wisconsin center for assisted living pealcomplexes (rcac); and adult family homes (afh). this unique...

PEALPerformance Excellence in Assisted Living

www.whcawical.org/peal-program/

2 0 1 7 GUIDE


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PEAL PARTICIPATION GUIDE August 2016

Wisconsin Center for Assisted LivingWisconsin Health Care Association

Dear WiCAL Member,

Congratulations! Your assisted living facility is now an official member of the Performance Excellence in Assisted Living (PEAL) program.

WHCA/WiCAL is excited for you to join the majority of our assisted living members by participating in this quality improvement program. Our staff thanks you for your time and efforts in the collection and submission process and appreciates your dedication to quality care.

This Peal Participation Guide walks you through the steps of PEAL and provides useful information in order for you to be a successful participant in this program.

Please note there is no additional charge to participate in the PEAL. The only requirement is to be a dues-paying member of the Wisconsin Center for Assisted Living (WiCAL).

In This Packet:

PEAL .............................................. 3

WCCEAL ....................................... 5

WCCEAL Goals ............................. 6

WCCEAL Funding ......................... 6

Member Benefits .......................... 7

WCCEAL Timeline ......................... 8

Data Information ........................... 9

How to Submit Quality Improvement Variables ............... 10

Definitions ................................... 11

How to Submit the Annual Resident Satisfaction Survey ....... 16

Survey Response Rates ............... 18

Form for CBRF’s .......................... 19

Sample Satisfaction Survey ......... 20

WCCEAL Membership Rules ..... 22

Frequently Asked Questions ...... 23

Contact Information .................... 24

PEAL PARTICIPATION GUIDEJANUARY 2017



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What is PEAL?PEAL stands for Performance Excellence in Assisted Living. Exclusively available to WiCAL member facilities, this program provides a solid foundation for performance improvement and operational success.

PEAL is a voluntary program open to all WiCAL members. There is no additional charge to participate in the PEAL program. The only requirement is to be a dues-paying member of WiCAL.

Participating facilities will receive training and educational tools in recognized performance excellence and quality improvement processes. Specifically, the PEAL program is based on the Baldrige Healthcare Criteria for Performance Excellence as the foundational of the program.

This reflects validated management practices against which an organization can measure itself. It is accepted nationally and internationally as the model for performance excellence across business sectors.

PEAL is part of the larger Wisconsin Collaborative Coalition for Excellence in Assisted Living (WCCEAL), a joint collaboration between the Wisconsin Department of Health Services, DHS, the four major provider associations, and the University of Wisconsin Center for Health Systems Research and Analysis (CHSRA). WiCAL members participate in PEAL in order to be a part of WCCEAL. PEAL and WCCEAL operate concurrently and of offer valuable comparison data through participation in WCCEAL.


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Recently, the PEAL website has been refreshed to become more user-friendly. New sections have been created to organize information. Tabs for PEAL and WCCEAL were added to brief members with background summaries on both programs. Participation steps and instructions were also outlined in a grid on the main page with relevant handouts attached. In the “PEAL Tools” tab, participants can access handouts, templates, and examples exclusive to WiCAL PEAL members. Additional tools and resources are added regularly to provide excellence in performance management.

Participating facilities will receive training and educational tools in recognized performance excellence and quality improvement processes.

Exciting training and education will focus on the utilization of evidence-based standards of performance management and quality assurance. Previous training modules include how to form and maximize efficiency of a Quality Committee; and how to use Root Cause Analysis to problem solve incidents or concerns in long-term care.

You can review past webinars in full on the PEAL website! www.whcawical.org/peal-program/

Schedule for the WiCAL PEAL Monthly Webinar Trainings.

Webinars will take place via the Adobe Connect software platform from 1:00 pm - 2:00 pm on the following dates:

These webinar topics are not only great for managers, but are also useful for staff within the community!Please stay tuned to CareConnection for the most up-to-date information!

January 12, 2017 PEAL 2017: Your Quality Advancement Roadmap

February 9, 2017 Strategies to Assess and Prevent

Falls in Assisted Living Communities

March 9, 2017 The Importance of Pharmaceutical Reconciliation in Care Transitions

April 5, 2017 – IN PERSON Kalahari Resort in Wisconsin Dells

Developing and Maintaining a Robust Performance Improvement Process

May 11, 2017 Quality Improvement Process: Operationalizing your Quality

Committee

June 8, 2017 Resident Satisfaction Surveys and

Putting Data into Action

July 13, 2017 INTERACT Introduction

August 10, 2017 Effective Outbreak Prevention

and Response

September 14, 2017 Emergency Plan and Procedures for

Assisted Living Facilities

October 12, 2017 Incorporating Resident Preferences in

Menu Planning Options

November 9, 2017 Part 1: PEAL 2017 Retrospective

December 14, 2017 Part 2: PEAL 2018 Prospective


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WCCEALPEAL is part of the larger Wisconsin Collaborative Coalition for Excellence in Assisted Living (WCCEAL) program. Created in 2009, the WCCEAL program is a group of dedicated people organized to improve the outcomes of individuals living in Wisconsin assisted living facilities including Community Based Residential Facilities (CBRF); Residential Care Apartment Complexes (RCAC); and Adult Family Homes (AFH).

This unique public-private collaboration includes:

n Wisconsin’s 4 assisted living provider associations. n The Wisconsin Department of Health Services (DHS) Division of Quality Assurance and Division of Long-Term Care. n Wisconsin state ombudsman’s program. n The Center for Health Systems Research and Analysis (CHSRA).

PEAL and WCCEAL operate concurrently and combine to make up a cohesive quality improvement program. Each assisted living provider association has its own distinct quality improvement program approved by DHS. PEAL is the WiCAL exclusive program.

WiCAL members must participate in PEAL in order to be a part of WCCEAL.

Participating assisted living communities collect and submit quality improvement data through WCCEAL. This valuable data allows individual facilities to measure and compare their performance against themselves and their peers.

Specifically, participating facilities provide limited Quality Variable information on a quarterly basis, as well as complete an annual resident satisfaction survey.

Data submission is limited, yet provides important comparison information as to your performance in the areas of fall prevention, infection control, and the increasingly important readmission rates. As importantly, the annual resident satisfaction survey permits you to gain invaluable information and insight from your residents and their families as to the greatest measure of quality, resident satisfaction. For CBRF providers, this annual survey allows you to use this in compliance with your regulatory expectation to conduct such annual survey.

FOR MORE INFORMATION VISIT THE WCCEAL WEBSITE! wcceal.chsra.wisc.edu/

CONTACT THE WCCEAL HELP DESK [email protected] | Toll-Free: 1.888.300.8098


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WCCEAL Goals n Incentivize Assisted Living Communities to strive for excellence through internal quality improvement. n Collaborate with provider associations to develop a comprehensive QI & QA program and to help their members to be successful. n Collaborate with the CHSRA to improve long- term care and health systems by creating performance measures and developing information and decision support systems. n Provide regulatory relief for high performing Assisted Living Communities. n Define the level of excellence that will be recognized by public funding agencies, insurance companies, Assisted Living Communities, advocates, legislators, general public and other key stakeholders

The WCCEAL program is gaining national attention and is expected to continue to gain significance as

other states look to Wisconsin as an example.

In 2015 WCCEAL was recognized as a Bright Idea

through the Harvard Innovations in Government Program, a program of the Ash Center for Democratic Governance and Innovation at the Kennedy School of Government

at Harvard University.

FundingCHSRA awarded $200,000 to develop and pilot-test WCCEAL from the 2011 ICTR Community Collaboration Grant.

CHSRA awarded $150,000 to investigate falls prevention programs among WCCEAL members, from the 2014 ICTR Dissemination and Implementation Award.

DHS and CHSRA awarded a $1,000,000 grant to scale up the statewide impact of WCCEAL from the 2015 Wisconsin Partnership Program Community Impact Grant.

Music & Memory SM awarded $10,292 to pilot-test the Music and Memory program with iPads in ALCs, from the Park Family Foundation.

NATIONAL ATTENTION

WCCEAL Goals • Incentivize Assisted Living Communities to strive for

excellence through internal quality improvement

• Collaborate with provider associations to develop a comprehensive QI & QA program and to help their members to be successful.

• Collaborate with the CHSRA to improve long-term care and health systems by creating performance measures and developing information and decision support systems.

• Provide regulatory relief for high performing Assisted Living Communities.

• Define the level of excellence that will be recognized by public funding agencies, insurance companies, Assisted Living Communities, advocates, legislators, general public and other key stakeholders.

Funding CHSRA awarded $200,000 to develop and pilot-test WCCEAL from the 2011 ICTR Community Collaboration Grant

CHSRA awarded $150,000 to investigate falls prevention programs among WCCEAL members, from the 2014 ICTR Dissemination and Implementation Award

DHS and CHSRA awarded a $1,000,000 grant to scale up the statewide impact of WCCEAL from the 2015 Wisconsin Partnership Program Community Impact Grant

Music & Memory SM awarded $10,292 to pilot-test the Music and Memory program with iPads in ALCs, from the Park Family Foundation

National Attention

The WCCEAL program is gaining national attention and is expected to continue to gain significance as other states look to Wisconsin as an example.

In 2015 WCCEAL was recognized as a Bright Idea through the Har-vard Innovations in Government Program, a program of the Ash Center for Democratic Govern-ance and Innovation at the Ken-nedy School of Government at Harvard University.


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Member Benefits of PEAL/ WCCEALThe PEAL program is the perfect balance, providing extensive benefits while also being mindful of the limitations on members’ time, and unlike other programs, there is no additional cost for participating.

Tying provider reimbursement to quality measures and improvement continues to grow in popularity, and performance data will play a more critical role in everything from payment policy to care transitions. Being able to both demonstrate commitment to performance improvement and provide meaningful comparison data is becoming even more critical.

Being involved in a Quality Improvement program has many advantages and can help address pertinent issues:

Improve Resident and Family Satisfaction

n Establish Standards of Care. n Reduce Hospital Readmissions. n Identify Areas for Improvement.

Strengthen Staff Commitment

n Staff Retention Strategies n Support your Staff’s Passion to Make a Difference. n Positive Organizational Change. n Access to Cutting-Edge Educational Materials and Training.

Be a Desirable Partner

n Establish value in the minds of potential health care partners such as hospitals, Accountable Care Organizations (ACOs), and Managed Care Organizations (MCOs). n The WCCEAL program is gaining national attention and is expected to continue to gain significance, having received a substantial grant award to further the project from the Wisconsin Partnership Program, designed to support and extend innovative health projects.


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QTR 4 SUBMIT PERIOD

MEMBERSHIP QTR 1 SUBMIT PERIOD



MEMBERSHIP

QUARTER 1 REPORTING PERIOD




JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

QUARTER 1 SAVE PERIOD



QUARTER 3 SAVE PERIODQ

TR 4

RE

PORT

S

QTR

1 R

EPO

RTS

QTR

2 R

EPO

RTS

QTR

3 R

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SUR

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SURVEY RETURN

SUR

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PERIOD ACTIVITY DATES DURATIONSurvey Satisfaction Survey Period January 1 - May 15 4 - 5 months

Survey Return January 1 - April 30 4 months

Survey Generation January 1 - January 31 1 month

Generation Deadline January 31

Postmark Deadline April 30

Final Survey Entry & Review May 1 - May 18 2 weeks

Survey Reports Available May 19

Quarter 1 Reporting Period January 1 - March 31 3 months

Membership Period February 1 - February 14 2 weeks

4th Quarter Reports Available February 1

Save Period February 19 - April 15 2 months

Submission Period April 1 - April 15 2 weeks

Quarter 2 Reporting Period April 1 - June 31 3 months

Membership Period May 1 - May 14 2 weeks

1st Quarter Reports Available May 1

Save Period May 19 - July 15 2 months

Submission Period July 1 - July 15 2 weeks

Quarter 3 Reporting Period July 1 - September 30 3 months

Membership Period August 1 - August 14 2 weeks

1st Quarter Reports Available August 1

Save Period August 19 - October 15 2 months

Submission Period October 1 - October 15 2 weeks

Quarter 4 Reporting Period October 1 - December 31 3 months

Membership Period November 1 - November 14 2 weeks

1st Quarter Reports Available November 1

Save Period November 19 - January 15 2 months

Submission Period January 1 - January 15 2 weeks

WCCEAL Timeline


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Data InformationAn important part of internal quality assurance and improvement is to know data about key aspects of your operations, how this data changes over time and how you compare to other assisted living communities. As part of the WCCEAL initiative each community will collect and report key indicators to a central repository.

These indicators include:

n Demographics including intended, primary and secondary client groups served; occupancy; staff size; RN Access; staff retention. n Quality improvement structure including quality improvement activities; infection control; staff immunization. n Quality improvement process including receiving input; improving satisfaction; and communication. n Quality improvement outcome including falls, infections and hospital readmissions.

As a member of WCCEAL, you are required to submit quality improvement variables on a quarterly basis. The Center for Health Systems Research and Analysis (CHSRA), at UW Madison will process this data. Individual community data will not be shared with the Department of Health Services or with other communities.

The quarterly reporting periods are as followed:

Quarter 1: January 1st to March 31st. Data needs to be submitted from April 1st - April 15th

Quarter 2: April 1st to June 30th. Data needs to be submitted from July 1st - July 15th

Quarter 3: July 1st to September 30th. Data needs to be submitted from October 1st - October 15th

Quarter 4: October 1st to December 31st. Data needs to be submitted from January 1st - January 15th

PLEASE NOTE: Data can be SAVED BEFORE the Submit period for your convenience to allow participants ample time to enter in data. However, you CANNOT SUBMIT until the specified date.

Participants must log in and submit the saved data accordingly.


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How to Submit Quality Improvement VariablesHere are the steps to submit your quality improvement variables:

STEP 1

Go to the WCCEAL website: wcceal.chsra.wisc.edu

n Enter your Username and password (Your password was sent to the contact email that you provided) n Click on, “Quarter 1” (January 1– March 31) under the heading Input Quality Improvement Variables n Read the instructions carefully n You can print the full instruction list ahead of time by clicking the Full Instructions link on the top of the form n Clicking the “+” will expand sections A-D

STEP 2

n Clicking on each variable will give you a detailed definition (also found in the full Instructions) n Sections A-D of the QI variable form can be used throughout the reporting period as a tracking tool and data can be entered and saved for your use at any time. Once all of your information is accurate and up-to-date, you can submit the form during the 2 week submission period simply by clicking the “submit” button (the submit button is only active during the 2 week submission period). n As you prepare for data submission please be mindful of questions which ask for total numbers specific to the last day of the reporting period.

STEP 3

n You can get started on entering this information now and click the “save button”. Under the “Save Button” there will be a date/time indicator showing the last time you entered the data. You can change your data any time prior to the submission date. The system will not allow you to submit the data until the submission period (from April 1 to April 15 for example).

STEP 4

n At the end of the reporting period there will be a number of reports available regarding your community and aggregate data your will be able to compare to.

Thank you for contributing to the WCCEAL mission: Excellence in Wisconsin assisted living through internal quality improvement.


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Information on Quality Improvement VariablesThis form provides a mechanism for entering, saving and submitting your QI Variable information. Sections A-D of the QI variable form can be used throughout the reporting period as a tracking tool and data can be entered and saved for your use at any time. Once all of your information is accurate and up-to-date, you can submit the form during the 2 week submission period simply by clicking the “submit” button (the submit button is only active during the 2 week submission period). As you prepare for data submission please be mindful of questions which ask for total numbers specific to the last day of the reporting period.

*CAUTION: Information cannot be resubmitted after you click the “submit” button. If you have a problem please contact the help desk.

DEFINITIONSSECTION A

1. OCCUPANCY This is the number of current assisted living residents to whom you are providing care and service on the last day of the reporting period. This includes residents who are temporarily out of the ALC, such as residents who are currently in the hospital or with family.

2. PUBLIC PAY SOURCES of public funding for care and serves in assisted living facilities include: Family Care, Partnership, Legacy waivers (COP, COP-W, CIP), IRIS, PACE.

3. INTENDED CLIENT GROUP This is the client group that is typically the group that you serve and that you are marketing to.

n Advanced Age: With functional impairments that commonly accompany advanced age. n Developmentally Disabled: Who have a developmental disability as given in s. 51.01 (5), Stats. n Alcohol/Drug Dependent: Who are alcoholic as given in s. 51.01 (1), Stats., or who are drug dependent as defined in s. 51.01 (8), Stats. n Physically Disabled: With physical disabilities. n Terminally Ill: Diagnosed as terminally ill. n Irreversible Dementia/Alzheimer’s: With irreversible dementia, such as Alzheimer’s disease. n Correctional Clients: Under the legal custody of a government correctional agency or under the legal jurisdiction of a criminal court. n Emotionally Disturbed/Mental Illness: Who are emotionally disturbed or who have a mental illness as given in s. 51.01 (13) (a) n Veterans Administration n Traumatic Brain Injury: With traumatic brain injury. n Pregnant Women/Counselling: Who are pregnant and in need of counseling services.


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4. PRIMARY POPULATION (Same categories as client group)

5. SECONDARY POPULATION This could be blank and your community would only list one primary population.

6. OVERALL STAFF This is the total number of personnel that are in the category “employee” in relation to this ALC. It should be a positive whole number. “Employee” as defined under DHs 83.02 (22) means any person who works for an ALC or for an entity that is affiliated with the ALC or that is under contract to the ALC, who is under direct control of the ALC or corporation affiliated with the ALC and who receives compensation subject to state and federal employee withholding taxes. For example, if this ALC has three employees one of whom is a full time employee (based on a 40 hour work week), one works half time, and one works fifteen hours per week, then enter 3 for this item.

7. DIRECT CAREGIVER STAFF The licensee and all employees who have one or more of the following responsibilities for residents: supervising a resident’s activities or whereabouts, managing or administering a resident’s medications, providing personal care or treatments for a resident, planning or conducting training or activity programming for a resident. Direct caregiver staff does not include volunteers and employees who work exclusively in the food service, maintenance, laundry service, housekeeping, transportation, or security or clerical areas, and employees that do not work on the premises of the assisted living community. For example, if this ALC has three employees one of whom is a full time employee (based on a 40 hour work week), one works half time, and one works fifteen hours per week, then enter 3 for the first part of this item and 1.87 for the second item. The second item, FTE, is calculated by dividing the number of employee hours per week by 40, so 40/40 + 20/40 + 15/40 = 1.87.

8. NETWORK/CORPORATE STAFF Examples might include quality assurance staff, RNs, pharmacists, trainers, and infection control staff.

9. RN ACCESS a) This answer should be “yes” if one of the staff members counted above as “employee” is a registered nurse, or “no” if none of the employees counted above are registered nurses. b) If the answer is “no”, please indicate if the ALC has any kind of access to nursing care from a registered nurse, and briefly explain how.

10. STAFF RETENTION This is the percentage of employees that have worked in your community for more than 1 year. “Employee” means any person who works for a community and who receives compensation subject to state and federal employee withholding taxes. You do not differentiate between part-time and full time employee. You take the number of employees you have today that have been working at your community for at least 1 year and divide by the number of employees who were employed with your community 1 year ago today. Then multiply by 100 for staff retention percent. Example: Today a CBRF has 17 employees who have worked for the CBRF for 1 year or more. One year ago today the CBRF had 62 employees. (17/62)x100 = 27% retention rate.


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SECTION B

1. QI ACTIVITIES The purpose of this section is to describe what structures (organizational, technological, policies and procedures, etc.) the ALC has in place that are dedicated to systematically improving the quality of service and care in the facility. We are interested in defining Quality Improvement (QI) as broadly as possible, at this stage of the project. Activities such as QI Committees, Process Improvement Committees, Quality Improvement staff positions, memberships in QI organizations, participation and/or attendance at QI related conferences and professional meetings, etc. are all of interest to our reporting system. We also are interested in specific QI projects or initiatives in which your community has engaged. We encourage participating communities to describe these activities using whatever terminology your community uses in planning and implementing these initiatives Please be as specific and detailed as possible, explaining what structures your ALC has put in place to improve quality. (200 word limit)

2. INFECTION CONTROL An infection control program based on current standards of practice to prevent the development and transmission of communicable disease and infection. If yes, please describe it in 100 words or less.

3. STAFF IMMUNIZATION Participating communities will report the number of staff immunizations for influenza during the last calendar year (2013).

SECTION C

1. INPUT PROCESS MECHANISMS To receive information from residents and families include any tool or procedure used by communities to receive and document information sent to them by residents or families. This includes information that is solicited by the community or communication initiated by residents or families and sent to the community (such as complaints, suggestions, pertinent information about resident condition, etc.) Examples might include: Completed forms filled out by the resident or family, Phone lines, email addresses, or mailing addresses, Reception or information desk, Resident relations office or department or manager

2. IMPROVING SATISFACTION This refers to any processes the ALC uses to systematically improve resident satisfaction based on resident feedback including surveys, complaints, suggestions, and other, as well as observations from staff and family members. What processes does the facility use to not only obtain and analyze that feedback, but more importantly to address the needs, problems, and opportunities for improvement that it raises.

3. PERSON-DIRECTED CARE Person-Directed Care is an ongoing, interactive process between residents, caregivers and other stakeholders that support an individual’s privacy, choice, dignity, respect, individuality, and independence in directing their daily life.


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4. RESIDENT GROUP INPUT This refers to the residents having the opportunity to be involved in some form of group discussion and feedback mechanism such as a resident council or house meeting.

5. COMMUNICATION In addition to obtaining information from residents and families, the ALC needs to communicate information to residents and families. Please briefly explain all the ways in which the ALC does that.

SECTION D

1. FALLS WITH INJURY FALL: An event which results in a person coming to rest on the ground or other lower level precipitated by a misstep such as a slip, trip, or stumble; or as a consequence of loss of consciousness or complication from a medical condition; loss of grip or balance; from jumping; or from being pushed, bumped, or moved by another person, animal or inanimate object or force.

Fall with injury: A fall with injury is defined here as a fall that results in an injury requiring medical treatment such as

n wound, n fracture, n head injury such as a concussion or hematoma, n serious sprain or ligament damage causing decreased mobility or function, or n other damage to the body.

2. INFECTIONS

a) Norovirus Norovirus gastroenteritis (both criteria 1 and 2 must be present):

1. At least 1 of the following GI subcriteria

a. Diarrhea: 3 or more liquid or watery stools above what is normal for the resident within a 24-hour period

b. Vomiting: 2 or more episodes of vomiting in a 24-hour period

2. A positive stool specimen or diagnosis from a clinician


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b) Influenza Influenza - like illness (both criteria 1 and 2 must be present)

1. Fever

2. At least 3 of the following influenza-like illness subcriteria

a. Chills

b. New headache or eye pain

c. Body aches

d. Sore throat

e. New or increased dry cough

3. HOSPITAL READMISSIONS For the reporting period, this is the number of residents re-hospitalized within 30 days after being discharged from an initial hospital stay. These are re-hospitalizations for any cause, and include re-hospitalizations to the discharging hospital or any other hospital. This would exclude planned re-hospitalizations (where the re-hospitalization was a planned event as part of a plan of care).


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How to Submit the Annual Resident Satisfaction SurveyAs a member of WCCEAL, you are required to conduct at least an annual satisfaction survey of your residents/tenants. The Center for Health Systems Research and Analysis (CHSRA), UW Madison will process the surveys. Individual survey results will not be shared with the Department of Health Services.

An important part of internal quality assurance and improvement is to know your residents/tenants. Resident/tenant satisfaction surveys are very effective modes of communication that can help you determine resident/tenant overall satisfaction and can help you spot trends.

It is very important that all surveys are completed and submitted to CHSRA by April 30, 2017. Following are the steps to complete the resident/tenant satisfaction surveys for your community:

STEP 1

n Go to the WCCEAL website: https://wcceal.chsra.wisc.edu n Enter your Username and password Username: [Username] Password: Sent to [Contact email address] n Click on, “Generate Satisfaction Survey” n Customize the survey cover page form n Click “Save and Generate Survey PDF” n Print the number of “Satisfaction Surveys” based on your current census.

STEP 2

n Give the following items to each of the residents/tenants or legal representative to complete: Satisfaction Survey with Cover Page Self-addressed stamped envelope (included in this mailing based on licensed beds) n Please submit only one satisfaction survey for each resident. n Encourage full participation.

STEP 3

n If the envelope is left open, you may review or make a copy and then seal and mail. n If the envelope is sealed, please mail. n The decision to remain anonymous (sealed envelope) is the resident/tenant decision.


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STEP 4

n Periodically log into the WCCEAL website to view how many satisfaction surveys have been submitted for your community.

n Summary information about your community’s satisfaction results will be available on the WCCEAL website.

n At the end of the reporting period, the following Satisfaction Survey Results will be available: Your community resident/tenant satisfaction results Comparison of your community to aggregate data on all WCCEAL participants Comparison of your community to aggregate data on all participants within your association Comparison of your community to aggregate data on peer group WCCEAL participants


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Survey Response RatesConsumer satisfaction is a critical component of any internal quality assurance and quality improvement system and is one of the cornerstones of the WCCEAL program. In order to remain WCCEAL members you must participate in the WCCEAL satisfaction survey process.

All residents/tenants of your assisted living (AFH, CBRF, RCAC) community must be offered the opportunity to complete the WCCEAL survey on an annual basis.

During this reporting period, all completed WCCEAL satisfaction surveys must be mailed to the Center for Health Research & Analysis (CHSRA) using the self-addressed envelopes provided to you by CHSRA.

We expect a high response rate from each WCCEAL participating community.

HERE ARE SOME IDEAS TO IMPROVE YOUR RESPONSE RATES:

n Kick off this initiative during a family resident/tenant meeting n Put reminders in your monthly bills, newsletters or other communication that you send to resident/tenants and their families n Sell the importance of this to your staff so they can help improve the response rate n Set goals, make it fun, have prizes for meeting your goals n Contact your associations for other ideas

You can view your on-going satisfaction results by logging into the WCCEAL website.

* For CBRF providers, the WCCEAL annual resident satisfaction survey can be used in compliance with your regulatory expectation to conduct such annual survey. Please complete the form on page 19 or online on the WCCEAL website.


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WCCEAL Goals • Incentivize Assisted Living Communities to strive for

excellence through internal quality improvement

• Collaborate with provider associations to develop a comprehensive QI & QA program and to help their members to be successful.

• Collaborate with the CHSRA to improve long-term care and health systems by creating performance measures and developing information and decision support systems.

• Provide regulatory relief for high performing Assisted Living Communities.

• Define the level of excellence that will be recognized by public funding agencies, insurance companies, Assisted Living Communities, advocates, legislators, general public and other key stakeholders.

Funding CHSRA awarded $200,000 to develop and pilot-test WCCEAL from the 2011 ICTR Community Collaboration Grant

CHSRA awarded $150,000 to investigate falls prevention programs among WCCEAL members, from the 2014 ICTR Dissemination and Implementation Award

DHS and CHSRA awarded a $1,000,000 grant to scale up the statewide impact of WCCEAL from the 2015 Wisconsin Partnership Program Community Impact Grant

Music & Memory SM awarded $10,292 to pilot-test the Music and Memory program with iPads in ALCs, from the Park Family Foundation

National Attention

The WCCEAL program is gaining national attention and is expected to continue to gain significance as other states look to Wisconsin as an example.

In 2015 WCCEAL was recognized as a Bright Idea through the Har-vard Innovations in Government Program, a program of the Ash Center for Democratic Govern-ance and Innovation at the Ken-nedy School of Government at Harvard University.

This facility participates in the Wisconsin Coalition for Collaborative Excellence in Assisted Living (WCCEAL).

As a member of the WCCEAL program, the facility has provided the resident and/or legal representative a Department approved Resident Satisfaction Survey (DHS 83.35(4)).

This letter serves as notice that the resident and/or legal representative was provided a Department approved Resident Satisfaction Survey on ______________.

This letter should be placed in the resident’s record to comply with DHS 83.42(i).

00001 (CBRF) - Sample Community 01 Wisconsin Coalition for Collaborative Excellence in Assisted Living

2017 WCCEAL Satisfaction Survey

Your satisfaction with your living experience at Sample Community 01 is important to us.

Please share your opinion with us by filling out the attached survey.

I. For each item, please mark the box that best indicates your opinion. 2. Please detach the completed survey.3. Place it in the attached preposted envelope (no stamps needed).4. If you wish to remain anonymous, please seal the envelope. If remaining anonymous is not important to you, you do not need to seal the envelope.5. Place the envelope in the comment box at the front desk. Survey will not be valid after April 30, 2017.

This satisfaction survey is part of a state wide initiative called the Wisconsin Excellence in Assisted Living (WCCEAL). The goal of WCCEAL is to continuously improve the quality of service provided by participating assisted living provider organizations. WCCEAL is an unprecedented collaboration between:

• Wisconsin Department of Health Services• University of Wisconsin-Madison• Center for Health Systems Research and Analysis (CHSRA)• Board on Aging and Long-Term Care• LeadingAge Wisconsin (formerly WAHSA)• Wisconsin Assisted Living Association (WALA)• Wisconsin Center for Assisted Living (WHCA/WiCAL• Residential Services Association of Wisconsin (RSA WI)

For more information, please visit https://wcceal.chsra.wisc.edu

Thank you for taking a few minutes to let us know how you feel about living here.

SAMPLE

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2017 WCCEAL Satisfaction Survey 00001 (CBRF) - Sample Community 01

A. STAFF1. The staff members are courteous

2. The staff members are available to talk with me

3. The staff members know what I like and dislike

4. I can get help When I need it

B. RIGHTS1. I was informed of my rights

2. The people who work here protect my rights

3. My privacy is respected

4. I am informed of rate and policy changes that might affect me

5. I am treated with dignity and respect

C. ENVIRONMENT1. The residence is homelike and well-maintained

2. I feel safe here

3. My personal belongings are safe here

D. ACTIVITIES1. Activity programs are offered daily that interest me

2. There are opportunities for me to fulfill my spiritual needs

3. I have the opportunity to socialize with others

E. MEALS AND DINING1. I get enough to eat

2. The menus offer a variety of food selections

3. I can participate in meal planning if I want

4. My special diet needs are met

5. The food is to my liking

6. The temperature of the food is to my liking

F. HEALTH MANAGEMENT CARE1. My Family/representative is kept informed about me as I choose

2. My choices of health care providers are respected

3. I get the care and services I need

4. I receive medications on time in a manner acceptable to me

G. OVERALL1. My lifestyle choices are respected

2. I am satisfied with my overall experience here

3. I would recommend this residence and its services to a friend or loved one

H. COMMENTS. How can we improve your living experience?

Survey filled out by o Resident (tenant) alone o Resident assisted by helper o Helper on resident’s behalf

Helper is o Family member o Guardian/POA o Friend o Staff/volunteer

Resident (tenant) has lived here o 0-6 months o 7-12 months o 1-2 yearso Over 2 years

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SAMPLE

00001 (CBRF) - Sample Community 01 21

Status Rules Consequence

Member (Listed)Listed as New member if enrolled for less than 2 quarters.

Satisfy membership conditions. n Full website access. n Regulatory relief if ALC also qualifies for abbreviated survey.Satisfy membership duties

Suspended (Not listed) Fail to satisfy membership duties. n Expected to continue submitting. n Community member users lose access to any reports (present or past).

Deactivated (Not listed) Fail to satisfy membership conditions. n Community member users lose website access for that ALC (previous data available on reactivation).Or suspended for 4 consecutive quarters.

Deactivated (Not listed) Change of ownership or license number. n Community member users may obtain read-only access (with association’s approval if applicable).

Dis-enrolled (Not listed) No longer a member of WCCEAL. n User lose website access for that ALC.

Membership status is determined during the Membership Period at the beginning of each quarter. n Membership conditions are assessed by DQA-BAL and the associations and updated by them on the WCCEAL website. n Membership duties are assessed at the beginning of each quarter by the WCCEAL website.

Type of Criteria Criteria Updated by

Membership conditions Assisted living license. DQA-BAL

Membership in an association. Association

Membership in an association’s QI program. Association

No extreme regulatory action DQA-BAL

Membership duties Submit QI Variables on time quarterly. n At least 3 quarters in any 4 consecutive quarters

Website

Submit Satisfaction Survey on time yearly. n At least 25% response rate, except if enrolled in first quarter of year.

Website

Extreme regulatory action: Two or more statement of deficiencies within a rolling 12 month period that included any violation(s) that meet any of the following. n Enforcement based on the statement of deficiency delivery date. n Results in serious harm, has a potential for serious harm, or indicates a breakdown in facility systems that could lead to serious harm. n Creates a condition or occurrence that presents a substantial probability that death or serious mental or physical harm to a resident will result (or did occur). n Creates a condition or occurrence that presents a direct threat to the health, safety or welfare of a resident. An enforcement order for no-new-admit, impending revocation, or revocation order within a rolling 12 month period.

Extraordinary circumstances: In the case of extraordinary life changing events (e.g., medical crisis) experienced by ALC staff who are responsible for WCCEAL submissions, the ALC’s association may petition the WCEAL advisory group by sending information one week prior to the monthly meeting. At the meeting, the present members of the advisory group may, be majority vote, grant the ALC an exemption from the membership duties for a duration not exceeding two submissions.

Getting back to good standing:

Status Resolution

Suspend due to QI variables membership duties. Continue submitting until have 3 quarters of submissions in last 4 consecutive quarters.

Suspend due to Survey membership duties. Continue submitting QI variables and submit the next year’s Satisfaction Survey with at lease the minimum response rate required for that year.

Deactivated due to DQA-BAL membership conditions Resolve failures to meet DQA-BAL conditions.

Deactivated due to association membership conditions. Resolve failures to meet association conditions.

Deactivated due to suspension for 4 consecutive quarters. Association petitions the WCCEAL advisory group on behalf of ALC.

WCCEAL Membership Rules

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PEAL/WCCEAL Frequently Asked QuestionsWhat is the time commitment associated with participation in PEAL/WCCEAL? WiCAL is very mindful of the limitations on members’ time, and the program is designed to allow members to work at their own pace. Participating facilities must:

n Participate in monthly one hour webinars. n Provide limited Quality Variable information on a quarterly basis. n Participate in the annual resident satisfaction survey.

Is There a Lot of Paperwork Reporting That I Must Provide? The PEAL program will emphasize operational excellence and will not rely upon lengthy and frequent reporting expectations. In addition participants will include limited monitoring in order to evaluate the outcomes of the overall program. The monitoring is critical for the WCCEAL program to demonstrate the benefits of such program.

Will Surveyors Have Access to This Information? DQA staff will not have access to information. The only information shared will be (1) identification of facilities that are participating and are in good standing, and (2) aggregate evaluation data from the UW-Center for Health Systems Research and Analysis (CHSRA), a WCCEAL program partner. WiCAL will receive some information in order for us to be able to assist members that require such assistance.

What Will It Cost? There will be no charge for participation in the PEAL program, although some of the trainings throughout the course of the year may have standard registration fees associated with a program. Every effort will be made, however, to minimize any costs associated with participation in the program.

Will There Be Training Provided? Absolutely! The training will at a minimum include the following:

n Understanding your organizational environment, relationships and situation: Explanation and discussion of the significance and importance of identifying the fundamental components of the facility’s organization, including, the developing a mission and vision statement to guide efforts. n Development of an effective quality improvement system, including the planning and operation of effective and efficient quality committees. n Quality Committee Fundamentals: This training will not simply be a narrative, but also include practical steps that members will want to use and incorporate into their quality improvement committee to achieve effective and efficient results. Training will provide foundational and specific instruction on how to conduct a proper meeting, how to structure a committee appropriately, and other important formalities that will improve efficiencies and outcomes of provider efforts. n Performance Improvement Processes: Following training about the development of quality improvement committees, we will move to training on recognized processes for performance improvement efforts. Specifically this will include tracking and benchmarking of data, identification of opportunities for improvement, root cause analysis, PDSA cycles, and similar recognized processes that further performance improvement.


Wisconsin Center for Assisted LivingWisconsin Health Care Association

ADVOCACY. EDUCATION. EXCELLENCE.

Contact InformationWiCAL staff is more than happy to answer and of your questions and assist you with anything they can!

Brian Purtell, Executive Director at [email protected] Kate Dickson, MPA, Director of Research and Data Analysis at [email protected] Kelsey Mueller, MPA Candidate at [email protected]

PEAL Website: www.whcawical.org/peal-program/

WCCEAL Website: wcceal.chsra.wisc.edu/

Contact the WCCEAL Help Desk:

[email protected]

Toll-Free: 1.888.300.8098

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wisconsin center for assisted living pealcomplexes (rcac); and adult family homes (afh). this unique...

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