Indiana Healthcare Leadership
Conference: Improving Nutrition
Review of Quality of Care
Initiatives
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Nursing Home
Quality Status: 2007
High number of immediate jeopardy
violations (5th highest)
 High number of deficiencies per
standard survey (7.6 compared with
national average of 6.9)
 Above average number of deficiency
free surveys (11.7% compared with
national rate of 8.3%)

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Quality Improvement
Efforts: Studies

Medical error reporting system (2005)

Staffing study (2009)

Bladder scanner study (2009)
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Quality Improvement
Efforts: Education Programs

Alzheimer’s and dementia care
training programs (2005)

Leadership Conference (2007)

Consultant program (2004)

Healthcare Quality Resource Center
(2009)
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Quality Improvement
Efforts: Communications

ISDH LTC Newsletter (2008)

Monthly meetings of provider
associations and ISDH (2008)

Regular meetings with consumer
organizations to discuss quality of
care concerns (2005)
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Quality Improvement
Efforts: Survey Process

Implemented MDS 3.0 (2010)

Implemented CMS Special Focus
Facility Program (2008)

CMS and ISDH consistency
workgroups (2008)

Review of immediate jeopardy surveys
with provider associations (2008)
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Quality Improvement
Efforts: Collaborative Initiatives

Indiana Pressure Ulcer Initiative
(2008 – 2010)

Indiana Healthcare Associated
Infection Initiative (2009 – 2011)
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Quality Improvement
Efforts: Regional Projects

Health Care Excel (QIO) statewide
support of CMS GPRA goals (2004)

Health Care Excel pilot of CMS care
coordination project in Evansville (2009)

CMS Critical Need Nursing Home
Project Pilot in northwest Indiana (2010)
coordinated by Health Care Excel
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Quality Improvement
Efforts: New in 2011

Community Foundation of St. Joseph
County Regional Nursing Home
Collaborative (2011)

ISDH Survey Report System (2011)

ISDH Posting of Surveys (2011)
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OUTCOMES TO QUALITY
IMPROVEMENT EFFORTS
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Indiana Pressure Ulcer
Initiative

CMS GPRA Initiative – 2005 – 2007

Indiana Healthcare Leadership Conference
on Preventing Pressure Ulcers – October
2008

Indiana Pressure Ulcer Initiative – August
2008 – November 2010

Quality Improvement Organization
ongoing projects with providers
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Indiana Pressure Ulcer
Initiative: Outcomes
9.0%
8.5%
8.0%
Series1
7.5%
7.0%
6.5%
Source: CMS GPRA data from PDQ
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Indiana Restraint Reduction
Initiative

CMS GPRA Initiative: 2005 –2007

Indiana Healthcare Leadership Conference
on Restraints and Behavior Management:
March 2008

Quality Improvement Organization
ongoing projects with providers

Focus by provider associations
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Indiana Restraint Reduction
Initiative: Outcomes
6.00%
5.00%
4.00%
3.00%
Series1
2.00%
1.00%
0.00%
Source: CMS GPRA data from PDQ
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Indiana Healthcare Associated
Infection Initiative

Overview
– Collaborative initiative
– Two-year initiative from Sept 2009 – Dec 2011
– 130 participating facilities (80 nursing homes)

Priorities
– Catheter associated urinary tract infections
(CAUTI)
– Clostridium difficile (CDI)
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CDI & CAUTI Event Totals (Averaged)
50
46
45
Number of Events
40
CDI
Events
38
CAUTI
Events
34
35
31
30
29
29
25
20
18
15
15
16
15
15
12
10
5
August
September
(34/81)
Previous (42/81)
October
(37/81)
Next
November December
(41/81)
(34/81)
January
(26/81)
*Numbers
below each
month
indicate #
of facilities
reporting
over total
facilities.
Hand Hygiene Compliance
90%
85%
86%
86%
84%
82%
80%
79%
75%
Before
Patient
Contact
After Patient
Contact
76%
74%
*Numbers
next to each
month
indicate # of
facilities
reporting
over total # of
facilities
70%
70%
67%
65%
65%
60%
55%
50%
September (25/81)
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October (29/81)
November (33/81) December (26/81)
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January (24/81)
Indiana Nursing Homes:
Deficiency Free Surveys





2006:
2007:
2008:
2009:
2010:
33 facilities - 7.0%
47 facilities - 9.6%
55 facilities - 11.0%
56 facilities – 10.7%
51 facilities - 10.3%
Source: ISDH QAMIS
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Outcomes: Average Number of
Deficiencies per Standard Survey
Indiana
National
Region V
(fewest is 1st)

Fed FY 2007
 Fed FY 2008
 Fed FY 2009
 Fed FY 2010
7.6
8.0
7.2
7.1
Source: CMS data from CASPER 11/8/2010
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6.9
6.9
6.8
6.3
4th
5th
4th
4th
Outcomes: Percent of LTC with a “J”
or Higher on Standard Surveys
Indiana
National
Region V
(lowest is 1st)

Fed FY 2007
 Fed FY 2008
 Fed FY 2009
 Fed FY 2010
5.0
4.6
1.8
2.9
Source: CMS data from CASPER 11/8/2010
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2.1
2.9
2.7
2.5
4th
5th
2nd
2nd
Outcomes: Number of Immediate
Jeopardy Findings on all LTC Surveys
Indiana
Region V
(lowest is 1st)

Fed FY 2007
 Fed FY 2008
 Fed FY 2009
 Fed FY 2010
68
50
35
33
Source: CMS data from CASPER 11/8/2010
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5th
5th
3rd
3rd
Outcomes: Average Number of Onsite
Survey Hours on Standard Surveys
Indiana
National
Region V
(lowest is 1st)

Fed FY 2010
83.7
105.6
Source: CMS data from CASPER 11/8/2010
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1st
COMING QUALITY
IMPROVEMENT PROJECTS
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Coming Initiatives for 2011
Healthcare Associated Infections

Three online learning modules
designed for staff and consumers

Consumer brochure

In-service programs
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Coming Initiatives for 2011

Education programs for wound care
and infection prevention leading to
increased staff certification

Updated aide curriculum

Long Term Care Bed Tracking
System
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Coming Initiatives for 2011

Leadership Conference on care
coordination and transition

Complete 50% of training for Quality
Indicator Survey (QIS) Process

Develop a care coordination and
transition initiative for 2012
implementation
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Improving Nutrition
Conference Checklist

Provide an in-service on information and
resources provided at today’s conference

Develop a plan for improving nutrition

Identify and implement 3 activities for
improving nutrition
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