Advancing Excellence
in
America’s Nursing Homes
Keep Moving!!
The AE Goal to Increase Resident
Mobility
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A Word from CMS
Karen Tritz
Acting Director, Division of Nursing Homes
OCSQ
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Overview
Mobility Goal Work-group Chair:
Mary Jane Koren, M.D., MPH
About the Campaign
(www.nhqualitycampaign.org)
It’s National, Voluntary, Aligned, and Free
• Registrant:
 Register/Update Profile
 Select Goals (at least 2 – 1 organizational & 1 clinical)
 Work hard to improve performance!
• Take it up a notch - be an Active Participant!!
 All of the above PLUS
 Submit Data so you can compare your results to others
(see QAPI element 3: “review findings
against benchmarks”)
 Get credit: be recognized as a participant!!
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Quality Improvement Resources
for NINE Goals
Hospitalizations
Staff Stability
Pressure Ulcers
Medications
Antipsychotics
Consistent
Assignment
Infections
C. difficile
Mobility
PersonCentered
Care
Pain
Management
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Thank you to the entire
workgroup
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Mary Jane Koren, M.D., M.P.H.
Jo A. Taylor, R.N., M.P.H.
Mary Tinetti, M.D.
Jennifer Brach, PT, Ph.D.
Kris Mattivi, M.S., P.T.
Lisa Bridwell
Linda Sue Davis, R.N. M.S.N.
Lorraine Hiatt, Ph.D.
Melanie McNeil
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Urvi Shah, M.P.H.
Adrienne Mihelic, Ph.D.
Carol Scott
Elaine McMahon, M.S., R.N.
Tammy Rolfe, R.N., L.N.H.A.,
M.S., H.P.M.
• Carol Benner, Sc.M.
• Ruta Kadonoff
• Chris Condeelis
Understanding “Why Mobility?”
Jo A. Taylor, R.N., M.P.H.
Carolinas Center for Medical Excellence
Two Models
Poor Clinical Outcomes
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Falls
Restraints
Pressure ulcers
Urinary tract infections
Pain
Dehydration
Poor nutrition
Delirium
Medical Model
Quality of Care and Resident Life
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Quality relationships
Workforce stability
Consistent assignment
Effective leadership
Teamwork
Critical thinking
Real time problem solving
Individualized care strategies
Person Centered Care Model
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Two Models
In a medical model, fall prevention makes the most
sense, at any cost.
In a person centered care model,
mobility moves out ahead.
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Individualized Care
• Practical management of the resident’s fall risk
– post fall investigation
– interdisciplinary root cause analysis
– individualized interventions for identified risk factors
fundamental strategies of person centered care
The Mobility Goal contains information to implement
a practical falls management program.
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Mobility
One of the best ways to reduce the
seriousness of falls is to preserve
and enhance resident mobility.
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What is mobility?
• Mobility means being able to move your own body or having
someone help you move from place to place.
• Mobility is not just walking. It is about strength, flexibility,
balance and staying power.
• It includes:
– Turning over in bed
– Getting up from a chair
– Standing
– Using a cane, walker or wheelchair to get around
– Moving from place to place within or outside the nursing
home.
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Why is mobility important?
For residents maintaining or improving mobility
• Strengthens muscles and bones
• Improves appetite
• Gives a sense of confidence and well-being, which improves mood
• Reduces serious falls
• Improves sleep and energy level
• Makes it easier for residents to socialize and participate in group
activities
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Why is mobility important?
For staff, helping to keep a resident mobile
• Facilitates self-care so residents can do more for themselves
• Makes transfers easier and safer for staff as well as residents
• Promotes safer walking, fewer serious falls
• Enables residents to access toilets more quickly and easily to
promote continence
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How will mobility be
measured?
Uses 2 new composite measures constructed from MDS-3 items
% of Residents with Improvement in Personal Movement
– looks at how independently an individual can move in bed, transfer, or
walk in their room and corridor. It is the individual who is “responsible”
for, or carries out, the movement.
% of Residents with Improvement in Life Space Mobility
– considers area within the entire NH through which an individual moves
during a set period of time. Movement can be independent or assisted
by another person or device (such as a w/c). Greater life-space mobility
would theoretically relate to greater involvement in life situations or
greater participation in social activities
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What happened to physical
restraints?
Why were residents being restrained?
• To control “problem behaviors”
• To prevent falls
What have we learned?
• “Problem behaviors” are symptoms of unmet needs and most often
can be managed with non-pharmacologic interventions and person
centered care
• Physical restraints do not eliminate falls – they can actually make
falls more serious and have devastating consequences
The Mobility Goal contains information to continue to
make nursing homes restraint free – it can be done!
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Isn’t this goal really just for
the therapy staff?
No, this is not just a job for therapists!!
Keeping residents as physically functional and
independent as possible is:
• Everybody’s job – aides, nurses, dietary,
housekeeping, administration … the whole team
• As important a part of routine daily care as skin
care or vital signs
• As much about the environment as it is about care
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This diagram is
courtesy of Dr.
Lorraine Hiatt, a
member of the
Mobility work
group
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Polling Question
Where are you on the mobility scale?
Physical restraints
Alarms
Antipsychotics (AP)
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Restraint free
 Alarms
 AP’s
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Schedule focus
Little time/staff for ambulation
Role of therapy
Limited areas for walking
W/C seating all day
Excess safety
Medical model
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Resident focus
Staff encourage self care & movement
Frontline staff monitor resident mobility
Exercise activities
Environment for mobility
Walking and dining programs
Person Centered Model
QAPI Five Elements
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Element 1: Design and Scope
Element 2: Governance and Leadership
Element 3: Feedback, Data Systems and Monitoring
Element 4: Performance Improvement Projects
Element 5: Systematic Analysis and Systemic Action
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What the workgroup
developed or identified
Use the Mobility Goal “package” of resources to improve
care and become QAPI compliant
• AE’s Circle of Success – PDSA change framework for systematic
performance analysis leading to systemic action (QAPI Element 5)
• Data measurement & tracking tools (QAPI Elements 3, 4 and 5)
• Root cause analysis tools – called “Probing Questions” (QAPI
Element 5)
• Consumer, staff, and leadership fact sheets (QAPI Element 2)
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Mobility Resource
Package
Evidence-based or field tested educational materials and
clinical practice tools (QAPI Element 1)
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Walking programs
• Restraint reduction
Dining programs
• Falls management
Exercise programs
Environmental design
Bed mobility
Transfer
Wheelchair seating & mobility
Balance, endurance, strength
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AE INCREASE RESIDENT MOBILITY
WEBSITE RESOURCES & TRACKING TOOL
Adrienne Mihelic, Ph.D.
PlanDoStudyAct
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Explore the Goal
www.nhqualitycampaign.org
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www.nhqualitycampaign.org
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Why choose mobility?
www.nhqualitycampaign.org
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PlanDoStudyAct
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Where am I?
www.nhqualitycampaign.org
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PlanDoStudyAct
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Study
www.nhqualitycampaign.org
www.nhqualitycampaign.org
Examine Processes
Probing Questions
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Examine Processes
www.nhqualitycampaign.org
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PlanDoStudyAct
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Improve
www.nhqualitycampaign.org
http://www.nhqualityc
ampaign.org/star_inde
x.aspx?controls=Mobili
tyImprove
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Engage
www.nhqualitycampaign.org
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Data and the
Quality Improvement Process
How do I know where I am?
Where do I want to be?
What processes are
associated with my
outcome?
When I change a process,
how do I know it had the
effect I wanted?
How am I doing compared
to other nursing homes
working on this goal?
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QA and PI
Quality Assurance
Performance Improvement
Reactive
Proactive
Episode or event-based
Aggregate data & patterns
Prevent recurrence
Optimize process
Sometime anecdotal
Always measurable
Retrospective
Concurrent
Audit-based monitoring
Continuous monitoring
What went wrong?
How can we be excellent?
Tracking Tools
Support both QA and PI
• Easy view of individual records allows
resident-level view
• Matrix of individual data allows scanning
for patterns
• Summary information helps identify
opportunities to improve at the system
level
The Tracking Tool
AE_MobilityTrackingTool.xls
www.NHQualityCampaign.org
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Thank you pilot testers!
Step 1: Monthly mobility assessment on every resident you are tracking. 8 items.
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Thank You
For making our nursing homes
better places to live, work, and
visit!