advancing excellence in america’s nursing homes mary jane koren, m.d., mph chair, advancing...
TRANSCRIPT
Advancing Excellence in
America’s Nursing Homes
Mary Jane Koren, M.D., MPHChair, Advancing Excellence
Vice President, The Commonwealth Fund
Advancing Excellence: The NH Quality Campaign Overview of the presentation
• Background
• Description of Advancing Excellence:
– Purpose and structure
– Process: how it works
• Accomplishments
– Evidence of impact
– Other achievements
• Building on what works
– Using AE to test new ideas
– Working with CMS: QA/PI and the QIO’s 10th SOW
– Factors associated with why AE has been successful 2
Background
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Industry Characteristics Facility Characteristics•15,800 facilities ( approx. 1.68 million beds) - 1.4 million residents on any given day; - 2.8 million discharges/yr
•>95% of beds are Medicare or Medicaid certified•66% for-profit, 28% not-for-profit, 6% gov’t.•52% are part of a multi-facility group
•110 beds average size•Median occupancy 86% and dropping gradually•Generally, high staff turnover
- CNAs 71% annually- Nurses 48.9%- Administrative staff 35.5%
•Old buildings: average NH is over 30 years old
Context for the NH Quality Campaign
Antecedents to Advancing Excellence
• The Sioux Falls Group formed in 2000
– Share information about each others’ initiatives and strategies;
– Create effective coordination among themselves; and
– Proactively, through their respective organizations, lead important national improvement initiatives
• IHI’s 100,000 Lives Campaign 12/04-6/06
– “Some is not a number, soon is not a time”
– Modeled on a political campaign
– Based on 6 evidence-based practices
– Established and promoted a set of achievable goals for US hospitals
– Generated unprecedented amounts of social pressure for hospitals to participate 5
Description of AE: Purpose and Structure
6
Advancing Excellence is…
• Largest national coalition of NH stakeholders (30 organizations) working together to help NHs improve care
• An opportunity for NHs to demonstrate their commitment to self-improvement (>47% participate) outside regulation
• An independent organization incorporated in 2010, recognized as 501(c)(3)in 2011
• Funded by
– CMS for the web-site and analytic support
– The Commonwealth Fund for program support
– Members for communications and other special needs
http://www.nhqualitycampaign.org
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Nationally: Board of Directors• Sets Goals• Develops
resources• Provides support
Statewide: LANES• Recruit NHs• Coordinate
statewide activities
• Provide support
Facility• Registers for AE• Selects 3 goals
and sets targets• Uses AE’s web-
based tools and resources
AE functions on 3 levels
Board of Directors
Voting Members• Alliance for Quality Nursing
Home Care• Alzheimer’s Association• American Academy of Nursing
-- Expert Panel on Aging • American Association for Long
Term Care Nursing (AALTC)• American Association of
Nurse Assessment Coordinators (AANAC)
• American College of Health Care Administrators (ACHCA)
• American Health Care Association (AHCA)
• American Health Quality Association (AHQA)
• AMDA – Long Term Care• LeadingAge (formerly AAHSA)• National Association of Health
Care Assistants (NAHCA) • National Consumer Voice for
Long Term Care • The Commonwealth Fund • The Evangelical Lutheran Good
Samaritan Society
• Association of Health Facility Survey Agencies (AHFSA)
• Foundation of the National Association of Boards of Examiners of LTC Administrators (NAB)
• Gerontological Advance Practice Nurses Association (GAPNA)
• Hartford Institute for Geriatric Nursing
• National Association of Directors of Nursing Administration in Long Term Care (NADONA/LTC)
• National Association of State Long-Term Care Ombudsman Programs (NASOP)
• National Gerontological Nursing Association (NGNA)
• PHI• Pioneer Network• Service Employees International
Union (SEIU)
Non-voting/Government Members• Administration on Aging• Agency for Healthcare Research
and Quality (AHRQ)• Assistant Secretary for Policy and
Evaluation (ASPE)• Centers for Disease Control and
Prevention (CDC)• Centers for Medicare & Medicaid
Services (CMS) and its contractors, the Quality Improvement Organizations (QIOs) and State Survey Agencies
• Department of Veteran’s Affairs
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3. Restraints
6. Advance Care
Planning
5. Pain
8. Staff Satisfaction
7. ResidentSatisfaction
4. Pressure Ulcers
2.Consistent Assignment
1. StaffTurnover
Advancing Excellence Goals
AE is committed to three audiences:
• NHs: – AE selects meaningful issues aligned with national initiatives
– Provides free, practical, evidence-based resources to support organizational stability and performance improvement
• Direct care staff: – AE’s tools designed so workers can join in on QI efforts– Solicits feedback about how they feel about their job
• Residents and their families: – AE promotes open communication and participation of families
and residents in care planning. – Encourages measurement of “customer” satisfaction as a part of
the home’s QI process
http://www.nhqualitycampaign.org
13
AE goals compared to other initiatives
Local Area Networks of Excellence (LANES)
• Neutral space where stakeholders can come together to build working relationships • Divisive issues (e.g. 5 Star, reimbursement, the survey) are
deliberately set aside or avoided
• Must learn to work together toward a shared goal – better care for the resident
• The aim is create ongoing learning networks or “learning communities” of stakeholders and of NHs
http://www.nhqualitycampaign.org
Key Members of the LANE
• QIO
• Ombudsman
• State Survey Agency
• Nursing Home Association Reps
• Culture Change Coalition Rep
• Others can include consumer advocacy groups, state Medicaid agency, health care professionals (e.g. state AMDA chapters), unions, etc.
http://www.nhqualitycampaign.org
Process: how it works
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Becoming part of the AE Campaign
• Nursing homes register on website
• Choose 3 goals minimum – 1 clinical, 1 organizational plus 1 more (however, may pick all 8)
• Identify benchmarks and set targets
• Use the web-site to access AE’s resources and tools
• Collect and monitor data using PDSA/PI methods
• Enter data on AE website regularly
http://www.nhqualitycampaign.org
Campaign Benefits
• Focuses on things consumers, surveyors and payers are concerned about
• Increased staff stability: less turnover, better retention • Saves money • Improves performance• Builds better relationships among staff and residents/families
• Improves satisfaction (staff/resident/family)• Lets them be part of a learning network, lets them compare
their performance with others • Complements other initiatives
• QA/PI (ACA section 6102)• QIO program initiatives (10th SOW just starting)• Preparation for payment reforms
http://www.nhqualitycampaign.org
Free Campaign Tools
• Evidence-based or field tested
• Downloadable, ready to use
• Standardized formatting, user-friendly Excel worksheets for data collection
• Clear, easy to understand instructions
• Calculations, trend graphs and charting functions built-in
• Compatible materials provided for consumers
http://www.nhqualitycampaign.org
Advancing Excellence Tools
• Staff Turnover Calculator• Consistent Assignment Calculator• Pressure Ulcer Monitoring Tool• Restraint Monitoring Tool• Pain Monitoring Tool• Advance Care Plan Monitoring Tool• Suggest tools to measure Staff Satisfaction and
Resident/Family Satisfaction
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22
23
24
25
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Accomplishments
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Recruitment
•Participating nursing homes in Phase 2:+ 7398 ( 47%)
4726 Charter members 1965 New participants•Participating consumers: 3053•Participating nursing home staff: 1860
- September 1, 2011
www.nhqualitycampaign.org
29
AZMOOKDCNHVTVAKYMAWINEWYWVNMALNVCOORKSMEARRIVI
GASD
0 10 20 30 40 50 60 70 80 90 100
Recruitment % by State
30
PRIL
MTHI
LANYMSIA
NDSCNJNCWACACTFLIDIN
UTTXAKMDTNPAMNMI
OHDE
0 10 20 30 40 50 60 70 80 90 100
Recruitment % by State
2005Q3
2005Q4
2006Q1
2006Q2
2006Q3
2006Q4
2007Q1
2007Q2
2007Q3
2007Q4
2008Q1
2008Q2
2008Q3
2008Q4
2009Q1
2009Q2
2009Q3
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
611,300634,500 647,000 655,700
679,500
380,500354,500
327,500300,500
273,700
519,800543,200
563,800595,500
611,300
Pressure Ulcer Quality Measures
High Risk
Low Risk
Post Acute Care
Nu
mb
er
of
Nu
rsin
g H
om
e R
es
ide
nts
in D
en
om
ina
tor
The Relative and Absolute Number of Residents at High Risk for Developing Pressure Ulcers is
Increasing
Physical Restraints
High Risk Pressure Ulcers
Campaign Progress
•Campaign participants* have improved faster than non-participants in all things measured.
•Campaign participants* improved faster in the goals they selected to work on in every case.
•Campaign participants that set targets improved the most
*In the aggregate…
Progress toward Campaign Goal
High RiskPressure
Ulcers
PhysicalRestraints
CCPain
PAC Pain
0% 20% 40% 60% 80% 100% 120% 140%
Participants SelectingGoal and Setting Target
Participants SelectingGoal
Non-Participants
End of Phase 12009 Quarter 3
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Change and Relative Improvement in National QMs Q3 2006 to Q3 2010
Change and Relative Improvement in National QMs
Q3 2006 to Q3 2010
Restraints Pressure Ulcers Chronic Care Pain
Acute Care Pain0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
18%
37%
12%
58%
Q3 2006 Q3 2010
Advancing LANE Performance
21 Statewide Performance Improvement Projects in 14 States
• Increased use of Consistent Assignment• Decreased Staff Turnover• Decreased Pressure Ulcers• Decreased Physical Restraints• Increased Advance Care Planning• Increased website data entry
www.nhqualitycampaign.org
More than 50% nursing home participation
Accelerating LANE Performance States
Critical Access Nursing Home State
Changing LANEs Project
LANE Participation in Advancing Excellence Fall 2010
Arkansas Restraint Rate2005 Q3 through 2009 Q3
6.2
13.6
4.2
3.3
Res
iden
ts w
ho
Wer
e P
hys
ical
ly R
estr
ain
ed (
%)
3.3
2.6
2010 Q3
Finding new ways to measure quality: a new measure for Consistent Assignment
Consistent Assignment:
• Uses a person-centered frame for the measure by asking, “How many CNAs touched the resident in the course of the month”
• Same CNA takes care of the same resident every time, all of the time
• Optimally? Could be as low as 6 – 8 over the course of a month
www.nhqualitycampaign.org
Promoting research on the impact of this staffing practice:
• Using Consistent Assignment 85% of the time associated with fewer survey deficiencies, 41 % fewer empty beds, and 31% less turnover – recent study by Dr. Nick Castle
• Small study by Dr. Barbara Bowers on consistent assignment – currently in progress
www.nhqualitycampaign.org
Building on what works
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The Critical Access NH Pilot:Can AE LANEs help to reduce disparities in NHs?
• 18 NHs from 4 States (GA, IL, IN, OH)
• NH selection based on quality measures, number of deficiencies, % Medicaid, % minority population, geographical area, media attention, etc.
• Only one nursing home has dropped out.
• One nursing home was added at the request of the State Health Department.
CANH LANE Successes
• LANE members, and the NHs, stayed at the table• NHs were enabled to share experiences with peers• LANEs learned to take responsibility for overcoming impediments e.g.
getting NH corporate offices to pay attention• CMS Region IV very engaged• Possible use of model following the project in at least 2 states
CANH: Facility Successes
– “We used to have 5 or 6 call-outs a night. Now we only have one a week…”
– “We’ve gone back to Nursing 101. Instead of having the nurses call the doctor when a resident has a fever, we have empowered the nurse and allow him or her to try Tylenol, compresses and other nursing care… our hospital admissions have decreased”
– “The dietary staff that used to fight with each other all the time are now working together to help the residents…”
– DON and Administrators are doing MDS resident interviews and realize they have been “missing the boat.”
CANH: Facility Successes
Quality Assurance/Performance Improvement (QA/PI)
• The Affordable Care Act, Section 6102 requries CMS to– Strengthen QA requirements in nursing homes– Provide technical assistance to nursing homes in order to meet
new requirements.
• Law specifies implementation by December 31, 2011
• QA/PI plans must be submitted to HHS Secretary one year later
www.nhqualitycampaign.org
Aims for the 10th SOW:
• C.6 Beneficiary and Family Centered Care
– Patient and Family Engagement Campaign
• C.7 Improving Individual Patient Care
– Reduction of Health-Care Acquired Conditions
• C.8 Integrating Care for Populations and Communities
– Improving Care Transitions Leading to the Reduction of Readmissions
– Using Data to Drive Dramatic Improvement in Communities
Drivers for creating change: Tasks under the 10th SOW
• C.10.1 Supporting and Convening Learning and Action Networks;
• C.10.2 Providing Technical Assistance; and
• C.10.3 Care Reinvention through Innovation Spread 48
QIO 10th SOW
Lessons from IHI Why Learning Networks are Important
• Engages leaders• Shared aims or goals • Welcomes everyone and harnesses energy• Self-conscious – participants are a part of the whole• Non-linear• Devolves control/bottom-up learning• Manages knowledge nimbly • Seeks critical mass – not total coverage• Values asking, not merely sharing
www.nhqualitycampaign.org
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AE is an example of a collective impact initiative
Collective impact initiatives represent ongoing commitments by key stakeholders from different sectors to a common agenda for solving a specific social problem
– Use the LANE, often with major help from the QIOs, as the supporting infrastructure
– Forge new partnerships across interest groups – Build strong working relationships among important players
through continuous, ongoing communication – Concentrate on identifying and then addressing the common
problem – Jointly agree on what success will look like and having a shared
measurement system– Use mutually reinforcing activities to maximize existing resources
