Value of your
AHCA/NCAL
Membership
Presented by:
Peggy Connorton & Urvi Patel
Session Overview
 AHCA/NCAL Quality Initiative 2015-2018
 AHCA/NCAL National Quality Award Program
 LTC Trend Tracker
 Questions?
2015- 2018
Cornerstones for AHCA
Quality Initiative 2015-2018
 Aligning with national priorities
 Build on previous efforts

Quality Initiative 2012-2015
 Inclusive of post-acute care and long term care
National Priorities
Systems Outlook
 Model based on Baldrige and QAPI Philosophy
 Systems Orientation utilized to accomplish goals
Organizational Success
Increase Staff Stability
Target: Decrease turnover rates among nursing staff (RN, LPN/LVN,
CNA/LNA) by 15% or achieve/ maintain at or less than 40% by March 2018
Increase Customer Satisfaction
Target: At least 25% of members will measure and report long-stay resident
and family satisfaction and/or short-stay satisfaction using the Core-Q
survey by March 2018
Reduce the Number of Unintended Health Care Outcomes by March
2018
Improve Short Stay/Post-Acute Care
Safely Reduce Hospital Readmissions
Target: Safely reduce the number of hospital readmissions within 30 days
during a skilled nursing center stay by an additional 15% or achieve and
maintain a low rate of 10% by March 2018
Improve Discharge Back to the Community
Target: Improve discharge back to the community by 10% or achieve and
maintain a high rate of at least 70% by March 2018
Adopt Functional Outcome Measures
Target: 25% of members will adopt the use of the mobility and self-care
sections of the CARE tool and report functional outcome measures
Improve Long-Stay/Dementia Care
Safely Reduce the Off-Label Use of Antipsychotics
Target: Safely reduce the off-label use of antipsychotics in long-stay nursing
center residents by 25% by Dec. 15 and by 30% by Dec. 2016
Safely Reduce Hospitalizations
Target: Safely reduce hospitalizations among long-stay residents by 15% or
achieve/ maintain a low rate of 10% or less by March 2018
Cornerstones for NCAL Quality
Initiative 2015-2018
 Set goals that are achievable and meaningful
 Consider what data is available through the Patient Safety
Organization
 Alignment with AHCA goals
NCAL Quality Initiative Goals
(by March 2018)
Keep nursing and direct care staff turnover below 40%
At least 90% of customer (residents and/or families) are satisfied with
their experience
Safely reduce hospital readmissions within 30 days of hospital
discharges by 15%
Or reach (and maintain) a low rate of ≤5% rate
Safely reduce the off-label use of antipsychotics by 15%
Or reach (and maintain) a low rate of ≤5% rate
How to Measure
LTC Trend TrackerSM – AHCA/NCAL’s Turnover and
Retention Upload
CoreQ satisfaction questions
National Patient Safety Organization for Assisted Living
(PSO)
National Patient Safety Organization for Assisted Living
(PSO)
Key Resource
The Staff Stability Toolkit
via AHCA/NCAL Bookstore
Learn more at
QualityInitiative.ncal.org
Turning Complaints into Compliments
INTERACT for Assisted Living
Consumer Fact Sheet on Antipsychotic Drugs for Persons Living with
Dementia
Goal Tracking
 AHCA
 LTC Trend Tracker (staffing, Rehospitalization, antipsychotics,
discharge to community)
 NCAL
 LTC Trend Tracker (staffing)
 PSO (antipsychotics and Rehospitalization)
 Soon to come
 CoreQ
 Quality Initiative Tracking Report
AHCA/NCAL National Quality
Award Program
Background
 Launched in 1996
 Approx. 10,000 applications and 4,000 awards
 Criteria based on the Baldrige Performance Excellence Program
 The mission of the AHCA/NCAL National Quality Award
program is to promote and support the application of continuous
quality improvement in AHCA/NCAL member organizations
Three Levels of Distinction
 Organizations must achieve the award at each level to
continue to the next level
1.
Bronze – Commitment to Quality
2.
Silver – Achievement in Quality
3.
Gold – Excellence in Quality
Number of Recipients
3,405
495
24
Number of Recipients in MO
39
7
1
Who is succeeding?
Organization A
Organization B
 Morning Stand-Up
 Morning Stand-Up
 Issues of the day: hostile family
 Issues of the day: hostile family
member and no food delivery for
the kitchen
 In the past, had the same issue
with the produce delivery system
member and no food delivery for
the kitchen
 In the past, had the same issue
with produce delivery system
 "Green Code"
Reactive to Proactive
Market
Skilled Nursing Care Center
Integrated Management System
Mission, Vision and Values
Workforce
Customers
Leadership &
Strategy
Results
Operations
Measurement, Analysis and Knowledge Management
*Adopted from Quantum Performance Group
Baldrige Core Values
 Visionary leadership
 Focus on the future
 Patient-focused excellence
 Managing for innovation
 Organizational and personal
 Management by fact
learning
 Societal responsibility and
 Valuing workforce members and
community health
partners
 Focus on results and creating value
 Agility
 Systems perspective
Baldrige and QAPI
Baldrige

Organizational Profile

Leadership

Strategy

Customers

Measurement, Analysis, and Knowledge
Management

Workforce

Operations

Results
QAPI
 Design and Scope
 Governance and Leadership
 Feedback, Data systems, and
Monitoring
 Performance Improvement
Projects
 Systematic and Systemic Action
Value Proposition
 Silver and Gold Quality Award recipients have better
performance outcomes
o
Five Star Performance
o
Patient Health Care
o
Financial
Five Star
Off-Label use of Antipsychotics
30 Day Hospital Readmissions
Occupancy Rate
2016 Program Cycle
Event/Deadline
Date
Intent to Apply Launch
Mid-September
Intent to Apply Deadline
November 19, 2015
Application Submission Launch
December 7, 2015
Application Deadline
January 28, 2016
Survey History
Your
Member
Resource
Resident Characteristics
Staffing Information
Cost Report & Medicare Utilization
CMS Five Star Rating
www.ltctrendtracker.com
If you hear the word “data” and
it makes you want to run just r it
with the word “candy”
Who Collects Data on LTC?
 Government Accountability Office (GAO)
 Office of Inspector General (OIG)
 Centers for Medicare and Medicaid Services (CMS)
 Centers for Disease Control – National Center for Health
Statistics (NCHS)
 Trade Associations (NCAL, ALFA, Leading Age, ASHA, NIC)
 Hospital and Healthcare Compensation
Why Data Matters
 Must manage by facts, not feelings
 Shows how well you are performing and areas for improvement
 Without we function in an atmosphere of blame

problems are hidden

results are excused

people are blamed
 It’s a team effort! All staff are important in quality improvement.
What People Know About You
 Hospitals track your data
 Five Star
 Yelp
 Google
 Facebook
 Twitter
 State Surveys
 Health Grades
 Word of mouth/reputation
The Future of LTC Trend
Tracker
 Fall 2015
 Customer satisfaction questions aka “CoreQ”:
 Hospitalization report
 Five Star download
 Spring 2016 –
 Additional AL measures:
o
o
o
o

30-day hospital readmission rates
Off-label use of antipsychotics
Occupancy rates
Lengths of stay
Quality Initiative tracking report
www.LTCTrendTracker.com
What is Risk Adjustment
 Risk adjustment is a corrective tool used to level the playing field
regarding the reporting of patient outcomes by adjusting for the
differences in risk among specific patients.
 Risk adjustment also makes it possible to compare hospital and doctor
performance fairly. Comparing unadjusted event rates for different
hospitals would unfairly penalize those performing operations on
higher risk patients (those who are sicker or have more comorbidities).
Source: http://www.sts.org/patient-information/what-risk-adjustment
Risk Adjustment
Building A
Building B
 Low Acuity
 High Acuity
 Admissions 100/year
 Admissions 100/year
 Rehospitalization Rate
 Rehospitalization Rate 15%
10%/month
month
 Expected Rate 10%
 Expected Rate 15%
 Ratio 1
 Ratio 1
Benefits of LTC Trend Tracker
 AHCA member resource
 Benchmarking against your peers
 Increases efficiency – saves you time
 Data in one central place – pulled using Medicare number
AHCA Quality Metrics
 Rehospitalization
 Discharge to Community
 Length of Stay
Data Source
 MDS 3.0
 Over a 12-month period
 Based on admission assessment (5 day or OBRA)
 Discharge assessment
Rehospitalization Measures
 National measures based on claims
 Excludes ER visits & observation stays
 Excludes Medicare Advantage & private insurance
 Most measures
 Fail to risk adjust for differences in patients
 Claims allow for limited clinical information to risk adjust
Rehospitalization Data
 MDS 3.0-based measure
Adjusted rate
 Expected rate
 Actual rate

 Use in telling your story to hospitals
 Benchmark your Rehospitalization to your peers
Rehospitalization
How to interpret your results

How do I compare to others? – look at risk adjusted results

Are you getting better? – look at your actual results

Are you admitting sicker patients? – look at your expected

Are you admitting more or less than expected? – look at your actual to expected ratio
How to interpret your results
Risk adjusted is getting better but your actual & expected have not
- Means you are doing better compared to others but you are not improving much
- Your admissions have about the same acuity over
time (e.g. they are not sicker in Jun 2014 compared to
Jun 2013 – based on expected rate)
- Your ratio is 1.0 or less meaning you send fewer patients back to the hospital
than expected (this is why your risk adjusted value is 3-4% points less than your
actual (21% vs 18%)- however you still have room to do better since your ratio is close
to 1.0 most of the time.
Rehospitalization Report
Actual Rehospitalization
Risk Adjusted Trend
How to talk to hospitals
How to display for a hospital
Expected VS Actual
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
act Org
Dec-12
17.60%
Mar-13
12.50%
Jun-13
12.70%
Sep-13
14.40%
Dec-13
16.10%
Mar-14
16.50%
Jun-14
16.20%
Sep-14
15.00%
act Peer
20.40%
20.30%
20.20%
20.10%
19.80%
19.80%
19.80%
19.60%
Exp Org
22.30%
21.90%
22.80%
23.50%
23.50%
23.70%
23.60%
23.50%
exp peer
20.50%
20.50%
20.50%
20.40%
20.30%
20.20%
20.10%
20.10%
Show how your patients differ
 In this example the expected return is higher than the actual
 This means that this center is sending fewer patients back to
the hospital they are expected
 They are doing better then their peers
 You could then show your correlation to other metrics such
as five star and LOS
Discharge to Community
 Determine how you compare in your d/c to community
rate
 Private home, apartment, board/care, assisted living, or
group home as indicated on MDS discharge assessment
 Uses MDS Data from the d/c assessment
Discharge to Community
Report
How to use DC to Community
 See how you are doing on your dc rate to home and other
nonclinical settings
 It can also tell you if you are sending more or fewer than
expected individuals back to the community given the
clinical characteristics of the population of individuals
admitted to your center
 Use negotiations with hospitals, Manage Care organizations
and others.
Five Star Rating Reports
 3 Reports
 Overall, Staffing and QM Report
 QM-- Identify focus QMs for quality improvement
 Predict impact of QM improvements on Five-Star QM
Rating
 Predict Staffing Five Star Rating
Five Star QM Report
 Look at your current QM Five Star Rating
 Determine QMs to focus from the Five Star QM Report
 Look at your current resident population
 Enter your scores and see the affect on your overall QM
score
 Members use this report to see if they will maintain their
five star rating
Sample Five Star Overall
Changes with Staffing
 Look at Staffing Five Star Report

Determine expected vs reported
o
Did you enter the correct data during last survey?
o
What does CMS Expect you to run?
 Look At CASPER Staffing Report for reported hours
Five Star Staffing Rating
Five Star Staffing Report
RN hours
Five Star Staffing Report
Five Star QM Rating
SS Stay Antipsychotic
LS Antipsychotic
FUTURE CHANGES TO
FIVE STAR IN 2015 & 2016
 CMS plans to add additional quality measures to Five-Star
•
•
•
•
Rehospitalizations
Discharge back to community
Staffing turnover and retention
Other measures from IMPACT act

Change how much measures contribute to scoring based on CMS
audits of MDS and Staffing reports

Linkages to individual state reporting and inspection results
CMS raised the bar, now SNFs
return to work of quality
improvement

Outline of a strategy for improving your Five Star rating:




Decrease survey score (frequency of tags weighted by scope and severity)
o
Monitor deficiencies (Trend Tracker)
o
Implement strategies to reduce them
o
Must be consistent, as survey score is 3-year average
Increase RN and DCS staffing
o
Monitor staffing (LTC Trend Tracker)
o
Implement strategies to increase PPDs (see the Trend Tracker Five Star staffing predictor)
Improve the 11 QMs
o
Monitor QMs (LTC Trend Tracker)
o
Implement strategies to improve them (see the Trend Tracker Five Star QM predictor)
o
Also must be consistent, as there is roughly a 6 month delay before appearing in Nursing Home
Compare, and most measures are based on 12 months of data. So sustain improvement for at least 18
months.
Also decrease rehospitalizations and increase discharge to community rates, as they will be added to Five Star
QM component in 2016
The full list of elements to target
in your Five Star strategy…
Benefits of Joining the
National PSO for AL
 Access to data

For benchmarking

Detect and address emerging quality issues as they arise

For the AHCA/NCAL Quality Award Program
 Reduce liability costs and exposures
 Access to resources including webinars, policies & procedures,
and training material to improve quality
 Improve safety and quality, leading to better resident outcomes
www.ncalpso.org
What Data Does the PSO
Collect?
 Demographics
 Falls
 Pain Management
 Pressure Ulcers
 Infection Control
 Unplanned
Hospitalizations
 Hospice
 Elopements
 Depression
 Medication Management
www.ncalpso.org
You Have Data…now
what?
How to Use Data
 As part of Root Cause Analysis (RCA)
 Quality Assurance & Quality/Performance Improvement (QAPI)

PDSA – Plan, Do, Study, Act
 Referral programs/working with other providers
 Marketing
 Resident/Family/Staff Satisfaction
What is your data telling you?
1.
Demonstrate good clinical care/outcomes?
2.
Low readmission rates?
3.
Excellent customer experience scores?
4.
Staff stability?
Share your outcomes
 Share outcomes with staff, residents and families
 Show progress in the break room
 Talk about outcomes at meetings, resident and family
council
 Share with other providers
Setting Your Goals
 Make it a SMART goal
 Specific – reduce Rehospitalization by 10%
 Measurable – current turnover (X%) a 10% decrease is
(X%)
 Achievable – can your center do this? Do you have
support? What can you do to make it achievable
 Realistic – think about everything else going on in your
center, setting up goals that are not realistic is setting
your center up for failure which is counter-productive
 Time-targeted – by 12/31/2015
Setting Goals
 EXAMPLE Goal 1 (remember SMART):
 Goal- Reduce Rehospitalization
 Measurable – Reduce Rehospitalization by 10
 Time frame: by 7/23/2016
 Activities to support this goal
1. Implement Interact tool
2. Identify trends for improvement when are the most readmissions to the
hospital?
3. Train Staff and Physicians
4. Develop protocols for readmissions
5. Implement program by October 31, 2015
Quality Improvement: PDSA
 Plan Do Study Act (PDSA)
 Commonly used quality improvement tool
 Others include
 Root Cause Analysis (5 Whys)
 Flow Charts
 Many others!
 Can utilize with any quality improvement project
PDSA: Plan
Step 1: Plan
Plan the test or observation, including a plan for collecting
data.
 State the objective of the test.
 Make predictions about what will happen and why.
 Develop a plan to test the change. (Who? What? When?
Where? What data need to be collected?)
From the Institute for Healthcare Improvement
http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx
PDSA: Do
Step 2: Do
Try out the test on a small scale.
 Carry out the test.
 Document problems and unexpected observations.
 Begin analysis of the data.
From the Institute for Healthcare Improvement
http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx
PDSA: Study
Step 3: Study
Set aside time to analyze the data and study the results.
 Complete the analysis of the data.
 Compare the data to your predictions.
 Summarize and reflect on what was learned.
From the Institute for Healthcare Improvement
http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx
PDSA: Act
Step 4: Act
Refine the change, based on what was learned from the test.
 Determine what modifications should be made.
 Prepare a plan for the next test.
From the Institute for Healthcare Improvement
http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx
What you can do
 Embrace Value Based Purchasing Programs – they allow
you more control over your payment
 Embrace data and the feedback it provides
 The details matter – learn the details of each proposed
measure and train your staff
 Keep an open mind as you perform root cause analysis
 Establish a common goal within your center
When you get back
 Look at Rehospitalization rates, implement INTERACT
 Review your Five Star Rating

Use your clinical systems and root cause analysis to make
changes
 MDS Process
 Use Free Tools such as Advancing Excellence or LTC Trend
Tracker.
Questions