
activities to assist the facility and/or attending physician to
promote optimal resident care.

Task 10 (Community): The Medical Director represents the
facility in the event of “untoward” events.

Task 12 (Resident Rights): The Medical Director
participates, when necessary, in family meetings and similar
activities to assist the facility and/or attending physician to
assure respect or resident rights by facility staff and family
members.
16.9-16.12
75
298
17 Quality Management
Learning Objectives

17 Quality Management

Core Curriculum on
Medical Direction


Explain quality measures that are used in
calculating the 5 star nursing home ratings.
Explain the differences between quality,
quality assurance and quality improvement.
Describe QA principles and tools.
Understand the difference between run and
control charts and how they may be
effective in long term care.
2
Quality Improvement
Quality Improvement


“It is easy but fatal in management to confuse
coincidence with cause and effect.”

“The world is drowning in information but is slow
in acquisition of knowledge.”

“Nothing will happen without change.”
“Your job is to manage the change
necessary to create the new climate.”
W. Edwards Deming

– tons of it
DATA
INFORMATION – a lot
– some
KNOWLEDGE
– pretty rare
WISDOM

Deming

3
4
Quality Improvement

Quality
A successful quality improvement effort
requires:
 The personal will to change.
 The belief that the organization is
capable of change.
 The wherewithal to undo old habits by
a tenacious commitment to learning all
aspects of quality.
 Doing it.
5

Points to remember about quality:




Subjective
Affected by
 Values
 Beliefs
May change as knowledge bases changes.
In the real world, is defined by the
“customer.”
6
299
17 Quality Management
Quality Assurance vs.
Quality Improvement
Quality Improvement

Beyond “projects” to an integrated strategy.






Organizational transformation is needed, not a parallel
add-on organizational universe that is known as “quality
improvement” disconnected from the “real work.”
Quality and continual improvement need to be a formal
part of an integrated organizational management
package.
Executive commitment to quality.
Can not overlook the cultural/psychological issues of
quality improvement.
Medical Director can not do this alone.

More later!
QA- focus on activities required to satisfy
regulators and identify outliers.




QI – focus on continuous efforts to meet
consumer needs.


7
Quality Assurance vs.
Quality Improvement


QA vs QI
Results oriented thinking
Failures, attribute blame – “incompetence”
QI – collects data to expose process
variation, discuss it, and reduce that which is
unintended and inappropriate.



Process oriented thinking
Process breakdowns
Finding hidden opportunities for improvement
9
Quality Assurance vs.
Quality Improvement

10
The statistical framework needed for
quality improvement is generally not
taught as part of medical education
(or to anyone else in long term care!)

Focus shifts to the “negative” end of
performance.
QI – Potential of high achievers to
influence the process.

Balestracci p285
Quality Assurance vs.
Quality Improvement
QA – Climate of defensiveness and a
lack of cooperation.


Customers needs must be met.
Interdepartmental, cross functional team approach is
8
often most effective.
QA- collects data to identify “perceived”
individual negative variation and to correct
outliers.


Quality by inspection
Prevent outliers
Zero defects

More later
Focus shifts to the “positive” end of
performance.
11
12
300
17 Quality Management
QAA
Quality Assessment and Assurance
F Tag 520



(1) A facility must maintain a quality
assessment and assurance committee
consisting of –
 (i) director of nursing services
 (ii) a physician designated by the facility;
and
 (iii) at least 3 other members of the
facility’s staff.
F Tag 520

(2) The quality assessment and assurance
committee (i) meets at least quarterly to identify issues
with respect to which quality assessment
and assurance activities are necessary and
 (ii) develops and implements appropriate
plans of action to correct identified quality
deficiencies.
13
14
QAA

CMS Five Star Rating
F Tag 520

(3) A state or secretary may not require
disclosure of the records of such committee
except insofar as such disclosure is related
to the compliance of such committee with the
requirements of this section.

(4) Good faith attempts by the committee to
identify and correct deficiencies will not be
used as a basis for sanctions.
15
16
Five Star Rating - Summary

17
The overall five-star rating is assigned
based on the five-star ratings for:

Health inspection (survey) domain.

Direct care staffing domain.

MDS quality measure domain.
18
301
17 Quality Management
CMS Initiative 2011
Health Inspections:
Rating Methodology


CMS’ Five-star ratings
are only for
comparison within a
state.
Fluctuations possible
with no change quality
of care provided.
10
Quality Assurance and Process
Improvement (QAPI)
20

23.33
23.33
23.33
1Star
2 Stars
3 Stars
4 Stars
5 Stars



19
Quality Assurance and Process
Improvement




Independent contractor
Pilot testing ongoing
Provision for stakeholder feedback.
Goal
 Establish on line resource library
 Upgrade current QAPI program
 Best practices approach
Clinical Trials vs. Everyday Needs
21
Key Idea:
Clinical Trials vs. Everyday Needs



Establishment of standards relating to quality
assurance and process improvement.
Purpose of program is to strengthen current
requirements and promote accountability for resident
20
care and safety by nursing facilities.
Key Idea:
CMS will establish a prototype QAPI
program.


The Patient Protection and Affordable Care Act
(ACA)
Many provisions for which CMS is responsible for
implementing.
Survey and Certification Group
 Section 6102
22
Organizational Dysfunction
The Universal Process Flowchart
Clinical trials are useful to providers who need to
know that their medical treatments are founded
on solid basic research.
Create a stable population where outside
variation is severely controlled.
Clinical trial research statistical methods make
assumptions and control variation in ways that
cannot be replicated in the unstable environment
of the real world.
23
Balestracci p3
24
302
17 Quality Management
Key Idea:
Clinical Trials vs. Everyday Needs


Key Idea:
Clinical Trials vs. Everyday Needs
SUMMARY
 Basic research
Goal is to expose the variation between
individual use and the research use of
the protocol – not ignore it.


And not just to “reduce variation,” but:
Statistical Process Control

To reduce any inappropriate and
unintended variation.
Efficacy of procedures or treatments.


Effectiveness under clinical conditions.
Improvement of processes and outcomes.
Monitoring performance.
25
26
Approaches to Fix “What is
Wrong”
Approaches to Fix “What is
Wrong”
Need to have:

Less

And more:










Level 1 fix: Incident – reacting immediately to the
undesirable output to make it right -damage
control, cleaning up, fire-fighting, “whack-amole.”

Level 2 fix: Process – fixing the process so that it
doesn't’t happen again.

Level 3 fix: System – asking whether this incident
is symptomatic of a deeper system issue where
processes like these are unintentionally designed.
Damage control, firefighting, whack-a-mole
Gathering of appropriate data
Finding out about customers
Understanding processes
Correct diagnosis of sources of variation
Reduction of variation
Coaching
Training
27
Approaches to Fix “What is
Wrong”


28
Medical Director Challenge
“Best efforts are not enough.”
“Best efforts will not ensure quality.”
“Best efforts are no guarantee that they will be
beneficial to the process.”
“When you improve quality you decrease costs
because of less rework, fewer mistakes, fewer
delays, better use of time and materials.”
Deming
AND FOR US: IMPROVE CARE
29
30
303
17 Quality Management
Quality Management:
Definition

Quality Management:
Importance

Organizational activities designed to:





Moreover:

Continually improve performance and
productivity levels.
Improve the efficiency and predictability of the
care process.
Reduce unnecessary care and waste.
Contain costs.
Improve patient outcomes and quality of life.

SURVIVE
--Dimant
31
Historical Role of Nursing Home
Quality Committees





With managed care and with PPS systems,
the
 Ability to demonstrate “high-quality”
outcomes.
 Ability to provide that care with efficiency
and cost-effectiveness.
May mean the ability to:
Basic Statistical Lesson
Key Concept -Variation
Poorly organized data
No lateral communication
High variability
Little feedback
No Impact

The usual way data is presented in
your nursing home:
 The 1-point Curve
 The 2-point Curve
 The 3-point Curve
33

32
34
Basic Statistical Lesson 2
Basic Statistical Lesson
Key Concept -Variation
Key Concept -Variation
The 1-point Curve

The 2-point Curve
100

90
80
70
60
50
40
30
Common practice
 Last month to this month.
 Last year to this year.
 Last quarter to this quarter.
20
10
0
Jan10
Feb10
Mar10
Apr10
May10
Jun- Jul-10 Aug10
10
Sep10
Oct10
Nov10
Dec10
Jan11
35
36
304
17 Quality Management
Basic Statistical Lesson
3 Point Curves
Key Concept -Variation

Upward
Trend
The 2-point Curve
Downturn
100
90
80
Rebound
70
Setback
60
50
40
30
Turnaround
20
10
0
Jan10
Feb10
Mar10
Apr10
May10
Jun- Jul-10 Aug10
10
Sep10
Oc t10
Nov10
Dec10
Downward
Trend
Jan11
37
38
Basic Statistical Lesson
So how do we move ahead?
Key Concept -Variation

The 3-point Curve – “Trends”

False explanations given to each
“trend” resulting in false solutions
that increase variation and increase
costs.
“We can’t solve problems by using the same
kind of thinking we used to create them.”
Albert Einstein
39
How good is good is good enough?


Q: If a system has 100 independent
occurring elements, each of which
functions properly 99.9% of the time,
what is the probability that the entire
system will function correctly???
A: The entire system will function properly
only about 90% of the time (0.999 to the
100th power).
41
40
If 99.9 % were good enough…

The IRS would lose over 2 million documents this
year…

There would be a major plane crash every 3 days.

16,000 items would be lost in the mail every hour.

There would be 37,000 ATM errors every hour.

12 babies would be given to the wrong parents each
day.

291 pacemakers would be incorrectly installed this
year.

107 erroneous medical procedures would be
performed daily.
42
305
17 Quality Management
QM: Implementation
The Wisdom of Others

“Cost savings will not be achieved by
cutting corners, but rather by eliminating
processes that lead to poor outcomes
and ultimately high costs.”
Ellen G. Lasser. Outcomes and Performance
Measurement: Redefining How Healthcare is
Strategized and Delivered”. Healthcare Executive.
July/Aug 1999
43
44
Business Case for Quality
The Wisdom of Others

“Improving quality reduces costs.”

“Need to reduce the causes of costs.”
Balestracci
http://www.hmc-benchmarks.com/hospital-benchmark/resources/cost-quality-matrix.php
45
46
What is the objective of data use?
47

To develop a new way of thinking via
a common organizational language
based in process and understanding
variation to motivate more productive
daily conversations for everyone.

To solve problems.
48
306
17 Quality Management
*
Basic Statistical Lesson
What is the objective of data use?

To eradicate rampant waste caused by
poor everyday organizational use of data.
Key Concept - Variation


For example: the usual demand for
explanation for why a number is different from
either it’s predecessor or an arbitrary goal.

Incorrect conclusions and actions resulting
from these approaches unwittingly inflict
damage and demoralize culture.
Walter Shewhart- 1920’s
 There is always variation in
anything that is being measured.

In statistical thinking terms: there are
inputs causing variation that are always
present and conspire in random ways to
affect a process’s output.
49
50
*

Basic Statistical Lesson
Basic Statistical Lesson
Key Concept - Variation
Key Concept - Variation
Questions to ask:


First: Is the process stable? In other
words, is the process in statistical
control?
Second: What are the causes of
variation in the process?
Two types of variation:

Controlled, stable
 Common cause variation

Uncontrolled, unstable
 Special cause variation
51
52
*
*
Basic Statistical Lesson
Key Concept - Variation

Controlled / stable


Key Concept - Variation
Common cause variation

Is the process in statistical control?
Basic Statistical Lesson



Output is predictable within well-defined limits, but
impossible to predict where any specific result will lie
within those limits.
Common cause variation is due to the way that the
processes and systems have been designed and
built.
Combination of existing people, methods, machines,
materials, environment, and measurement.
53
Wheeler p 127
54
307
17 Quality Management
*
Basic Statistical Lesson 2
Basic Statistical Lesson
Key Concept - Variation
Key Concept - Variation

Special cause variation

Uncontrolled (unstable) variation
Process affected by special causes.
 Behavior changes unpredictably.
 No one can predict process capability

Wheeler p126
55
56
*
Basic Statistical Lesson 2
Basic Statistical Lesson
Key Concept -Variation
Key Concept -Variation

Walter Shewhart- 1920’s

Two kinds of mistakes.


Wheeler p130
Walter Shewhart- 1920’s

Two kinds of mistakes.


58
Basic Statistical Lesson
Key Concept -Variation
Key Concept - Variation

Sounding a false alarm.
57
Basic Statistical Lesson

Mistake 1. Treating a fault, complaint,
mistake, accident as if it came from a
special cause when in fact there was
nothing special at all, i.e. it came from the
system: from random variation due to
common causes – Tampering.
Mistake 2. Treating a fault, complaint,
mistake, accident as if it came from a
common cause, when in fact it was due
to a special cause
Missing a signal in the data.
59
We learn nothing of importance by
comparing two or three results
when they all come from a stable
process.
Most data of importance to
management are from stable
processes.
60
308
17 Quality Management
Key Concept –
Using Variation for Improvement

Controlled (stable) variation


Variation
When special causes have been eliminated so
that only common causes remain, improvement
has to depend upon management action.
Uncontrolled (unstable) variation


Human tendency is to
treat all variation as
special cause.
Impossible to evaluate the effects of changes in
design, training, policies, which might be made
to the process by management.
61
62
Quality Improvement
In a Process-Oriented Context
Davis Balestracci
Quality Improvement
In a Process-Oriented
Context
Davis Balestracci

First: Your current processes are
perfectly designed to get the results they
are already getting and designed to get,

With it's corollary:
 Insanity is doing things the way you
have always done them while
expecting different results.
63
64
Quality Improvement
In a Process-Oriented Context
Quality Improvement
In a Process-Oriented Context
Davis Balestracci
Davis Balestracci

Second: The current processes are also
perfectly designed to take up more than
100% of people's time working in them,

Third:
improving quality = improving process

With it's corollary:
 It is amazing how much waste can be
disguised as useful work.

Problems:
Breakdown in current work processes,
or,
Lack of consistent work process
65
66
309
17 Quality Management
85/15 Process Rule

Individuals have direct control over
only 15% of their work problems.

The other 85% are controlled by the
process in their work environment.

Deming 4% - 96%
Six Sources of Process Problems
Balestracci
67
68
Six Sources of Process Problems
Six Sources of Process Problems

1. Inadequate knowledge of how a
process actually works.


Variation in people’s perceptions of how
things currently work.
2. Inadequate knowledge of how a
process should work.


Variation in people’s perceptions of how
things should work.
Poor process design.
69
70
Six Sources of Process Problems
Six Sources of Process Problems

3. Errors and mistakes in executing
procedures.



Variation in how people are trained to do
the work.
Variation in how people actually do the
work.
4. Current practices that fail to
recognize the need for preventive
measures.


71
Environmental factors that make the
process perfectly designed to have
undesirable variation.
Human fatigue, sensory deficit, sensory
overload.
72
310
17 Quality Management
Six Sources of Process Problems

Six Sources of Process Problems
5. Unnecessary steps, wasteful
measures.

6. Variation in inputs and outputs.



Dealing with everyday variation.
Complexity added in past due to
inappropriate reactions to experienced
variation.
Untested solutions implemented.
73
74
Six Sources of Process Problems
Summary
1. Inadequate knowledge of how a process
actually works.
2. Inadequate knowledge of how a process
should work.
3. Errors and mistakes in executing procedures.
4. Current practices that fail to recognize the
need for preventive measures.
5. Unnecessary steps, wasteful measures.
6. Variation in inputs and outputs.
Process Analysis

The most serious problems in
service processes result from
variation caused by:
The lack of agreed-upon
processes.
More later
75
Quality Management:
Data
It’s Processes not People

While we must still hold individuals
responsible for high standards of
performance, we now recognize that
most errors result from faulty
systems, not faulty people.

Change in focus from the 15% to the
85%.
76

77
Typical areas of focus in the long term
care continuum:
 Infection control
 Nutrition
 Medication errors
 Falls and injuries
 Pressure sores
78
311
17 Quality Management
MDS 3.0

Where will I get all this data?

Opportunities to assess quality through the
facility own data collection opportunities
with 3.0.
Assessments are done for OBRA.




79
Day 14 then quarterly
Annual review
Discharge
Assessments are done for PPS.

Days 5, 14, 30, 60, 90
80
MDS 3.0

Potential areas for quality monitoring:








BIMS scores
PHQ-9 scores
Pain management
Late loss ADL (toileting, eating, transfers, bed
mobility)
Urinary incontinence/ infections
Weight loss
Prognosis (less than 6 months)
81
Pressure ulcers
CMS 672
82
CMS 672
83
84
312
17 Quality Management
Quality Management: Data
Quality Assurance and Assessment


Facility Reports





Pressure ulcers
Infection control
 UTI with and without catheters
Falls
Warfarin use
 INR > 3.5
Resident and family complaints
Criteria for choosing which indicators to use out
of the vast array which present themselves.







Reason for monitoring the item or process.
Appropriateness of indicator to item or process.
Ease of measurement (data collection).
Ease or ability to analyze data.
Cost of collection and analysis.
Cost/benefit comparison of all indicators identified
which relate to the particular item or process.
Pareto Principle – more later
85
86
The Deming Philosophy
Continuous improvement approach is based on
the late Dr. W. Edward Deming’s philosophy:
“Improve constantly and forever every process for planning,
production, and service”
87
88
Key Ideas
Ways Work Gets Done
Benefits of Deming Philosophy



Less rework, less inspection
Increased/improved:
- Productivity
- Customer satisfaction
- Service quality
- Profits over the long term
- Competitive position
- Behavioral environment
- Organization culture
Decreased cost

“Viewing our organizations as systems
helps us achieve a customer focus and
reduce waste and inefficiency.”

89
Brian Joiner
90
313
17 Quality Management
Process Oriented Thinking
Systems Thinking




Plan
Core business of medical practice:


The Model for Continuous
Improvement - PDCA
Deliver health care to customers.
Meet obligations to insurance payers.
Meet obligations to the overall community.
The entire system must be studied and
optimized as a whole.
Not separating health care delivery from
health care management.
START
Act
Do
Check
91
The Right Tool
for the Right Job!
Tools










Brainstorming
Focus Groups
Multi-voting
Incidence / Prevalence
Flowcharting
Pareto Charts
Run Charts
Control Charts
Fishbone Diagrams
How / How Charts
93
94
Focus Groups
Brainstorming



Facilitator
Ground Rules




92
No bad ideas.
Encourage participants
to “think outside the box”
But not a “free for all” or “gripe session.”

Facilitator meets with a group of “customers” to
identify their needs, attitudes, and their
perception of how (and how well) things are
working. (Family Council may be able to serve
this purpose for some items.)
Useful for:


Large flip chart for notes helpful.


95

Identifying customer expectations
Describing the process in question
Identifying root causes
Evaluating results
Drawing conclusions
96
314
17 Quality Management
Incidence
Multi-Voting




After looking at a list of ideas (or problems or
solutions) have each person in the group vote for
as many ideas as they want (only one vote per
idea) and select ideas with most votes.
Re-vote, with each person allowed
(0.5 x # of selected ideas) votes; can apply one or
all votes to any selected idea.
Continue re-voting until list is trimmed to the
desired number ideas.
Facilitator to set any ground rules.
97
Incidence


In September Shady Pines had 5 facility
acquired urinary tract infections. They
had a stable census of 120 residents.

What is the incidence of facility acquired
urinary tract infections?
98
Incidence
Number of new UTI’s
5_UTI
3600 (BDOC)
Average census x time
Average census x time = bed days of care(BDOC)
Assume stable census of 120 patients in month of
September then BDOC= 3600
Multiply incidence by 1000 to get # per 1000
resident days
X
1000 =
1.4 UTI per thousand resident days
BDOC = 120 resident x 30 days
99
10
0
Prevalence
Prevalence
Shady Pines has 4 elders with pressure
ulcers. None of the ulcers are new.
What is the prevalence of pressure
ulcers in the facility?
4 elders with pressure ulcers X 100
120 elders at risk
0.33X 100 = 3.3 %
10
1
10
2
315
17 Quality Management
Process Analysis

Incidence
A lack of agreed-upon processes

Number of counted items or events
per unit of time.


Prevalence
Number of counted items or events
at a given time.
Unintended variation in individual work
processes.
Management’s perceptions of these
processes.
There can be big differences between what
is written down- the way the system is
intended, or thought to operate, and what
actually happens.
FLOWCHARTS
10
3
10
4
Flowcharting
What does it do?

To allow a team to identify the flow or
sequence of events in a process; helps
picture the process.



10
5

Shows where simplification /
standardization possible.
Compares / contrasts actual vs. ideal flow,
thus identifying improvement opportunities.
Facilitates agreement on the steps of a
process & examines impact of activities of
process performance.
Identifies areas for data collection and
analysis.
Describing the Process

Include “front-line” personnel


They can tell you what is stopping them from
doing their job.
Also gives you an opportunity to see if they:
 Know what should be done.
 Know how to do it.
 Understand why it is important.
 Think their way is better than the required
way.
10710
7
10810
8
316
17 Quality Management
The Pareto Principle
The Pareto Principle

80% of the observed variation in a
process is caused by only 20% of the
process inputs.

20% of the variation causes 80% of the
problems


Juran 1920’s
The “vital few” vs the “trivial many”
10
9
11
0
The Pareto Principle
20% - the “vital few”
 Long-standing, perennial opportunities that have
never been solved despite repeated efforts.
 Root causes are deeply entrenched in the
culture.
 Require more formal ad higher-level guidance.
 Solution processes are lengthy, require patience
and persistence.
 Need to have top-level management involved.
11
 Can have a significant impact.
1





#
How do I do it?
 Decide on problem to be analyzed.
 Brainstorm or collect data to select problems or
causes to be analyzed.
 Choose unit of measurement and timeframe for
the study.
 Collect data (real time or historical).
 Compare relative frequency of each problem or
cause.
 Graph the frequencies with a cumulative % line to
11
interpret the results.
3
Take as much time to solve but have less
“value” to the organization.
However, may be “vitally” important to
individuals who work in these situations.
 “useful many”
Common tendency for these individuals to
distract from primary task.
Need to address in context of the larger
problem.
11
2
Instances of Concerns Possibly
Contributing to Weight Loss
Pareto Chart

80% - the “trivial many”
100%
50
45
40
35
30
25
20
15
10
5
0
80%
60%
40%
Cumulative %

The Pareto Principle
20%
Supplements
Acute Illness
Dietary Stafing
CNAs
11
4
317
17 Quality Management
50
45
40
35
30
25
20
15
10
5
0
Data Analysis - Run Charts
100%
80%
60%
40%
Cumulative %
20%
Supplements
Acute Illness
Dietary Stafing
CNAs
11
5
11
6
Quality Improvement: Case 1
Data Analysis - Run Charts


Falls with Median
Graphical representation of data over
time.
14
12
Time ordered plot of a set of data in it’s
naturally occurring order with the median
of the data drawn in as a reference line.
10
8
6
4
Ignoring the time element implicit in
every data set can lead to incorrect
statistical conclusions.
2
00
ar
-0
Ap 0
r- 0
0
M
ay
-0
Ju 0
n00
Ju
l-0
Au 0
gS e 00
p0
O 0
ct
-0
No 0
v0
De 0
c0
Ja 0
n0
Fe 1
b0
M 1
ar
-0
Ap 1
rM 01
ay
-0
Ju 1
n01
Ju
l-0
Au 1
g0
Se 1
p0
O 1
ct
-0
No 1
v0
De 1
c01
b-
M
n00
0
Ja

Fe
#
Instances of Concerns Possibly
Contributing to Weight Loss
11
7
Data Analysis - Run Charts

11
8
Data Analysis - Control charts
What information can you get from
the run chart?
Stability
 Common cause vs. special
cause


Will discuss in breakouts.
11
9
12
0
318
17 Quality Management
Data Analysis - Control Charts

Data Analysis - Control Charts
Common Cause




What are the common cause inherent
limits of the process;
Control Chart

What is the common cause variation
around the average that indicates stable
behavior?
Time plot of the data that includes
lines added for the average and
natural process variation.
How much difference between two
consecutive data points is “too much?”
12
1
Quality Improvement – Case1
Control Chart
12
2
Data Analysis - Control Charts
Falls with Average and Control Limits

14
Control Chart – Limits
12

These limits represent a common
cause range around the average
where individual data points may be
expected to fall if the underlying
process does not change.

Will discuss in breakouts.
10
Falls
8
Average
Upper Control Limit
6
Lower Control Limit
4
2
Ja
n00
M
ar
-0
0
M
ay
-0
0
Ju
l-0
0
S
ep
-0
0
N
ov
-0
0
Ja
n01
M
ar
-0
1
M
ay
-0
1
Ju
l-0
1
S
ep
-0
1
N
ov
-0
1
0
12
3
12
4
Fishbone Diagram
Process Analysis

Fishbone Diagrams

Show the causes of a certain event. A
Fishbone or Ishikawa Diagram can be
useful to break down (in successive
layers of detail) root causes that
potentially contribute to a particular
effect.
12512
5
Weight Loss
12612
6
319
17 Quality Management
Fishbone Diagram
Fishbone Diagram
CNA assistance with meals
Type of Patient
CNA assistance with meals
Short staffed
Type of Patient
Inadequate
training
Hospice
Obese patient
on diet
Ortho
Rehab
High toileting needs
Holiday call-offs
Lack of
interest
Wages not competitive
Don’t understand
importance
Weight Loss
Weight Loss
New
Dietician
Wages not competitive
Poor presentation
Holiday call-offs
Dietary Staffing
Wrong Temperature
Monotonous Menu
Dietary Staffing
Food Not Appetizing
Food Not Appetizing
12712
7
12812
8
Generate Solutions
How / How Form
The Big Picture
How? Greater variety of supplements
• Group of related interdependent
processes working together to achieve a
How?
Improve Caloric
Supplementation
How? Optimal timing of supplements
Goal:
Decrease
number of
residents
losing
weight
goal
System • common
Made up of a culture, structure and
boundary
How? Limit # of therapeutic diets
available
How?
Eliminate
restrictive
diets
Process
How? Team to review need for restrictions
on individual patients
How?
Improve food appearance
People
How? Provide garnishes
How? Table settings
• Have beliefs, values,
interests, needs
• Have roles which are
made up of functions
and tasks
12
9
13
0
Key Concept - Improvement

• Sequence of tasks aimed at
accomplishing a goal
• Produce data which can be
analyzed
Key Concept - Improvement
Studying a process in time.

Assess current performance.
 Establish a baseline for improvement
efforts.
 Assess improvement efforts.
 Predict future performance.
 Ensure that improvement gains are
held.
13113

1
Process Improvement
Phase 1 – Stabilization
 Phase 2 – Active improvement
 Phase 3 – Monitoring

13213
2
320
17 Quality Management
Key Concept - Improvement

Key Concept - Improvement
Process Improvement


Phase 1 – Stabilization
Process Improvement
 Phase 2 – Active improvement
Eliminate common causes.
Pareto analysis
 Fish-bones
 Flow charting
 Recalculate control limits.
Eliminate special causes.
Gets the process where it should have been
in the first place.
 Problem solving, putting out fires.
 No real improvement at this level.
 Control, Run charts




13313
3
Key Concept - Improvement

Putting It All Together
Process Improvement

13413
4


Phase 3 – Monitoring
Constant vigilance
 Implement additional improvements as the
need arises (continuous improvement).




How do we operationalize this in LTC?
How do we know what to evaluate?
What is the role of the Medical Director?
What is the role of the IDT?
How will this improve care?
13513
5
5 Stage Plan for Improvement
13
6
Stage 1:
Understand the Process

Describe the process.
How does it work?
How should it work?

Observe


The Team Handbook, Scholtes, Joiner
13713
7
13
8
321
17 Quality Management
Stage 2:
Eliminate Errors




Stage 3:
Remove Slack
Identify mistakes in execution.
Need for preventive measures.
Proper education
Proper training

Unnecessary steps
13
9
Stage 4:
Reduce Variation




14
0
Stage 5:
Plan for Continuous Improvement
Run charts
Control charts
Special cause
Common cause

PDSA/CAP-Do
Hold the gains
Standardize

Checklists


14
1

14
2
Organizational Transformation
Organizational Transformation
To achieve a quality culture:

Adoption of ways of life:




All employees are educated in basic quality
improvement tools and philosophy.
Use of data is integrated and statistically
based.
Feedback is an integral part of organizational
culture, is nonjudgmental, and is based on
being committed to people’s success.









14
3
Customer-first orientation
Continuous improvement
Elimination of waste
Prevention, not detection
Reduction of variation
Statistical thinking and use of data
Adherence to best known methods
Use of best available tools
Respect for people and their knowledge
Results based feedback
14
4
322
17 Quality Management
Breakout
14
5
323
18 Risk Management
Learning Objectives

18 Risk Management


Core Curriculum on
Medical Direction

Identify areas of high risk in your facility.
Analyze a risky situation.
Participate in the development and
implementation of risk management
policies and procedures.
Assist facility in developing and/or
maintaining a corporate compliance
program.
2
Risk Management Outline





Overview: Defining, Analyzing and
Reducing Risk
Corporate Compliance
Disaster Planning
Employee Issues
The Role of the Medical Director
18.1 - 18.5
3
4
Risk Management Includes

Risk management includes
activities involved in defining,
analyzing and reducing risk.
An integrated process of defining
and monitoring specific areas of
risk
and

5
Developing and implementing a
comprehensive plan to prevent,
mitigate or respond to actual or
potential risk.
6
324
18 Risk Management
Risk Concerns Can Come From
Outside or Inside the Facility.
Why Risk Management?

External Factors: Natural disasters,
public perception, surveyors, scandal

Internal Factors: Internal disasters
(fire, power loss), issues with
employees, residents, families
Effective risk management
saves lives and money.
7
8
High Risk Situations/Scenarios

What risks
have you
experienced?






Quality of care
Transitions of care
Employee
injuries/exposures
Disgruntled
employees
Visitors
Disaster response
Physical plant






Difficult families
Poor documentation
Ethics/compliance
Unions
Errors
Criminals/sex
offenders
9
High Financial Risk For Lawsuits
Regarding Care are Falls, Abuse
and Wounds.
How Do You Identify High Risk
Areas in Your Facility?




Complaints
Incident reports,
Reports to public
health/survey results
Quality indicators



10
Staff interviews (exit
interviews)
Audits
Going to meetings
and learning
something new that
you are not doing.







11
Falls (60% of claims)
Wounds (10% of claims)
Injuries-other
Wandering/AWOL
Neglect And Abuse
Clinical Practice Failures
Weight Loss – “starving mother”
12
325
18 Risk Management
Lawsuits are Related to Poor
Care Outcomes Linked to:





The Root Cause of Many Risky
Situations is…
Failure to assess.
Failure to follow your own policies.
Failure to follow up/report.
Inadequate/altered records.
Failure to communicate.



Poor communication.
Poor relationships/engagement.
Poor attention to detail/apathy.
and

occasionally just bad luck.
13
The Process of Risk
Management Involves:




14
Risk Management Analysis
Seeking out and reviewing information
and trends.
Identifying priorities.
Analyzing areas of greatest risk.
Implementing systems and checks and
monitoring to assure best practices are
followed.





Individual or systems problem?
Scope of problem
Involved systems
Who is affected?
What are the best practices out there?
15
For Example: INR is 10.
What Do You Do?





16
For Example: A Visitor Touched a
Resident in a “Promiscuous” Way.
Individual or systems problem?
Scope of problem
Involved systems
Who is affected?
What are the best practices out there?
17





Individual or systems problem?
Scope of problem
Involved systems
Who is affected?
What are the best practices out there?
18
326
18 Risk Management
Risk Management Begins With
Analysis and Then Moves to
Solutions.
Model Your Facility’s Response
on 4-step Process.

As a Medical Director,
resist the urge to jump to a
solution.



Immediate correction to index case.
Identify others potentially affected
(sweep the facility).
Review applicable systems and correct
potential pitfalls.
Monitor and modify as indicated.
19
What Might a Medical Director
Spearhead to Reduce Risk?
Common Solutions Involve:






20
Education
Standardized work processes
Supervision
Policies, procedure, guidelines
Improving assessment, documentation
Vigilance





Smoke free facility.
Reduce restraints.
Screen all potential admissions for sex
offender status.
Ethics consultation team.
Policy on timely MD communication.
21
Cornerstones of Risk Management

Anticipation

Participation

Communication

Documentation

Ongoing oversight of A, P, G, D
22
Anticipation


23
The art of guessing what bad things
might happen and preparing for them.
Tracking potential risks both for
prevention and early intervention.
24
327
18 Risk Management
RISK
Anticipate Through Tracking,
Audits







Participation
Hospital readmissions
QI/QM
Restraint rates
Complaints
Incident reports
Worker’s compensation
Staff “discipline”

Risk is everywhere and everyone’s job
is to prevent, identify and mitigate.

Participation is similar to engagement—
keeping an eye open for safety and risk.
RISK
25
Medical Director Participation:





26
Communication
Know your facility’s policies and culture.
Verify corrective action.
Support the administration to address
complaints, family concerns or “bad
outcomes.”
Design systems that take into account
“Human Factors.”
Provide mechanism for education.

How the staff communicates with each
other, with residents and
superiors/managers about risk both
when things are going right, and when
things go wrong.

How complaints and concerns are
handled.
27
28
Bad Communication=Bad
Outcomes
“Resident oxygen saturation less than
72%, tried to call MD, no call back, tried
twice. Will inform the next shift.”
Medical Director needs to establish
communication standards for
physicians.
18.6 - 18.7
29
30
328
18 Risk Management
How Does Your Facility Respond
to Errors?
Tell the Truth About Errors.


“Joint Commission” mandates timely
disclosure of adverse events to
patients.

Does your facility have a policy of full
disclosure?

Does your facility takes a “systems”
approach to errors? (“Just Culture”)
Notify physician, assess likelihood of
adverse event, notify patient and family,
monitor for adverse events, evaluate
what happened.
31
Documentation





32
What is Wrong With This Note?
Realistic policies and procedures.
Don’t collect data you are not going to
do anything about.
Consistency-- if not, explain.
Review attending documentation.
Document thought process.

“Family belligerent and constantly
complaining—I doubt they could ever be
satisfied with anything we do.”

“Nursing home physician discontinued
steroids causing exacerbation.”
33
What is Wrong With This Note?
34
What is Wrong With This Note?

“Stable, no change, BP 70/40”

The incident report suggests that Sally
might have been careless and not used
the lift correctly.

35
This elderly woman highly values comfort
and autonomy, as discussed with her
and her family, and prefers to walk and
fall to any alternative. Risk of falls
including fracture, head injury and death
are understood. Goal is to provide
sufficient supervision so she is found
quickly after inevitable next falls.
36
329
18 Risk Management
Corporate Compliance
18.8 - 18.10
37
38
False Claims Act
(31 U.S.C. 3729-3733)
“Lincoln Law”
Corporate Compliance is
assuring all rules and
regulations are followed.
Rewards whistle blowers who
report wrongdoing in dealing with
the federal government.
not just avoidance of actual harm.
40
39
The Seven (7) Basic Elements
of a Compliance Program
Federal Sentencing Guidelines

1.
2.
3.
4.
5.
6.
7.
Reward organizations who have
effective corporate compliance
programs and self report problems.
41
Written Code of Conduct.
Designated Compliance Officer.
Regular education and training.
Self-monitoring of compliance.
Employee ability to report an issue.
P&P for investigation, non-retaliation.
P&P to enforce disciplinary action.
42
330
18 Risk Management
Specific Risk Areas
Compliance - Goals
Reduce fraud and abuse.
Enhance operational function.
Improve quality of health care services.
Decrease cost of heath care.
Establish a culture of accountability.





Quality of Care
Assessing Functional
Capacity
 Medication
Management
 Staffing Issues
 Rehabilitation Therapy
 Assistance with ADLs

Resident Rights
 Privacy
 Dignity
 Self-determination
 Abuse & Neglect
43
Specific Risk Areas

44
Specific Risk Areas
Employee Screening
 Pre-employment criminal background
 Drug screening

Billing and Cost Reporting



Vendor Screening /Relations
 Hospice
 Ancillary Services (Lab, Radiology)
 Consultant Pharmacist
 Food Service



Services not provided, medically
unnecessary, duplicate.
Submitting Part A claims for ineligible
resident.
Upcoding, Unbundling
Forging Physician signature.
False cost reports.
45
46
Benefits of a Compliance
Program
Specific Risk Areas


Recordkeeping and Documentation


Procedure for amending medical record.
Survey-Friendly documentation.
47
Early Detection and Reporting

Minimizes the loss to the Government
from false claims.

Minimizes exposure to civil damages;
penalties, criminal sanctions, and
administrative remedies may be reduced.
48
331
18 Risk Management
Compliance: Medical
Director’s Responsibilities




Resource
Maintain a thorough working knowledge of
program.
Ensure provider education is occurring.
Review audits of provider documentation and
designated RUGs level after MDS is done.
Counsel and assist providers in adopting a
compliance culture.

Federal sentencing guidelines for
corporate compliance:
http://www.ussc.gov/2005guid/8b2_1.htm
49
50
It Will Never Happen to Us.
Disaster Planning
Katrina hits the Gulf Coast
U.S. nursing homes learn the hard way.
51
52
34 counts of Negligent Homicide
Failed to evacuate.
332
18 Risk Management
Disaster Planning

Disaster Planning
“It’ll never happen to us!”

The Grand Forks Flood…
55
56
Disasters are Defined by Levels

Definition: Any event that results in a risk of
injury or loss of life or property and results in
a demand for services that exceeds the
available resources.

Level:

Manageable with local resources.
Requires multijurisdictional
assistance.
III. Requires State/Federal aid.
I.
II.

Disaster Planning
The process of imagining what might
happen and what you would do and need.
 Supplies
 Staffing
 Outside help
Causes: External or Internal?
58
Annals of Long-Term Care 2000; 8(6): 47-50.
Disaster Planning
Disaster Management

Person Risk
Facility Risk
Aggregate Risk
Event Risk
Aggregate risk paradigm for nursing home evacuation decisions
JAMDA 2008; 9: 599-604
59
The decisions you need to make when
a disaster occurs:
 Evacuate or shelter in place?
 Who to save first?
 How many staff to keep, call?
 Notification to outside authorities,
agencies.
60
333
18 Risk Management
Resources
Resources
Dosa DM, Grossman N, Wetle T, Mor V
To evacuate or not
to evacuate: lessons learned from
Louisiana nursing home administrators
following Hurricanes Katrina and Rita Am
Med Dir Assoc. 2007 Mar;8(3):142-9.

Dobalian A, Claver M, Fickel JJ
Hurricanes Katrina and Rita and the
Department of Veterans Affairs: a
conceptual model for understanding the
evacuation of nursing homes.
Gerontology. 2010;56(6):581-8. Epub 2010
Mar 24.

61
62
Employee Risk Management
Resources

Blanchard G, Dosa D. A comparison of
the nursing home evacuation experience
between hurricanes Katrina (2005) and
Gustav (2008). J Am Med Dir Assoc. 2009
Nov;10(9):639-43. Epub 2009 Oct 12.
63
Employee Risk Management Keeps
More Staff on the Job and Saves
Money!
Employee Risk Management





64
Training/competency
Injuries/exposures/“light duty”
Unions
Turnover, staffing levels
Staff health and wellbeing…Happy staff
often translates to good care.
65

Raising employee flu vaccine rates
reduces morbidity and mortality for
residents and lost days of work for
staff.

Reducing worker’s compensation
claims saves money and pool
utilization, improving continuity of care.
66
334
18 Risk Management
Considerations for the
Medical Director
Unions
As Medical Directors, we may not:




Threaten employees in anyway regarding their
support of or opposition to the union.
Interrogate employees regarding their support
of or opposition to the union.
Promise employees a benefit or favor to gain
their support or opposition to the union.
Spy or conduct surveillance on employees
engaged in union activity.
Per Wagner Act (The National Labor Relations Act) – 1935
68
67
As a Medical Director…

Medical Director Liability

Medical Director responsible for
implementing all resident care policies,
as well as policies relating to incidents,
ancillary services, medication use, and
release of clinical information.

Responsible for coordination of medical
care in the facility.
We have liability for
administrative acts and failure of
oversight.
69
Medical Director Wears Two Hats
and Needs Insurance for Each.
Attending Physician
(Clinical)
OBRA (42 C.F.R. 483.75)
70
Physician Liability
Medical Director
(Administrative)
71

Facility, medical director and physicians
may be liable for deficiencies related to
physician services (F385-390;F280;
F283-84) and other clinical issues.

Assure you have adequate malpractice
insurance for both clinical and
administrative duties.
72
335
18 Risk Management
Medical Director Administrative
Liability – Negligence
To Do List:




Negotiate to be an additional named
insured for administrative acts under
Facility Directors and Officers
insurance.
Request copy as proof.
Require them to notify you if they
change carrier or policy.
Consider getting your own insurance.

Texas jury awarded punitive damages
against a medical director who failed to
warn a facility regarding a resident’s
violent history resulting in injury to
another resident. Malpractice carrier
refused to cover.
73
74
Physician/Medical Director
Liability Issues – Criminal



Risk Management Strategies
for the Medical Director
1985 – A medical director (Texas City, TX)
indicted for murder for multiple deaths in
facility.
1991 – Doctor in Monroe County, FL
charged with manslaughter related to death
of NH resident from diabetic coma.
1993 – GeriMed settled criminal charges for
deaths in two Philadelphia nursing homes.



Maintain sufficient level of involvement to
ensure the provision of quality care.
Ensure that the Medical Director is named
as a covered party in the facility’s
administrative liability insurance policy.
Watch out for (and demand quality
improvement efforts about) Red Flags…
75
What Can the Medical Director
Really Do:
Medical Director Role

76
Medical Directors need to do rounds
and chart audits and call attention to
problems.




Establish a system where staff are
rewarded for identifying risk so you can
obtain complete and all relevant
data/facts.
77

Ask for and review data.
Review and update policies.
Talk with staff.
Help the facility set priorities, analyze
risk and respond to bad outcomes.
78
336
18 Risk Management
Top 10 Things You Must Do:
Top 10 Things You Must Do:
1. Risk sharing conversations with
families and making realistic goals.
2. A procedure for amending medical
record, late entries.
3. Special surveillance for high risk
medications: antipsychotics, warfarin,
sedative/hypnotic.
4. Distribute “Do not use abbreviations “
and “read back” instructions to all
doctors and then audit.
5. Enforce standards on responsiveness
and behavior of on call physicians—
nurses have a place to bump it up.
6. Assure there is an incident report
tracking system with investigation.
79
80
What Gets Doctors in Trouble in
Court?
Top 10 Things You Must Do:
7. Address restraints.
8. Pay attention to disgruntled employees.
9. Make sure billing done in your name is
accurate.
10.Put all risk management activities
under the QI program to protect the
analysis from discovery.






Disgruntled employees.
Multiple incidents of substandard care.
Lack of knowledge of regulations or
facility policies.
Appearing not to care.
Inadequate documentation.
Altering documentation.
81
82
Risk Management:
Where Does the Lawyer Fit?
Legal Pearls



Defense attorneys represent the insurance
company that covers the attending physician or
facility; consider hiring own attorney.
Common strategy of plaintiffs: Divide and
conquer – don't play the blame game with the
facility—everyone loses.
You will likely win: Defense prevails in 75% of
cases that go to trial.
83







Designated staff member.
Open communication with legal counsel.
Preserve documentation.
Separate legal counsel as appropriate.
Maintain attorney-client and Peer Review
privilege.
Address administrative citations promptly.
Aggressive use of IDR and Administrative
Tribunals.
84
337
18 Risk Management
OOPS
Risk Management



Proactively actions that protect
resources (human and material).
Prevent, analyze and improve risk.
Deal with bad outcomes once they
happen.

Mistakes will happen, but if we are
focused on serving those around us,
and understand their needs, we may
be less likely to end up in court.
85
86
Risk Management
…Summary

Resources
The Medical Director has an important
role in managing risk for:
 Residents
 Employees
 The facility
 The Medical Director!


87
Your handouts include references to both
the original Beer’s list of high-risk
medications and medication-disease
interactions upon which the Medication
Regimen Review portion of the survey is
based, as well as the recently updated
version.
New Beers list/recommendations in 2012!
88
Resources

Additionally, AMDA has developed a
number of Clinical Practice Guidelines
specifically for long term care. These are
available at the registration desk or through
the AMDA website (www.amda.com).
89
338
19 Systems Theory
Learning Objectives
19 Integration of Problem Solving
and
Systems Theory


Core Curriculum on
Medical Direction
Describe the process of problem
solving.
Apply systems theory and medical
direction tools and skills to problem
solving in long term care settings.
2
1
Systems Theory


19.1 – 19.4
What is Systems
Theory?
How does
Systems Theory
relate to Problem
Solving?
3
4
Systems Theory

Systems Theory

Purpose:
Systems

To describe the interrelationships
and overlap between separate
disciplines (entities).




5
Are goal oriented, they have specific
functions.
Components work together to achieve a
common objective.
Have inputs from the environment.
Have outputs that they send into the
environment.
Are impacted by the inputs and outputs,
there are feedback loops.
6
339
19 Systems Theory
Systems Theory
Systems Theory
Organizations are systems, with definable
and predictable characteristics and
behaviors.
Organizations have a boundary, a
structure, and a culture.
Organizations contain subsystems and
are part of larger suprasystems.




Characteristics of organizations:

An assembly of roles (structure).

Creating a stream of activities (processes).

To achieve a shared goal (outcome).
http://ide.ed.psu.edu/change/systemsoverview.htm
7
Systems Theory


8
The Big Picture
• Group of related interdependent
processes working together to achieve a
Role: The set of behaviors an
organizational member is expected to
perform and feels obligated to perform.
goal
System • common
Made up of a culture, structure and
Roles contain:
Process


boundary
Functions - Major domains of activity within
the role and
Tasks - Specific activities used to carry out
a function.
People
• Sequence of tasks aimed at
accomplishing a goal
• Produce data which can be
analyzed
• Have beliefs, values,
interests, needs
• Have roles which are
made up of functions
and tasks
Pattee & Otteson, The Health Care Future, 1997
9
Systems Theory

Systems rarely exist in isolation.

Understanding the interdependence of
related systems is critical in problem
solving.
Systems Theory

11
Changes made to one system may
cause unexpected or unintended
changes in other systems!!
12
340
19 Systems Theory
System Characteristics: Boundary
Characteristics of a System


Boundary


Structure

Interface where
information flows
between systems.
Who is involved in the
process?
May be


Culture

13
14
System Characteristics: Culture
System Characteristics: Structure




Permeable – Information
flows freely (open
system)
Impermeable – Controls
or restricts the flow of
information (closed
system)
Interrelationships
Expectations
Role
Interactions
 Mission Statement
 Beliefs and Values
 What is the
organization all
about?
15
16
System Characteristics: Culture
System Characteristics: Culture
Essence of a
Culture





Essence of a Culture

Individual initiative
Risk tolerance
Direction
Integration
Management
support



17
Identity
Reward system
Conflict tolerance
Communication patterns
18
341
19 Systems Theory
Systems Theory &
Problem Solving: Health Care
Systems Theory & Problem
Solving: Health Care
Boundary
PROBLEM
NH Resident Does Not Receive
Medications in a Timely
Fashion.
NH
Pharmacy
Medical Providers
19
20
Systems Theory & Problem
Solving: Health Care
Systems Theory & Problem
Solving: Health Care
 Structure (interrelationships, expectations,
role, interactions)

Culture
NH: Resident care issues, regulatory
compliance, financial constraints
Pharmacy: timeliness, regulatory
compliance, financial constraints
Medical Providers: Patient care,
communication, financial
NH: Admissions, Admitting Nurse,
Admissions process
Pharmacy: Pharmacist, Tech, Driver,
Medication dispensing and delivery process
Medical Providers: Physician, PA, APN,
Communication process
21
22
Medical Director And
Problem Solving
Problem Solving In Systems



Problem solving refers to the entire
process of analyzing circumstances
and arriving at a workable solution.

Problems are opportunities.

23
Effective resolution of organizational
problems require some specific skills.
Skills help prevent biases and
perceptions of favoritism,
avoiding/defusing political agendas.
Power groups are the key groups
involved in the process. We need to be
part of the it!!
24
342
19 Systems Theory
Problem Solving
Assists


Awareness
Sensitivity
Problem Solving Process
Limits


Inattentiveness
Personal biases

Problem identification

Problem study

Problem correction
25
26
Problem Solving: Identification


Understand the process.

How does it work?

How should it work
Describe the situation.



Fact from fiction
Accurate global picture
Historical perspective
28
27
Problem Solving: Identification

Problem Solving: Identification

Determine scope of work





Breadth
Depth
Urgency
Time constraints
What needs to be addressed?
Identify difficulties/barriers

29
Group into problem areas
30
343
19 Systems Theory
Problem Solving: Study
Problem Solving: Identification

State the problem: Central statement defines
the problem and needs to be acceptable to
individuals who will be involved in the
correction.




Questions to ask:
 Is the proper system in place, and was it
carried out?
 Are the staff properly educated?
 Is it an employee performance issue?

Analysis of causal factors, and generation
of some solutions.
Listen before speaking.
Understand the issue(s).
Identify additional data: Acquire additional
info, facts about possible solutions.
31
32
Problem Solving: Study


Problem Solving: Correction
List findings:
Indisputable facts
discovered during the
research.

Choose the course(s) of action: Initiate
specific activities.

List conclusions:
Drawn from the
analysis and findings.
Develop recommendations: Choose those
that meet all of the important recommendations
and most of the other recommendations;
reconcile most desirable with the art of
possible.
33
34
Approaches to Fix
“What is Wrong”
Problem Solving: Correction


Determine the strategy: Process to
implement the action.


Justify the decision: “Sell” the decision to
have one share in ownership.

Implement the action: Who will be the
leader, when will it be done?

35
Level 1 Fix: Incident
 Reacting immediately to the undesirable output to
make it right -damage control, cleaning up, firefighting, “whack-a-mole.”
Level 2 Fix: Process
 Fixing the process so that it doesn’t happen
again.
Level 3 Fix: System
 Asking whether this incident is symptomatic of a
deeper system issue where processes like these
are unintentionally designed.
36
344
19 Systems Theory
Problem Solving: Correction

Problem Solving Pearls
Follow up: Evaluation of outcomes, adjust
strategy.





Alternative solutions: Brainstorming,

imagine all the possible solutions.



Pareto Principle
Focus on processes.
See the problem from the other person/system
point of view.
Separate the person/system from the problem.
Focus on interests, not positions.
Create value for your position.
Be creative.
Win-Win solutions


37

Emotional Intelligence




Getting to Yes, Fisher and Ury
The Seven Habits of Highly Effective People, Covey
Data Sanity, Balestracci
38
Negotiation
Self Awareness - Recognizing how you
feel.
Self Management - How you behave,
accountability, “insulate your hot buttons.”
Social Awareness - Empathy, “seek to
understand before being understood.”
Social Management - Managing and
motivating others.

Definitions:
 Position
Something that you have decided upon.
Defended by the negotiator.
 Determined by the underlying interest.



Interest


What caused you to assume your position.
Your motivating factor(s).
40
Position
Interest
Position Versus Interest
Position
Interest
Values
Needs
41
Become Entrenched
Common Ground
Win-Lose
Win-Win
Time Consuming
More Efficient if Identified
Adversarial: Fear of Losing
Face
Cooperative
42
345
19 Systems Theory
The Case of the Mystery
Pressure Ulcer


Common Questions
You are the Medical Director of a nursing
home facility. Your group cares for patients
at the facility.
While making routine rounds on a 81 year
old female patient who is PEG fed with a
dense left hemiparesis and mild vascular
dementia, you discover a 3 cm X 4cm stage
three pressure sore over her sacrum that
had not been reported.





“Is there a high incidence of pressure sores in my facility?”
(quality assessment)
“Are residents are not cared for properly and this is a
consequence” (prevention and risk assessment)
“CNA’s and nursing home staff do not recognize or report
pressure sores in patients to the leadership or attending
physicians.” (communication)
“How come I am the first one to notice this?” (leadership)
Is a terrible complication and the family will need to be
informed? (risk management)
43
44
A System Based Approach to
the Problem
In your role as Medical Director,
how would you approach this problem
from a systems point of view?
Problem Solving
with
Systems Theory
45
Problem Identification:
Describe the Situation
46
Problem Identification
 Fact from fiction – Who knew about the
pressure sore?
 Accurate global picture – Is this an
isolated case or do I have many pressure
ulcers in my facility?
 Historical perspective – Has this
happened before? Have there been
staffing changes?
47
 Determine the scope of the work.
 How long will it take?
 What information needs to be gathered?
 Who needs to be involved?
 Identify barriers.
 Financial
 Personnel
 Policy and Procedures
48
346
19 Systems Theory
Problem Identification:
State the Problem

Problem Solving: Study
How can we improve detection,
documentation & care of pressure
ulcers?

Review of the facility quality indicator
profile obtained from the executive director
reveals a pressure incidence of 7.8%.

This is above the norms for a facility like
yours with the type of patients you have.

No one in a position of leadership was
knowledgeable about the data.
50
49
Problem Solving: System Theory

Boundary

Structure

Culture
System Boundaries
Caregiving
Medical Care
Nursing
Administration
51
52
System Structure
System Culture
 Interrelationships
 What is the relationship between the DON,
Administrator, CNAs and Medical Director?
 Expectations
 Who is responsible for physician notification?
 Role
 Who determines skin care protocols?
 Interactions
 How does the IDT communicate with each
other?
53





Does the facility have a mission
statement?
What does the facility value?
How does the organization respond to
adversity?
How supportive is management?
What is the communication style in this
organization?
54
347
19 Systems Theory
Problem Solving Pearls








One Facility’s Solution
Pareto Principle
Focus on processes.
See the problem from the other person/system
point of view.
Separate the person/system from the problem.
Focus on interests, not positions.
Create value for your position.
Be creative.
Win-Win solutions



Getting to Yes, Fisher and Ury
The Seven Habits of Highly Effective People, Covey
Data Sanity, Balestracci

A meeting was called with the Director of
Nursing, Executive Director, and Medical
Director for the express purpose of
addressing this issue.

All agreed that the facility had a system
problem with skin care and a plan was
developed to address each aspect of
care.
56
55
Develop Strategies and
Recommendations
Develop Strategies and
Recommendations

Policies and procedures were revised.

A skin care nurse position was created, residents were
seen on a regular basis and skin care protocols were
developed.

In-services for the front line providers (CNAs) on
prevention and recognition were recognized as problem
areas and presented.

Therapists were asked to designate residents at special
risk for pressure sores due to their medical condition and
place a placard on the jacket of their chart as well as
57
educate staff on positioning residents.

At the time of the next survey, skin care was
a special area of investigation due to the
facility quality monitoring data. It had
improved slightly over the intervening 4
months and was back within range of other
facilities.

The designation of a skin care nurse who was
knowledgeable about all patients in the facility
was particularly pleasing to the survey team.
58
Small Group Sessions
Monitoring and Follow-up

At the monthly facility leadership
meeting, data gathered by the skin care
nurse was reviewed as the first agenda
item.
59
60
348
19 Systems Theory
Medical Director: Problem Solving
Through System Improvement
Problem Solving Pearls








Pareto Principle
Focus on processes.
See the problem from the other person/system
point of view.
Separate the person/system from the problem.
Focus on interests, not positions.
Create value for your position.
Be creative.
Win-Win solutions






Help create a more supportive work
environment.

Help prevent legal and regulatory
liabilities.
62
Final Thoughts
Effective physician leader and manager is
a skilled problem solver who:

Assess and help improve facility’s care
processes and practices.
Getting to Yes, Fisher and Ury
The Seven Habits of Highly Effective People, Covey
61
Data Sanity, Balestracci
In Summary


Gets to know the lay of the land: Political,
health care, systems involved.
Understands the values, mission, goals of the
organization.
Orchestrates many people’s efforts using
his/her leadership, managerial and problem
solving skills.
63
You’ll only get good at this if you try it at
home.
Good Luck in your efforts to practice this
new skill and in motivating your NH team
to adopt a systems based problemsolving approach.
64
349
20 Governance
Objectives

20 Governance

Core Curriculum on
Medical Direction


Describe relationships between Medical
Directors and governing body,
administrators and staff.
Illustrate basic governance.
Understand leadership and management
principles.
Compare and contrast the differences.
2
1
Organization
As a Social Organization

Four interest groups:
 Owners/Managers
 Clients/Customers
 Organizational Members
 The Encompassing Society
Administrators and Physicians
3
4
What You Are Trained To See
Physicians
Administrators and Physicians

Different Training


Different Goals


Different Values

“Us Vs. Them”


5
Well defined
diagnosis and
treatment
Slow changing truths
- clinical base
Individuals, cases,
stories
Principles and
practice of science,
medicine
Administrators




Broad assignment to
make everything work
Fast changing
conditions - reality
base
Trends, groups,
numbers
Principles of operations
and finances
6
350
20 Governance
Top Goals
Physicians



Usual Work Style
Administrators
Taking care of
patients

Welfare of
individuals


Patient safety:
reducing morbidity
and mortality
Physicians
Taking care of
business

Welfare of the whole
Organization safety:
legal, financial and
regulatory


Moves quickly and
decisively between
patients
Keeps track of many
separate cases
Responds to
individual case facts
and their implications
Administrators



Moves methodically
with big, long range
issues
Keeps track of many
interlocking tasks
Responds to aggregate
data and their
implications
8
7
Stereotypical Ways of Relating
Physicians




One-on-one
interactions
Autonomous; in
charge of decisions
Views feedback &
suggestions as
interference
No higher authority
Three Worlds of
Health Care
Administrators




Group interactions
Collaborative; in
charge of process
Expects evaluation
and feedback
Delegates extensively

Clinical

Operational

Financial
10
9
Clinical

Operations
Care Plans - Clinical Actions

Systems to Produce Services

Quality of care

Productivity

Achievement of health goals

Efficiency
11
12
351
20 Governance
Financial

Governing Body
Numbers / Accounting

Top Dog



Positive bottom line



Good value at right price
Functions



13
Mission Statement





Establish direction; long range planning.
Identify and promote core values.
Monitor organizational outcomes and
effectiveness.
14
Mission Statement
Brief
Describes organization’s reason for
being.
Tells about customer needs/desires, not
products.
Create with management and staff input.
Provides motivation, a sense of purpose.
“What business are we in?”
The final authority.
The ultimate responsibility.
The place the buck $tops.

Examples:

The mission of Eldercare Services is to
provide cost-effective, high quality
health care services to dependent frail
elderly.

The mission of EMA is to serve aging
persons.
15
16
Organization A
Organization Charts



Show relationships
Indicate lines of authority (where you are in
the pecking order…)
Exercise: Draw an organizational chart of
your facility or agency, showing GB,
Admin, Medical Director, medical staff, and
facility/agency staff (may or may not
separate out DON/clinical coordinator). 17
Governing Body
Administrator
Dir. of Nursing
Non-Nurs.
Staff
Medical Director
Nurs.
Staff
Medical
Staff
18
352
20 Governance
Organization C
Organization B
Governing Body
Governing Body
Administrator
NH Staff
Administrator
Medical Director
NH
Staff
Medical
Staff
Medical Director
Medical
Staff
19
20
Medical Director

Underlying tenet:

Identify and have access to the person
or body with the final authority.
20.1 – 20.2
22
21
Turf Interfaces

Goals of management team (Administrator, DON,
and Medical Director) should be to:
 Work cooperatively to achieve the goals and
objectives of the organization.
 Respect each other’s knowledge, skills and
responsibilities (and turf!!)
 Monitor, support and evaluate (and cooperatively
change as necessary) the structure and
processes that form the infrastructure of the
organization and which lead to outcomes.
23
Turf Interfaces

Medical Director and DON

Meet periodically (at least monthly) to discuss:
 Resident care delivery systems (staffing,
support services, etc.)
 Transfer/discharge issues
 Deaths
 Incidents
 Attending physician concerns
 QM/CQI
24
353
20 Governance
Turf Interfaces

Turf Interfaces
Medical Director and Administrator


Meet periodically (at least bimonthly) to
discuss:
 Policies/procedures
 Regulatory issues
 Financial issues
 Governing body issues
 Budget
Medical Director and Governing Body

Meet periodically (at full Board and/or Board
committee meetings) to discuss:
 QM/CQI
 Medical aspects of financial costs of
providing care.
25
26
Relationship of GB and Admin
Employer
Governance - Review
Employee
Governing Body
Administrator
Mission and Vision
Monitor quality and
process
Evaluate implementation
Evaluate administrator
Evaluate and act on
recommendations of
Administrator
Implement Mission
Manage the “how” to
accomplish the mission
Report results to GB
Recommend future
change






27
Organizational structure and function.
Decision-making process.
Power groups
 Tasks / “turf”
 Relationship of Medical Director to others.
Mission statements.
Aspects of the role of the Medical Director.
Personal preferences and management styles.
28
354
21 Committees
Objectives
21 Committees
Core Curriculum on
Medical Direction

Define the role and functions of
committees and committee members.

Apply an understanding of personality
types to your leadership role and how it
may influence team process.
2
1
Committees

Committees
How to make the most of your valuable
time.
3
Learning Goals





4
Committees
Understand how committees function.
Discuss the value of committees.
Define the Medical Director’s role.
Define the different types of
committees.
Discuss how personal characteristics of
committee participants contribute to the
functioning of the committee.
5

Committees play an important role in
nursing homes.

Many important responsibilities are
handled by committees that have
oversight and evaluative roles.
6
355
21 Committees
Committees

Standing Committees
Types of effective committees:
 Standing
 Ad Hoc

Established by bylaws and\or
governance structure.

Specific clear function.

Expectations for ongoing process and
outcomes via creating authority.
7
Ad Hoc Committees
8
Ad Hoc Committees

Address specific issues, opportunities or
problems.

Draws upon the special interests or
competencies of the staff.

Provides a flexible means of addressing
changing organizational needs or
regulatory requirements.

Finite Life Expectancy: Beware of the
ad hoc that won’t go away.
9
10
Formal vs. Informal

Strength of Committees
Formal:



Committees
Councils




Informal: May be an impediment to
effective committees.



Interest Groups
Friendship Groups

11
Pool knowledge and skills.
Staff identifies with the committee.
Staff takes ownership of decisions.
Meld individual and organizational
goals.
Integration of diverse departments.
Education
12
356
21 Committees
Value of Committees
Value of Committees

Involve more people in the process.

Relieve any one individual from full
responsibility for decisions.

Synthesize and integrate the differing
point of views without over compromising.

Encourage open and candid debate.

Create opportunity for members to
satisfy social and or esteem needs.

Promote more discussion about strengths
and weakness of possible actions.
13
14
Value Of Committees
Value Of Committees

Allows people to be heard.

Factors that may positively or
negatively affect the balance.

Allows people to give and receive
feedback to their roles.

Role negotiated with the administrator.



Drives tasks by leadership.

Mandated vs. internally driven
Medical Director’s participation
Recognition of contributions
15

16
Committees
Effective Committees
Need to avoid the possibility of group
think or risky think.

Allow forum for exchange of ideas and
opinions.

Reduced conflict.

Promote effective communication and
coordination between parties.


Group Think: Group harmony and
agreement becomes more important
than correctness of final decision.
Risky Think: Too much optimism and
risk taking.
17
18
357
21 Committees
Effective Committees
Committee Roles

Fulfill their function efficiently.


Clearly define each participant’s role.



Produce clear, organized and rational
reports, minutes and recommendations.


Oversight: Analyze information, oversee
process, make policy recommendations
Data presentation
Policy and procedure review.
Integrate and coordinate care.
Address various care related issues.
19
Medical Director and Committees





Be a model for effective leadership.
Define and articulate.
Encourage opportunity for dialogue,
discussion and creative controversy.
Serve as a role model.
Serve as a member, serve as chair.
20
Required Committees

Quality Assurance
21
Important Committees






22
Quality Assurance Committee
Pharmacy
Infection Control
Medical Records
Credentials and Medical Care
Safety
Ethics

23
Function:
 Identifies and address issues which
may negatively impact quality of care
delivered to residents.
 Develop and implement the corrective
action plans.
24
358
21 Committees
Quality Assurance Committee

Quality Assurance Committee
Members:
Director of Nursing
 Medical Director
 Meets Quarterly, though each home
may meet monthly.




Review of drug therapeutics and
recommendations.
Infection control, pressure ulcers,
quality indicators.
Review of safety, incidents, activities,
plant operations.
25
26
Infection Control Committee




Pharmacy Committee
Oversee facility wide surveillance for
infection potential.
Review and analyze infections.
Promote preventative as well as
corrective plans such as isolation
precautions.
Composition: DON, Admin, Infection
Control Nurse and Medical Director





Monitor drug usage and appropriateness
of use.
Develop drug utilization policies and
procedures (i.e. formulary).
Advise medical staff of changes.
Advise and assist pharmacy consultant.
Composition: DON, Pharmacist, Admin,
Medical Director
27
Safety Committee



28
Utilization Committee
Ensure that the environment remains
free of accidental hazards.
May review incident reports of
employees and residents.
Composition: Director Environmental
Services, DON, Admin, Medical Director

Medicare mandated for skilled nursing
home admissions.

Appropriateness of:




29
Admissions, los and discharges.
Use of medical services.
Use of ancillary services.
Does your facility have the resources to
handle these admissions?
30
359
21 Committees
Meetings: Organization

Meetings: Organization
Prepare statement that defines the
role\mission of committees.



Delineate authority and responsibility:
Is this investigative, decisional,
advisory?

Select Chair based on leadership, ability
and experience.
Appoint secretary and possibly
facilitator.
Choose individuals that may be affected
by any decision, yet keep numbers
small (e.g., 5-10).
31
Conducting a Meeting

32
Conducting a Meeting
The agenda is the key, the backbone of
the committee.

Hold to the agenda:



Develop and then distribute agenda,
minutes before the meeting.




Begin on time, end on time.
Identify the issue.
Review background info or review previous
meetings.
Review the present.
Develop options.
Consider an option.
33
Conducting a Meeting





34
Conducting a Meeting
Encourage clash of ideas.
Discourage suggestion squashing: Ask
for a better suggestion.
Manage ‘Killer Balls.”
Rephrase comments and to clarify and
stimulate further discussion.
Seek input from all.
35

Summarize the meeting.

Close on a positive note, highlight
achievement.

Review decisions made and
assignments.
36
360
21 Committees
An Effective Format for Minutes
Documenting the Meeting

The Minutes: Develop and distribute.
 Time, place, date, chair, members
 Agenda items
 Decisions reached
 Responsible parties
 Ending time, date and plan for next
meeting.
38
37
Documenting Meetings

Common Problems…
Should periodically review minutes for
overall purpose and relevance.




Address unresolved issues: Poor
problem solving abilities, meetings may
not be the optimal manner to address
issue(s).




Drift off subject  Define
 Membership
Poor preparation
 Purpose
Ineffective
 Goals/objectives
Lack of listening
 Authority/responsibility
Verbosity
Length
Lack of preparation
39
Common Problems…







Drift off subject
Poor preparation
Ineffective
Lack of listening
Verbosity
Length
Lack of preparation




40
Common Problems…
Distribute agenda
Keep close to agenda
Restate important
ideas
Minimize idle talk







41
Drift off subject
Poor preparation
Ineffective
Lack of listening
Verbosity
Length
Lack of preparation





Encourage free
discussion
Limit complaining
Limit obstruction
Subcommittees
Begin & end on time
42
361
21 Committees
Common Problems…







Drift off subject
Poor preparation
Ineffective
Lack of listening
Verbosity
Length
Lack of preparation




Meetings and Committees
Solicit agenda items
Provide informational
items
Provide specific
assignments
Contact members to
discuss assignments
43

Remember that each individual has
her\his own personal characteristics that
they bring to each meeting.
 Personality type preference
 Affects interactions
 Challenges for the chair
44
Small Group Sessions
45
362
22 Leadership
Objectives

22 Leadership


Core Curriculum on
Medical Direction


Brief review of organizations.
Culture: How the beliefs, attitudes and values
influence culture and compare that with politics.
Leadership principles and the Medical Director.
Brief review of management functions.
Understand the potential power sources in your
facility.
22
1
Organizations:
Saturday Morning Impact
Organizations:
The Path Not Taken


Insert “inputs” cartoon here



Review of basics of organizations.
Start by looking at the outside of our
facility.
Then step into the foyer and fell the
currents that influence behaviors.
Then find the white coats of leadership
and management.
44
3
Basics: Organizations

Organizations
Organization may be defined as:

An association or society of people
working together to some end, e.g.,
a business firm or political party.
A set of tribes connected only by a
common janitorial system.
Webster’s Encyclopedic Dictionary
5
66
363
22 Leadership
Bureaucracy

Organizations
The process by which energy is
converted to solid waste.

A system of roles (structures)

A stream of activities (process)

Designed to accomplish shared
purposes (outcomes)
77
88
Intangible Feature: Currents

Organization as Culture
Culture: Values, vision, mission,
infrastructure, history and people



Politics: Organizations viewed as
political systems that evolve influenced
by interests, conflict and power.

Each has it’s own attitudes, beliefs,
norms and values.
There is a shared meaning called
corporate culture.
“Is acquired knowledge used to interpret
one’s experience and generate social
behavior, dictates how we behave.”
99
Organization as Culture


10
10
Organization as Culture
Assumes that certain groups of
individuals have been functioning in an
interdependent manner via shared
meaning, understanding and
remembering.
Culture is the glue, the invisible bond that
binds the disparate realities, that gives
direction and sustains energy,
commitment and cohesion.
11
11



Creates distinctions between
organizations.
Conveys a sense of identity.
Facilitates generation of commitment
to something larger than oneself.
12
12
364
22 Leadership
Organization as Culture
Organization as Culture

Provides the social glue that binds the
organization together by providing
appropriate standards of behavior.

Serves as a control mechanism that
guides and shapes the attitudes and
behaviors of the members.

Culture is strong when its core values
are intensely held and widely shared.

Culture is a liability when values of the
members differ from that of the values
that advance the interests of the
organization, or when the culture
interferes with the need to adapt to new
realities.
14
14
13
13
Organization as Culture

What is your organization’s culture?

Are the values of members and
organization in agreement?
22.1 – 22.3
15
15
Politics and Responsibility

Politics Begin
Politics is inescapable part of human
existence because:



16
People have contrasting and common needs
and perspectives.
There are limited resources available to
meet desires and needs.
There are several possible ways to achieve
the same objective.
17

Interests collide, resources are finite
and choices need to be limited.

Power structure decides on course of
action and depending on outcomes,
acceptance.
18
18
365
22 Leadership
Politics And Responsibility
Levels of Politics




Making choices among several equally
viable alternatives.
Choosing from unequal alternatives.
Proposing alternatives worthy of
consideration.
Allowing advantages for special
interests.

All behavior is interest based

Any collection of people has mixed
motivations, varying degrees of self
serving conduct
19
19
20
Constructive Politics
Destructive Politics

Behavior that helps the organization to
attain it’s goals, everyone in the same
direction.

Allows debate on different perspectives
and needs while still emphasizing some
common good or goals.
21
21

Behavior that helps individuals
preferentially attain their goals despite the
impact on the organization or others
within it.

Typically focuses on manipulating
information and maneuvering people to
reinforce or preserve the power and
advantage of a select few.
22
22
Accountability and Politics




Highly inconsistent accountability is
source of major conflict.
Forces people into a self preservation
mode.
Becomes adversarial.
Distracts from customer orientation.
23
23
24
366
22 Leadership
Understanding Political Climate



Medical Director must be aware of the
organization’s overall political climate.
Politics is everywhere is unacceptable
rationalization.
Constructive political arena finds the
right balance between self interest and
common good.
Traditional Power Groups




Ownership/Board
Administration
Nursing Departments
Medical Staff
25
25
Traditional Power Groups



26
26
Ownership/Board
Motivation varies widely for these
different players.
Different interest, backgrounds,
perspectives, knowledge and skills.
Mutually interdependent.






Vision and direction
Values
Set goals and objectives
Select top management
Make money
Meet community needs
27
27
Ownership/Board




28
28
Traditional Power Groups
Appoints medical staff.
Serves on board committees.
Responsible for performance.
Draft long range plans.




29
29
Owners/Board
Administration
Nursing Department
Medical Staff
30
30
367
22 Leadership
Administration





Traditional Power Groups
Oversees and manages a system to
accomplish the goal’s and objectives.
Develops organizational structure.
Develops policies and procedures.
Ensures safe, clean environment.
Ensures compliance with rules and
regulations.




Ownership/Board
Administration
Nursing Department
Medical Staff
31
31
Nursing Department




32
32
Director of Nursing
Hires/evaluates nurses and nurse
managers.
Plans care delivery systems.
Ensures adequate education and
training for nursing staff.
Works with medical director to oversee
clinical care and to investigate, identify
and resolve clinical problems.

Acts as VP for Clinical Affairs.

Coordinates services of other disciplines.
(e.g., PT,OT,SW, etc.)
33
33
Traditional Power Groups




34
34
Medical Staff
Ownership/Board
Administration
Nursing Department
Medical Staff

35
35
Attending Physician:
 Does timely H & P.
 Monitors and treats chronic medical
problems.
 Evaluates and treats episodic illness
and injuries.
 Addresses rehab issues.
36
36
368
22 Leadership
Medical Staff

Attending Physician (cont.):
Provides for an call coverage.
Complies with Federal and State
requirements for visits.
 Works with Medical Director to
implement policies and procedures .


22.4 – 22.5
37
38
483.75(I)
Resident Care Policies
Medical Director

Medical Director two main responsibilities
as decreed by OBRA:
 Implementation of resident care
policies.
 Overall coordination of medical care.







Admissions, transfers, discharges
Infection control, restraints, accidents
Physician and non physician privileges
Ancillary services
Medication use
Release of information
Overall quality
40
40
39
Medical Director
Functions




Medical Director
Functions
Participates in administration decision
making.
Organizes and coordinates physician
services.
Ensures appropriateness and quality of
medical care.
Develops and conducts education
programs.

41
41




Monitors and promotes the health,
welfare and safety of employees.
Articulates the facilities mission to the
community.
Interacts with regulatory agencies and
third party payers on issues that affect
resident care.
Advocates for patients rights.
Promotes culture change.
42
42
369
22 Leadership
Medical Director
Expectations








Manage risk
Employee health
Inservice training
Develop policies and procedures
Interface with pharmacy
Manage consultants
Act as a role public relations
Provide direction for new training
Medical Director
Challenges





43
43
Organizations are much more complex.
Multiple accountabilities.
Less employee loyalty.
Less respect for authority.
Higher cynicism, less trust and
credibility.
44
44
Change in Long Term Care






Change in business focus.
Change in payment structure.
Change in affiliations.
Change in traditional care models and
expectations for service.
Change in settings of care.
Change in consumer expectations.
45
45
46
Change in Long Term Care

“The significant problems we face
cannot be solved by the same level of
thinking that created them.”
A. Einstein
47
47
48
370
22 Leadership
Leadership
Leadership

Utilizing the principles of effective
leadership to become an effective,
proficient and admired Medical Director.
49
49
Leadership



50
50
Leadership
Important social resource in this
complex world.
Societal changes have become medical
system changes.
We are often reporting to a non
physician.

Leadership appears to be the art of
getting others to do something you are
convinced should be done.
Bennis, Herding Cats
51
51
52
52
Achievements of
Effective Leadership




53
Aligns people.
Recognizes but reconciles diverse
motivations.
Gets everyone moving in the right
direction.
Inspires people towards common goals
and objectives.
54
54
371
22 Leadership
Achievements of
Effective Leadership



Prevents parochial goals from
overwhelming common ones.
Helps get people to do the right thing
even when less inclined to do so.
Shows people how to do the best
possible job, doesn’t just demand it or
reprimand for failure.
56
56
55
Leadership Concepts


Leadership Concepts
Formal: Based on structure,
appointment.

Medical Directors are both formal and
informal leaders in long term care.
Informal: Based on knowledge, skill,
judgment, character, values: Medical
Director.
57
57
Competencies, Traits and Skill
Competencies*
58
58
Competencies, Traits and Skills
Competencies

Management of Attention: Draw others
to them in part due to a capability to
communicate a focus of commitment.

Management of Meaning: Ability to
communicate, creation of an image.

Management of Trust: Values and
Character Count.

Management of Self: Know strengths
and nurture them, appreciate
weaknesses and modify them.
From Bennis, “Herding Cats”
59
59
60
60
372
22 Leadership
Competencies, Traits and Skills
Traits
Competencies, Traits and Skills
Traits

Self Knowledge: About their talents and
skills.

Open to feedback.

Eager to learn and improve.

Curious and risk takers.

Concentrate at work.

Learn from adversity.

Balance tradition with change.
61
61
Competencies, Traits and Skills
Traits

62
62
Competencies, Traits and Skills
Skills
Open Style:



Work well with systems.



Serve as models and mentors.



63
63

Communication
Interpersonal skills
Credibility
Strategic thinking
Knowledge
Ego strength
Team responsiveness
Humor
Leadership
Leadership
1. Relentlessly upgrade the team, using
each encounter to coach, evaluate and
instill confidence in the team.
2. Leaders live and breathe their vision
that is visible to all.
3. Leaders exude positive energy and
optimism. Their mood is catching, they
fight the gravitational pull of
negativism.
4. Leaders establish trust with candor,
transparency and credit.
5. Leaders have the courage to make
unpopular decisions and gut calls.
6. Leaders push with a curiosity that
borders on skepticism, making sure
their questions are answered with
actions.
“Winning” Jack Welch; HarperBusiness, 2005.
65
64
64
66
66
373
22 Leadership
Leadership
Leadership
7. Leaders inspire risk taking and
learning by setting the example.
8. Leaders celebrate! Work is too
much part of life not to recognize
moments of success. Be generous
in your praise.

Before your directorship: success was
about growing yourself.

As a leader, success is growing others.
68
68
67
Actions Admired and Respected
in a Leader:



Actions that exemplify desired values
and that foster congruence between
individual and organizational values.
Actions that relate everyday activity to
long range organizational goals and
vision.
Actions that communicate the
presence of predictability, honesty, and
concern.
69
69
Characteristics of Leaders



Actions Admired and Respected
in a Leader:


Actions that indicate a concern in
followers’ interests as they relate to
work, career, family, and extramural
activities.
Actions that indicate that leader’s
interest in self-knowledge and selfdevelopment .
70
70
Characteristics of Leaders
Think long term beyond the day’s crisis
or quarterly report.
Grasp the relationship of their unit or
organization to the larger reality and
structures of which it is a part.
Reach and influence constituencies
beyond their jurisdictions and
boundaries.
71
71



Value the intangibles of vision, values,
and motivation.
Possess the political skills required to
cope with conflicting interests.
Think in terms of renewal and seek
revisions of process and structure that
constantly changing reality requires.
72
72
374
22 Leadership
Areas for Medical Director
To be a Leader






Areas for Medical Director
as a Leader: Medical Care
Medical care
Policies and procedures
Communication
Education
Planning
Influence physician behaviors




Transmit the values to physicians and
staff.
Appropriate philosophies of care.
Promote interpersonal and
interdisciplinary cooperation.
Balance expectations.
73
73
Areas for Medical Director
To Lead: Medical Care



74
74
To Lead: Communication
Demonstrate effective geriatric practice
through patient care.
Help staff identify the highest
practicable outcomes.
Clarify issues of medical necessity and
medical unavoidability.




Must be able to listen.
Able to verbally respond.
Written skills.
Use images and symbols.
75
75
Areas for Medical Director
to Lead: Communication
76
Basic Leadership Skills:
Interpersonal Skills

Improve interpersonal communication.


Establish systems to enhance and
support intermodal communication.


77
77
Manage conflict without become a
participant.
Negotiation
How to handle people: Opportunity to
improve.
78
78
375
22 Leadership
Basic Leadership Skills:
Interpersonal Skills

Credibility: Both clinically and
personally.

Strategic Thinking: Create a vision.
Basic Leadership Skills:
Interpersonal Skills

Team Player:
 Group dynamics
 Accessibility
 Creative potential
79
79
80
Basic Leadership Skills:
Education

Areas for Medical Director to
Lead: Education
Knowledge:
 Payers, i.e. Managed Care
 Quality
 Technology
 Need to continue to learn.

Medical Care:
 Explain the possibilities for improving
care processes and outcomes.
 Demonstrate appropriate attitudes to
the attending physicians.
 Facilitate managing ethical issues in
specific cases.
81
81
Areas for Medical Director
to Lead: Education




82
Basic Leadership Skills:
Planning
Provide relevant information about
clinical and long term geriatrics.
Help staff handle actual cases, even if
not primarily medical.
Educate the community of facilities
services.
Help interpret clinical implications of
OBRA regulations.
83
83

Ego Strength:
 Willing to challenge the status quo.
 Maintain long term vision.
 Strong enough for flexibility.
 Handle ambiguity.
84
376
22 Leadership
Areas for Medical Director
to Lead: Planning
Areas for Medical Director
To Lead: Planning
Help the facility incorporate clinical
concepts into planning process.
Explain physician roles in services.
Establish effective employee health
programs, inservice, infection control….




Quality Improvement:
 Support the quality improvement
process and committee.
 Promote impartial problem solving.
 Identify potential and actual problems
to prevent or resolve.
85
Areas for Medical Director
to Lead

86
Where Does Culture Come
From?
Have a sense of humor:
 Smile
 Compliment someone
 Brush off the minor details
Leaders
88
88
87
Where do Leaders Come From?




89
Are chosen as opposed to appointed or
conferred from above.
Come from all personality types.
An expert in the promotion of values to
help maintain culture.
An individual who helps to remain
objective and diffuse political issues.
90
90
377
22 Leadership
Medical Director
Leadership Failures
Acquiring Leadership Skills





Join a committee.
Observe individuals/role models;
meetings.
Participate and gauge effects, be willing
to listen to feedback.
Seek leadership positions.
Seminars, reading, practice skills




Inability to tolerate and mediate discord.
Insufficient support by organization.
System in disarray.
Failure by organization to rethink
traditional responsibilities.
91
91
92
92
Take Home Message

Medical Directors with their unique
experience and perspectives by using
their leadership power may help bring
about critical changes in long term care
facilities.

The organization must be willing to avail
themselves of this potential leadership.
22.6 – 22.7
93
93
Management Functions

94
Management Functions

For the most part, our ability to impact
organizational structure and process
comes from our leadership skills.

Yet we need to appreciate our potential
as managers contributing to the overall
goals of our facility.
Managerial Concepts: How to get there
and stay there.
95
95
96
96
378
22 Leadership
Management Functions



Management
Broad definition: Efficient and effective
integration and coordination of resources
to achieve desired objectives.
Management is the planning and
directing of effort and the organizing and
employing of resources.
Management is the process of getting
things done through and with people.

The act of getting others to do
something that you are convinced
should be done.
Bennis, Herding Cats
97
97
98
98
Management Functions






Management Functions
Planning
Decision making
Organizing
Staffing
Directing
Controlling
99
99
Management Functions

Planning: Establish goals, select
objectives, and choose the desired state.

Decision Making: Commit to one of
several alternatives, committing to that
choice.

Organizing: Determine roles and
responsibilities, job descriptions,
coordination, organizational charts.
100
100
Management

Staffing: Determination of, recruitment,
orientation, training of personnel or
other resources.

Directing: Teaching, motivating, guiding

Controlling: Performance, goals,
corrective action, rewarding

Managers do things right.

Leaders do the right thing.
Warren Bennis
101
101
102
102
379
22 Leadership
Characteristics of
Effective Managers






Prerequisites of
Effective Managers
Analyze the information and figure out the
truth.
Deal effectively with sub-optimal
performance and failure.
Coordinate process.
Organize and direct systems.
Maximize productivity.
Recognize financial limitations.



Able balance personal needs for reward,
reassurance, support, and recognition
and similar needs of others.
Able to accept personal accountability
and responsibility for consequences of
decisions.
Able to influence decision makers
through education and negotiation.
103
103
The Physician as Manager
Favorable Attributes
104
104
The Physician as Manager
Favorable Attributes

Credibility

Personal motivation

Analytic ability

Physical and mental endurance

Self confidence and comfort with
authority over others.

Interpersonal skills

Ambiguity tolerance
105
105
Impact of Good Management


106
106
Management Styles
Maximizes performance.
Bad management undermines
productivity employee performance,
turnover, morale, and consistency of
quality of products and services are
often symptoms related to system
issues.
107
107

Need to appreciate various styles of
managers in order to develop strategies
to work with them.
108
108
380
22 Leadership
Management Styles




Decision maker: It’s me or the door.
The seller: Tries persuasion.
Will broker questions: Invites queries,
but still the decision rests with manager.
The possible change: Entices buy in by
considering some change. Still
proposes the course of action.
110
110
109
Management Styles



Management vs. Leadership
Actually presents problem and seeks
input: The manager still identifies the
problem.
Uses the group but places limits on
ultimate decisions.
Allows the group to make the decisions.
Manager is an equal partner.

Planning, budgeting

Direction/strategy

Organizing staff

Align with strategy

Problem solve

Motivating

Produce consistency

Produce clarity
111
111
The Physician as Manager
Transition Difficulties





112
Tendencies and Capabilities
New skills needed.
Move from controlling role to
persuasive one.
Naivete regaurding political infighting,
meetings and consensus building.
Change focus to primacy of
organization vs. to patient.
Psychological adjustment.
113
113

Those probably not well suited:
 Unpleasant/disagreeable
 Try to please everyone.
 Need to be liked.
 Abhor tough decisions.
 Don’t listen to other perspectives.
114
114
381
22 Leadership
Decision Making

Who makes the decision?
the individual or group with
22.8
115
116
Power

Utilizing the skills of leadership with the
functions of management we, with the
use of judicious and appropriate
‘power’, have the tools to effect
change.
118
118
117



Physician Power in
Long Term Care
Physician Power in
Long Term Care
Medical staffs and medical directors
have not used\appreciated the impact of
the potential of power in LTC.
Management, nursing and other staff
may ignore them or have their own
agendas.
Others may not have enough knowledge
to recognize physician input.

119
119


Ability to give good care often affected
by factors beyond immediate control.
Few physicians with many residents.
Medical Director has rarely exercised
any authority\power over the medical
staff.
120
120
382
22 Leadership
Physician Power in Health Care


Power
Hospitals: Medical staff with substantial
personal and economic stakes in
hospital and impact on patients.


The ability to force changes one desires
to occur;
Clout
Independent organization with
considerable clout.
121
121
122
122
Power

Power
The potential of one individual or group
to have the leverage to effect change,
even when people resist change out of
fear or self-interest.



Power is needed as people disagree on
goals and methods.
Power is needed as people are not
automatically inclined to do the right
thing, even when they know what it is.
Power is needed to remove obstacles to
achieving objectives.
123
123
124
124
Benefits of Power

Improve efficiency and capacity

Flexibility

Delegation
Distrust of Power

125
125
Mania to prevent concentration of power:
 Rotation of leaders
 Govt.: executive/judicial/legislature
 Business: mgmt./labor/owners
 College: trustees /students/admin
 Power corrupts.. And absolute power
corrupts absolutely.
126
383
22 Leadership
Power Gaps
Powder Keg





Power Seeking:
Inherently Bad?
Breeds bossiness
Petty dictatorial style
Rule dominated
Ineffective management
Frustration, failure

Be strong and influential rather than
dominating.

Disciplined expression of power
necessary for social leadership and
organizational effectiveness.
127
127
Power
Traditional Hierarchy




128
128
Power in the New Era
Power follows organization chart.
Direct care staff have least power.
Department managers have more.
VP’s, CEO’s, board members have
progressively more power.

Drastic readjustment of power structure.

Direct care providers wield greater
influence over means to accomplish
goals, especially clinical ones.
129
129
Inverting the Traditional
Long Term Care Approach


130
130
The Two Faces of Power
Management is unable to run
operations without adequate leadership
and staff support.
Both leadership and management must
support staff providing direct service.
131
131

Personalized Power

Socialized Power
132
132
384
22 Leadership
Personalized Power
Socialized Power

Low in inhibition

Strong inhibitory sense

Zero sum game

My victory is not your loss

Expensive acquisitions

Altruistic Power

Domination

Hesitation Power
133
133
Sources of Power
1.
2.
3.
4.
5.
6.
7.
8.
Power to punish
Power to reward
Formal position
Charismatic power
Expertise and skill
Information power
Reputation power
Connection power
Power



Coercive: Based on authority to punish,
instill fear, criticize, fire…

Reward: Based on ability to offer formal
rewards.
135
135
Power

134
134
136
136
Power
Legitimate: Based on individual’s right to
influence by virtue of formal position.
Charismatic: Based on respect and
admiration.
Expert: Based on belief that one’s skills,
knowledge and expertise can help
another.
137
137

Informational: Based on possessing or
access to critical information.

Connection: Based on access to
powerful persons.
138
138
385
Course Wrap Up
Course Wrap Up
Being an Effective and
Happy Medical Director
Becoming an Effective
Medical Director



9 functions (associated with their with multiple
tasks) of the medical director are now
available for your immediate use to assist you
in your role as a Medical Director.
They now have become your tools to help
you be more effective and efficient as a
Medical Director.
It may take some time using tools that one
may not have familiarity.
Becoming an Effective
Medical Director



Within each system there are a variety of
personality types.
We need to appreciate how we take in info,
process this data and orient ourselves in the
world. We need to nurture our strengths and
deal with our weakness.
By understanding how we relate to the world,
we will be able to better appreciate how others
orient as well as recognize how others perceive
and act in the world.
Becoming an Effective
Medical Director

Remember that you are part of a
system and that your actions are felt
throughout the organization.

Need to remember that each system
has their own boundary, structure and
culture. Understanding this helps with
discussions with other systems.
Becoming an Effective
Medical Director



Effective medical directors need to
understand their governance structure.
Medical Directors need to apply the
leadership concepts to their everyday
actions.
We need to be an active learner,
participate in the processes of the
nursing home and take an active role.
386
Course Wrap Up
Becoming an Effective
Medical Director
Becoming an Effective
Medical Director
Culture change is needed for:

Quality is job # 1.

Need to be part of the quality process in
a proactive manner that helps the
facility identify issues.
Changing the paradigm of long term care.
Making a more elder friendly community.
Working with the state and federal
agencies to modify the oversight process.
Becoming an Effective
Medical Director

Resident’s Rights are the cornerstone of
long term care. We need to read them,
understand them and assure they are
maintained by all.
Secrets
of being a
Happy
Medical Director
387