Four Part CMS Satellite Broadcast
From Institutional to Individualized Care
Part 1
Integrating Individualized Care
and
Quality Improvement
This material was designed by Quality Partners, the Medicare Quality Improvement Organization for Rhode Island, under contract with the Centers for Medicare & Medicaid Services
(CMS), an agency of the US Department of Health and Human Services. Contents do not necessarily represent CMS policy. 8SOW-RI-NHQIOSC-072006
CMS Satellite Broadcast Series:
From Institutional to Individualized Care
• Today: Integrating individualized Care with Quality
Improvement
• Part 2, Feb. 2007: Transforming Systems to Achieve
Better Clinical Outcomes
• Part 3, April 2007: Clinical Case Studies in Culture
Change Case Examples
• Part 4, Fall 2007: The How of Change
Quality Partners of Rhode Island
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Goals:
•
•
To help surveyors, providers, and consumers
understand how individualized care is the basis for
good care
To provide examples from providers who have
changed their systems to support individualized
care, and have seen better care outcomes as a
result
Quality Partners of Rhode Island
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Quality Improvement Practices:
•
•
•
•
•
Root cause analysis of clinical concerns
Pilot tests of new practices
Evaluation of their impact
Mid-course adjustments
Spread of good practices
Quality Partners of Rhode Island
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§ 483.25 Quality of care
• Each resident must receive and the
facility must provide the necessary care
and services to attain or maintain the
highest practicable physical, mental,and
psychosocial well-being, in accordance
with the comprehensive assessment
and plan of care.
Quality Partners of Rhode Island
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Practicable vs. Practical
Innate capability –
based solely on the
individual’s abilities,
limitations, and
potential –
independent of
external limitations
Quality Partners of Rhode Island
Capability based
on resources
available to support
a person’s abilities
and potential, and
to address their
limitations
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§ 483.25 Quality of care
“ A resident’s abilities … do not
diminish unless circumstances of
the individual’s clinical condition
demonstrate that diminution is
unavoidable”
Iatrogenesis = We caused it
Greek Origins:
Iatro = of or by a physician
Genesis = beginning
Institutionalized Care
Individualized Care
• Task Oriented
• Care systems and
daily routine focus on
needs, interests, lifestyle, preferences,
choices, and abilities
and strengths of
resident
• Depersonalized
• Fragmented
• Schedule-driven
• One size fits all
Culture Change Journey
Quality Partners of Rhode Island
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Health
Promotion
Institutional
Care
Old
Practice
Quality Partners of Rhode Island
New
Practice
Individualized
Care
Risk
Prevention
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Your Systems are Creating Your
Outcomes
What you’re doing is getting you
what you’re getting.
To get something different, you
have to do something different.
Science of Change:
Root-cause analysis
Small pilot-tests
Evaluation and Re-evaluation
Mid-course adjustments
Evidence-based solutions
Collaborative Learning, Spread
Quality Partners of Rhode Island
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Psychology of Change:
Build on Intrinsic Motivation
Holistic Approach - Personalize
Start where people are
Build capacity for change
Experiential learning
Climate Where Truth is Heard
Quality Partners of Rhode Island
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Government & Regulations
Family
Leadership
Community
Quality Partners of Rhode Island
Financial Resources
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Home:
A strong, intimate, fluid relationship
between the individual and their
environment
Judith Carboni 1987
Quality Partners of Rhode Island
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Home
•
•
•
•
•
•
•
Identity
Connectedness
Lived Space
Privacy
Power/Autonomy
Safety Predictability
Journeying
Judith Carboni, 1987
Quality Partners of Rhode Island
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Homelessness
The predominate state that occurs
when an individual’s relationship
with the environment has been
severely damaged
Quality Partners of Rhode Island
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Homelessness
•
•
•
•
•
•
•
Non-Personhood
Disconnectedness
Meaningless Space
Without boundaries
Powerless/Dependence
Insecurity/Uncertainty
Placelessness
Judith Carboni, 1987
Quality Partners of Rhode Island
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Home – Homelessness Continuum
Relationship of Person to Environment
HOMELESS
NESS
Severely
damaged
HOME
Damaged
Quality Partners of Rhode Island
Judith T. Carboni, 1987
Weakened,
impaired
Strong,
intimate,
fluid
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Homelessness
Severely damaged and tenuous
relationship between person and
environment
Home
Strong, intimate, fluid relationship
with the environment
Institutional
Care
Individualized
Care
Homeless
Home
Quality Partners of Rhode Island
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Health
Promotion
Institutional
Care
Quality Partners of Rhode Island
Individualized
Care
Risk
Prevention
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Health
Promotion
Institutional
Care
Old
Practice
Quality Partners of Rhode Island
New
Practice
Individualized
Care
Risk
Prevention
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Case Study:
Nursing Home Alarm Elimination
Program – It’s Possible to Reduce
Falls by Eliminating Resident Alarms
www.masspro.org/NH/casestudies.php
Way of Inquiry
Irritant
Catalyst
Awakening
Hope vs. Despair
Action
Quality Partners of Rhode Island
Immobilization
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Phase 1: Irritants
Phase 1: Irritant
An annoyance based on a
belief, behavior or
practice that
becomes a tolerated part
of the culture.
Quality Partners of Rhode Island
• We come to accept
it even though it
doesn’t feel quite
right.
• We rationalize why
it should be so and
the reasons why it
can not change.
• Example: Reality
Orientation
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Phase 2: Catalyst
• Causes us to begin
to ask why
• Alerts us to new
possibilities
• Example: Hearing a
success story from
others in an article
or at a conference
Quality Partners of Rhode Island
Phase 2: Catalyst
An external influence
suggesting news of a
difference that change
is possible and
necessary.
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Phase 3: Awakening
Phase 3: Awakening
A heightened sense of
awareness creating a
tipping point in one’s
personal sense of understanding and responsibility
in changing the belief,
behavior or practice.
Quality Partners of Rhode Island
• We can no
longer ignore
the need to
change the
irritant.
• Dawn of
hope.
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Hope
Gives rise to
growth, action,
& our greatest
humanity
Quality Partners of Rhode Island
vs.
Despair
Produces
resignation
&
surrender
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Hope
If we choose hope, we unleash our
energy to take action to bring about
change. We find ourselves putting our
energy into finding out what to do and
how to do it. We grow in the process.
Despair
If we go the route of despair, we feel
resigned to how things are and
surrender any hope of changing them.
We are immobilized and continue on
our current course.
The How of Change
• Personalize the situation: How would you
need it to be if you lived or worked here?
• Compare what you would need to what is
currently happening
• Bring people together to figure out how to
make changes.
• Pilot changes
Quality Partners of Rhode Island
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Health Promotion
New
Practice!
Action!
Action!
Institutional
Care
Individualized
Care
Action!
Action!
Old
Practice
Risk Prevention
Quality Partners of Rhode Island
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Each resident must receive and
the facility must provide the
necessary care and services to
attain or maintain the highest
practicable physical, mental,
and psychosocial well-being.
Quality Partners of Rhode Island
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