Achieving Quality in the Pursuit
of the Silver AHCA/NCAL
National Quality Award
Steve Izzo LNHA, MPH, Administrator
Karen Gentile RN, Assistant Administrator/DON
Meredith Weil LSW, Director of Social Services
Inglemoor Rehabilitation and Care Center (IRCC)
Livingston, New Jersey
1
Objectives
• Achieving and Sustaining Performance
Excellence using the AHCA quality award
application
• Applying Best Practices to achieve and
sustain quality
• Involving and Empowering Staff in
Performance Improvement Initiatives
2
Value of Participating in the
AHCA/NCAL Quality Award
• Focus on quality awareness throughout
the organization
• Framework for our Performance
Improvement program
• Tools, resources, education to achieve and
sustain performance excellence
• Engage and reconnect with staff
3
Tools and Resources
• Best Practices models
• CMS’s QI Indicators
• Advancing Excellence
• LTC Trend Tracker
• MyInnerview surveys
• AHCA quality award criteria
• CMS Five Star Rating (nursing home compare)
4
Inglemoor’s Quality Journey
• 2008 Bronze Award (awarded 2nd attempt)
• 2010 Silver Award (awarded 2nd attempt)
• 2011 Gold Award (1st attempt)
5
Quality Award Application
• Start Early do it through out the year
• Engage entire workforce
• Small team to write
• Professional review
• Resources and tools
• Network
• Don’t lose focus on your core competency
6
Post Acute
OVERALL SATISFACTION
100
87
89
98
RECOMMENDATION TO OTHERS
100
82
81
85
88
QUALITY OF LIFE DOMAIN
95
82
100
75
75
75
50
50
50
25
25
25
0
0
2008
2009
2010
State Nation
81
84
90
89
93
2009
2010
85
84
0
2008
2009
2010
QUALITY OF CARE DOMAIN
100
82
80
83
82
State Nation
2008
QUALITY OF SERVICE DOMAIN
100
75
75
50
50
25
25
0
State Nation
82
85
90
2008
2009
2010
82
81
0
2008
2009
2010
State Nation
State Nation
7
Family
RECOMMENDATION TO OTHERS
OVERALL SATISFACTION
100
85
93
89
93
88
100
88
85
94
89
QUALITY OF LIFE DOMAIN
100
88
100
88
75
75
75
50
50
50
25
25
25
0
0
2007
2007 2008 2009 2010 State Nation
2008
2009
QUALITY OF CARE DOMAIN
100
81
87
86
88
83
83
2010
85
84
87
85
85
0
State Nation
2007 2008 2009 2010 State Nation
QUALITY OF SERVICE DOMAIN
100
82
75
75
50
50
25
25
0
75
74
78
90
79
79
0
2007
2008
2009
2010
State Nation
2007 2008 2009 2010 State Nation
8
Employee
RECOMMENDATION FOR JOB
OVERALL SATISFACTION
100
80
92
84
100
87
73
75
80
87
84
91
80
69
50
50
25
25
25
0
2007
2007 2008 2009 2010 State Nation
2008
2009
2010
87
95
80
77
75
50
0
93
100
74
75
67
RECOMMENDATION FOR CARE
0
State Nation
WORK ENVIRONMENT DOMAIN
2007 2008 2009 2010 State Nation
TRAINING DOMAIN
100
100
75
70
73
74
79
67
75
64
68
74
72
82
71
65
50
50
25
25
0
0
2007
2008
2009
2010
State Nation
2007
2008
2009
2010
State Nation
9
Physical Restraints
6
5
Nursing Home
Score
State Average
4
3
National Average
2
1
0
Q2 2010
Q1 2010
Q4 2009
Q3 2009
Q2 2009
Q1 2009
Q4 2008
Q3 2008
Q2 2008
Q1 2008
Q4 2007
Q3 2007
Q2 2007
Q1 2007
10
High-Risk Pressure Ulcers
30
25
Nursing Home
Score
State Average
20
15
National Average
10
5
0
Q2 2010
Q1 2010
Q4 2009
Q3 2009
Q2 2009
Q1 2009
Q4 2008
Q3 2008
Q2 2008
Q1 2008
Q4 2007
Q3 2007
Q2 2007
Q1 2007
11
Post Acute Care Pain
35
30
25
Nursing Home
Score
State Average
20
National Average
15
10
5
0
Q2 2010
Q1 2010
Q4 2009
Q3 2009
Q2 2009
Q1 2009
Q4 2008
Q3 2008
Q2 2008
Q1 2008
Q4 2007
Q3 2007
Q2 2007
Q1 2007
12
Chronic Care Pain
5
4
Nursing Home
Score
State Average
3
National Average
2
1
0
Q2 2010
Q1 2010
Q4 2009
Q3 2009
Q2 2009
Q1 2009
Q4 2008
Q3 2008
Q2 2008
Q1 2008
Q4 2007
Q3 2007
Q2 2007
Q1 2007
13
Geographic Market: All (Nation) Peer Group: All (Peers)
Metric: Occupancy rate Percentile Peer Group: State
96
94
92
90
88
86
84
82
80
78
2005
2006
2007
2008
2009
All (Nation) - All (Peers)
Inglemoor Rehab and Care Center
State
14
Best Practice
Karen Gentile RN, BSN
Assistant Administrator/DON
15
Best Practice Guidelines
A best practice guideline is a “systematically
developed method for statements (based on
best available evidence) to assist practioner
and patient decisions about appropriate
healthcare for specific clinical
circumstances” (Field and Lohr – 2002, p.8)
The idea is with proper processes a desired
outcome can be delivered with fewer
problems and complications.
16
The Expected Benefits of
Using/Initiating Best Practices
•
•
•
•
Improved Quality of Care and Resident Outcomes
Increased knowledge; evidence based practice that will support
the care of our geriatric patients
Provides support for nurses and staff in our facilities
Improved quality of work life for staff
Implementing Best Practices
1. Evaluate your Facility Needs
•
•
Use of QI, resident/family surveys, employee surveys,
complaint investigation, quarterly meetings, staff meetings
Identify which performance measure and evidence based
practices offer the most promise for improving quality of
care and life within your facility
17
Implementing Best Practices
2. Find a well developed, evidence based
best practice guideline
• identify whether a credible organization
has evaluated the guideline process
18
Implementing Best Practices
3. Identify and engage stakeholders
• Identify the stakeholders who have
high influence and support the
implementation
19
Implementing Best Practices
4. Assess the environment for readiness for
Best Practice Implementation
• Identify the barriers and facilitators of
implementation
20
Implementing Best Practices
5. Use of Implementation Strategies
• Hold interactive educational meetings for
all staff
• Provide reminders to prompt behaviors
• Build consensus among team
• Provide ongoing monitoring and support
during the process
21
Implementing Best Practices
6. Evaluate the Implementation Process
• Provide baseline data before
implementation and benchmark to current
data
• Outcome  achievement of targets and
goals, adherence to Best Practice
Guidelines, increased health outcomes of
our patients
• Support staff/share with staff
22
Objective
• Limit and/or prevent the occurrence of falls
within the parameters that can be controlled
through structured interventions
• Minimize the severity of injuries sustained
• Provide the professional staff with acceptable
standards of practice that will enable them to
perform effectively
• Educate the resident, family and staff
• Limit the liability and financial risk to the facility
23
Key Elements to a Fall
Management Program
A. Assessment
• Clinical Assessment by RN
• Rehab Assessment
• Pharmacological Assessment
• Environment Assessment
24
Key Elements to a Fall
Management Program
B. Dynamic Treatment Plan
• Multidisciplinary implementation of interventions
based on results of the assessments and
resident preferences
•
The IDC Team must address:
a.
b.
c.
d.
e.
f.
g.
Resident, staff and family education
Room modifications
Residents daily routines
Physical limitations
Pain Management
Medication use
Proper and consistent use of assistive device
25
Key Elements to a Fall
Management Program
C. Evaluation
1.
Post Fall Evaluation
a. Fall Management Investigation
•
•
2.
Physical assessment
Contributing factors to fall
Reporting mechanism/tracking of falls within facilities
a. Facility Fall Summary
b. Action of the IDC Team
c. Collective review and analysis of trends in resident falls
throughout the facility
3.
Facility Protocol may include review by safety
committee, QI committee
26
Key Elements to a Fall
Management Program
D.
Education / Awareness
1.
Falls Program in service
a.
b.
Staff members
Resident / Family
Content of Review:
I.
II.
III.
Instruction and information concerning safety awareness
Proper uses of call bells, wheelchairs, assistive devices
How they can assist
27
Key Elements to a Fall
Management Program
E. Quality Improvement
1.
Collect fall data
a. Post fall tool
b. Fall summary report
•
•
Conduct interdisciplinary analysis of information
to gain knowledge
Review and revise Policies and Procedures
(P&P) as appropriate
- Retrain staff on new P&P
28
Performance
Improvement Cycles
Meredith Weil, LSW
29
Performance Improvement (PI) Cycle
1. Formal process of gathering meaningful
data points
2. Data is turned into useful information
through evaluation and analysis
3. The information is used to assess and
determine the current system strengths
and weaknesses.
30
Performance Improvement (PI) Cycle
4. The knowledge gained is applied to the
current system in the form of action plans
aimed to improve performance and
outcomes.
5. Sustain deployed action plans through
integration of learning from evaluation
and repetition of cycles.
31
Performance Improvement Tools
1.
2.
3.
4.
5.
6.
7.
8.
Design, Measure, Assess, Improve and
Control (DMAIC) Tool
Plan, Do, Check, Act (PCDA) Tool
Fishbone Diagram
Root Cause Analysis (RCA)
Cause and Effect Map
Failure Mode and Effects Analysis (FMEA)
SMART Tool
Pareto Analysis Chart (PAC)
32
Performance Improvement Tool
PDCA
1. Plan – Identify and target root causes of
problems and develop action plan
2. Do – Pilot planned solution and
implement activity
3. Check – Measure, Audit, Evaluate
outcomes
4. Act – Determine if improvements have
been met, refine and expand solutions,
and monitor progress
33
Inglemoor Rehabilitation and Care
Center’s 2010 PI Initiatives
• Dining Experience PI
• Callbell Response PI
34
Dining Experience PI Initiative
• The Dining experience was identified as an
area for us to improve our performance as
evidenced by poor customer satisfaction
survey responses in the area of quality of
meals, dining experience and an increase in
customer complaint forms in the same
areas over the past year.
35
Dining Experience PI Initiative
The Dining Experience PI team was chaired by a
department head and line staff from various
departments and levels of responsibility.
The team met and developed a resident
questionnaire to identify the root causes of the
problem. The team divided up the residents in
house and completed the questionnaires with them,
commencing the data gathering process.
36
Dining Experience PI Initiative
 Identified Root Causes of problem
1. Wrong food temperatures
2. Un-timely tray pass
3. Wrong food orders being given and missing
items on tray
4. Poor customer service dining staff impolite
5. Lack of menu selection and repetitious menu
cycles
37
Dining Experience PI Initiative
 Action Plans developed from gathered data
1. Complete necessary repairs to kitchen steam
table to keep food hotter prior to serving
2. Tray passes started earlier and supervisor
oversees timeliness of tray pass on units
3. Policy and procedure on selective menus
revised to ensure they were being delivered
timely and accurately.
38
Dining Experience PI Initiative

Action Plans continued
New system developed to have a second
person checking trays on the line to ensure
proper food and condiments are being given
5. Extensive inservicing with dining room staff on
good customer service
6. Revised menus with dietary staff to widen the
variety of meals to keep up with resident
expectations.
4.
39
Dining Experienced PI Initiative
Checking Stage
• This stage requires ongoing monitoring of action
plans to determine if they are successful
• Evaluate outcomes through the use of resident
satisfaction surveys and feedback
Acting Stage
• We have continued to monitor our outcomes and
refine and expand upon solutions. We repeat
this cycle to sustain results
40
Callbell Response PI Initiative
• Callbell Response was also identified in the
same way our dining experience was identified
as an opportunity for performance improvement
• Through resident surveys and complaint forms
we identified that our residents were dissatisfied
with the wait time
• We assembled a second PI team using the
same method as Dining initiative
41
Callbell Response PI Initiative
• Data was gathered through the use of a
callbell response questionnaire created by
our PI team and completed with the
residents
• Once data was gathered and evaluated,
the root causes for long callbell wait times
were identified by the PI team
42
Callbell Response PI Initiative
 Identified Root Causes of problem
1. Perceived lack of staff
2. CNA’s are busy assisting other residents
3. Staff turns callbell lights off telling patients they will be
right back and never return
4. Lack of oversight by nurses
5. High callbell volume during particular times of the day
(AM, Shift change, etc.)
6. Staff takes extended breaks too often
43
Callbell Response PI Initiative
 Action Plans developed from gathered data
1. Inservice nursing staff on all shifts on
approaches for improving callbell response
2. Reinforce resident’s routine and customary
preferences for care by developing a schedule if
possible to anticipate resident’s needs
3. Inservice ALL staff on their mandatory
participation in answering callbells, especially
during AM care
44
Callbell Response PI Initiative

Action Plans continued
4.
We created a callbell checklist for staff when answering call lights:
does the resident have water pitcher, phone, callbell, tissues, tv
remote in reach before staff exists room?
5.
Asking “is there anything else I can do for you?” before you leave
the room
6.
Continued customer service training. A staff member’s
positive/negative attitude can impact a resident who has been
waiting for care
7.
Maintain the highest staffing levels possible
45
Callbell Response PI Initiative
 Checking stage
•
This stage requires ongoing monitoring of
action plans to determine if they are successful
• Evaluate outcomes through the use of resident
satisfaction surveys and feedback
 Acting Stage
• We have continued to monitor our outcomes
and refine and expand upon solutions. We will
repeat this cycle to sustain results
46
The Power of an Engaged and
Empowered Workforce
“No company, small or large, can win
over the long run without energized
employees who believe in the
company’s mission and understand how
to achieve it.” Jack Welch, retired CEO of General Electric
47
The Power of an Engaged and
Empowered Workforce
 Building a Team of Engaged Employees starts with
leaders clearly stating expectations and responsibilities of
work along with purposes and function of work.
1. Recruitment phase – Purpose of work must be
communicated from the beginning of the recruitment
phase. This ensures the employee understands the
ultimate purpose and mission of the organization which
should help to attract potential employees to feel like they
have found a “home” and they are aligned with the vision
of the organization.
48
The Power of an Engaged and
Empowered Workforce
• The Hiring Phase – During this phase
leaders should carefully select employees.
Not just hire “a warm body” to do the job.
• The Orientation Phase – During the
orientation process employers should “set
the bar high” and offer the employee a
significant emotional opportunity to
become invested in the mission of the
organization.
49
The Power of an Engaged and
Empowered Workforce
• The Orientation Process – Employers should
talk about the culture of the organization, the
strategic objectives and why they are important
and relevant to the facilities mission statement.
Employers must identify those employee’s who
have potential to foster the growth of their
organizational culture.
• As leaders identify these employees they should
invest in them and involve them in quality
improvement endeavors.
50
The Power of an Engaged and
Empowered Workforce
• Ongoing Departmental Training – During these regular
opportunities to engage with employees, leaders should
reiterate expectations and responsibilities and relay
“excellence is expected everyday”.
Employers should use these opportunities to reinforce
and recognize employees who are engaged. Employers
must be sure their employees clearly understand that
their efforts will be encouraged, good work will be
rewarded, and their opinions and ideas matter.
• THE QUICKEST WAY TO DEMOTIVATE YOUR
ENGAGED EMPLOYEE IS FOR THEM TO SEE THEIR
LEADERS TOLERATE MEDIOCRACY OR POOR
PERFORMANCES!
51
The Power of an Engaged and
Empowered Workforce
•
Keeping Your Workforce Engaged and Empowering Them
•
Involve them! Solicit their input and opinions on major issues within
the organization.
•
According to MyInnerView (MIV), “employees need to know where the
bus is going”. MIV conducted a “2009 National Survey of Consumer
and Workforce Satisfaction in Nursing Facilities”. The results identified
consistent negative themes in their comments, foremost being that
employees felt that managers did not listen or pay attention to staff
issues. This included listening to employee concerns and a caring
attitude among supervisors. Supervisors must ensure their employees
feel like a part of the organization and that their co-workers are
committed to doing a good job too.
52
The Power of an Engaged and
Empowered Workforce
• “Employee engagement is achieved one
employee at a time; it is a marathon and
not a sprint. It starts with senior
management’s commitment and trickles
through every management layer of the
organization until every employee has a
clear line of sight about what matters most
and what they can do to make a difference
every time they walk through the door”.
(MIV Supplement, Oct. 2010)
53
The Power of an Engaged and
Empowered Workforce
“My InnerView’s “2009 National Survey of
Consumers and Workforce in Nursing
Facilities” shows that nursing facilities that
score higher on employee satisfaction also
score higher on family satisfaction. Nursing
Facilities that score higher on family
satisfaction also score higher on resident
satisfaction.” (MIV Supplement, Oct. 2010)
54
The Power of an Engaged and
Empowered Workforce
The true power of an engaged and empowered
workforce as a catalyst for change is astounding.
If your workforce is engaged and empowered
within your organization and satisfied with their job
they become the driving force behind providing
excellent patient care.
Without engaged employees, change will be met
with resistance and performance will suffer.
55
Contact Information
•
Steve Izzo, LNHA,MPH Administrator stevei@inglemoor.com
•
Karen Gentile, DON, RN Assistant Administrator don@inglemoor.com
•
Meredith Weil, LSW, Director of Social Service meredithr@inglemoor.com
•
Tisha Stellato, Director of Admissions tishaj@inglemoor.com
56