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Developing Quality Systems and Personnel
Developing Quality Systems and Personnel
Putting the Pieces Together Putting the Pieces Together
Developing Quality SystemsDeveloping Quality Systems
Objectiveso Identify components of quality
validation review processo Identify how to schedule and make
assignmentso Identify how to review findings
with teamo Identify how to monitor progress
Objectiveso Identify components of quality
validation review processo Identify how to schedule and make
assignmentso Identify how to review findings
with teamo Identify how to monitor progress
Impetus for changeImpetus for change
Average number of deficiencies per standard survey increased
Number of immediate jeopardy citations increased
QIS survey process
Average number of deficiencies per standard survey increased
Number of immediate jeopardy citations increased
QIS survey process
Quality Validation ReviewQuality Validation Review
ProactiveProcess orientedCollaborative Initiated 6 months prior to
anticipated standard surveyFollows 7 survey tasksUses Critical Elements from QIS
survey
ProactiveProcess orientedCollaborative Initiated 6 months prior to
anticipated standard surveyFollows 7 survey tasksUses Critical Elements from QIS
survey
Annual TimelineAnnual Timeline
Standard
Survey
DPNA
90 days 90 days
Quality V
alidatio
n Revie
w
90 days 90 days
Survey T
raini
ng and T
ools
Quality Validation ReviewScheduling and AttendanceQuality Validation Review
Scheduling and Attendance
Scheduling
Six (6) months prior to anticipated standard survey
Twice a year for higher risk centers
Scheduling
Six (6) months prior to anticipated standard survey
Twice a year for higher risk centers
Quality Validation ReviewScheduling and AttendanceQuality Validation Review
Scheduling and Attendance
A QVR (Quality Validation Review) has been scheduled at the ___ facility in Michigan ________. Please confirm your attendance plans by 5pm on ____ by responding to this email This process is designed to bring together resources to help the center achieve positive survey outcomes through active participation in identifying fragile systems. To accomplish this, there are various tasks that the Facility Administrator and ADNS must assign the various team members. The available team members are listed below. Attached is a QVR planning worksheet, please take a moment to print and assign the tasks prior to the start date of the QVR. In addition, you will want to have the following available: 1 – Office space for the QVR 2 – Blank flip charts 3 – Center floor plan 4 - Current census by unit 5 - List of residents with pressure ulcers, stage, admitted/center acquired 6 - List of residents with feeding tubes 7 - List of residents with catheters 8 - List of residents on dialysis 9 - State generated QI/QM report for last 6 months
Team Members Include: Facility - Administrator & Administrative Director of Nursing Facility Managers, Department Heads, All staff __________ - Quality Regulatory Consultant (Team Leader) __________ - Clinical Services Consultant __________ - Clinical Services Consultant Dietician __________ - Social Services Consultant __________ - Case Mix Specialist __________ - Regional Rehab Manager Facility should contact a nearby HCR facility for Human Resource support __________ - Regional Business Office Manager __________ - Divisional Safety Officer __________ - Plant Operations __________ - Housekeeping Operations __________ - Regional Director of Operations
Quality Validation ReviewAssignments
Quality Validation ReviewAssignments
Date Responsible Person Quality Validation Review Audits Comments
Center Level Task Reviews
Demand Billing
Personal Funds
Beauty Shop Audit/Observations
Smoking-Courtyard Audit
Human Resources Audit
Dining Observation
Infection Control
Kitchen/Food Service Observations
Date Responsible Person Quality Validation Review Audits Comments
Center Level Task Reviews
Demand Billing
Personal Funds
Beauty Shop Audit/Observations
Smoking-Courtyard Audit
Human Resources Audit
Dining Observation
Infection Control
Kitchen/Food Service Observations
Quality Validation ReviewProcess
Quality Validation ReviewProcess
Entrance conference Assignment review and completion target Follows 7 survey tasks Uses Critical Elements, QM/QI validation
tools Preliminary exit with administrator, DON Conference with facility and regional or
divisional management team Quality Milestone Action Plan development
Entrance conference Assignment review and completion target Follows 7 survey tasks Uses Critical Elements, QM/QI validation
tools Preliminary exit with administrator, DON Conference with facility and regional or
divisional management team Quality Milestone Action Plan development
Critical ElementCritical Element
QM/QI Validation ToolQM/QI Validation ToolPREVALENCE OF FALLS
CHRONIC CARE MEASURES: ACCIDENTS
Measure Description Numerator Denominator Exclusions Covariates
1.2 - PREVALENCE OF FALLS
Residents who had falls within the past 30 days (J4a is checked on the target assessment).
All residents with a valid target assessment
1. The target assessment is an admission (AA8a = 01) assessment.
2. J4a has missing data on the target assessment
CODING REVIEW
Room Resident Name
MDS A3A Date
(30 day look back)
MDS Coded (J4a is
checked)
Comments/Review (Fall is validated in 30 day look back period)
MDS Coded correctly (Consider exclusions and covariates)
(Y/N)
1.
2.
3.
4.
5.
6.
7.
PROCEED TO PROCESS REVIEW USING THE SAME RESIDENTS PROCESS REVIEW
Res. Number
Fall risk Identified (NAE, Off Cycle RAP, change in status, etc.)
(Y/N)
Investigation with Root Cause
Identified (Y/N)
Therapy Screen/
Eval (Y/N – N/A)
Observation (Interventions
in Place) (Y/N)
I/A Reports Trended
(Y/N)
RAP Complete (Y/N – NA)
Care Plan (Y/N)
Patient Information Worksheet
(Y/N)
Practice Guide
Followed (Y/N)
1 2 3 4 5 6 7
Summary of findingsSummary of findings
Grouping of like findings by F tagTeam conference
Agreement on:Citation or concernF tagScope and severityResponsibility for POC &
QMAPCalculation of SFF points
Grouping of like findings by F tagTeam conference
Agreement on:Citation or concernF tagScope and severityResponsibility for POC &
QMAPCalculation of SFF points
Plan of Correction DevelopmentPlan of Correction DevelopmentPlan of Correction
Facility Name: Region:
Facility #:Survey
Education Date:
SFF Score: 0
Tag ID / Scope
SeveritySFF
Points
Related Citations (Tag ID / Scope
Severity)SFF
Points Summary Statement of Deficiency
TARGET RESIDENTS What corrective action(s) will be accomplished for those residents found to have been affected by the
deficient practice
LIKE RESIDENTS How will you identify other residents having the potential to be affected by the same deficient practice and what
corrective action will be taken.
EDUCATION - PROCEDURE REVIEW
What measures will be put in place or what systematic changes will you make to ensure that the deficient
practice does not recur.
AUDITS How will the corrective action(s) will be monitored to ensure the deficient
practice will not recur (i.e., what quality assurance program will be put
into place).Process Owner
Target Date
CONFIDENTIAL: This document has been prepared for review and evaluation by the Quality and Assurance Committee and is entitled to the protection of the peer review, medical review, quality assurance privileges provided for by state and federal laws. It is not to be copied or distributed without express, written consent of the legal department
Plan of CorrectionFacility Name: Region:
Facility #:Survey
Education Date:
SFF Score: 0
Tag ID / Scope
SeveritySFF
Points
Related Citations (Tag ID / Scope
Severity)SFF
Points Summary Statement of Deficiency
TARGET RESIDENTS What corrective action(s) will be accomplished for those residents found to have been affected by the
deficient practice
LIKE RESIDENTS How will you identify other residents having the potential to be affected by the same deficient practice and what
corrective action will be taken.
EDUCATION - PROCEDURE REVIEW
What measures will be put in place or what systematic changes will you make to ensure that the deficient
practice does not recur.
AUDITS How will the corrective action(s) will be monitored to ensure the deficient
practice will not recur (i.e., what quality assurance program will be put
into place).Process Owner
Target Date
CONFIDENTIAL: This document has been prepared for review and evaluation by the Quality and Assurance Committee and is entitled to the protection of the peer review, medical review, quality assurance privileges provided for by state and federal laws. It is not to be copied or distributed without express, written consent of the legal department
Quality Milestone Action PlanQuality Milestone Action Plan
QUALITY MILESTONE ACTION PLAN: PRIVILEGED WORK DOCUMENT Location: Date: Completed By: Directions: Initiate plan when an opportunity for quality improvement is identified. Complete root cause analysis based upon data reviewed, se t target threshold and determine plan of action steps. Document progress towards goals, issue resolution or follow-up needed periodically and when desired outcome is obtained. The following symbols may be used for target dates: ▲ targeted completion date, + completed on targeted date, → completed after target date, targeted date extended.
Tasks/Approaches/Monitoring Responsible Person(s)
Confidential: This document has been prepared by, or at the direction of, the Quality Assessment and Assurance Committee for its review and evaluation. It is entitled to the protection of the peer review, medical review, quality assurance, or other similar privileges provided by state and federal law. This document is not to be disclosed, copied or distributed without prior consultation with the legal department.
Monitoring Monitoring
Responsibility of facility to assure completion of plan of correction
Regional consultant follow-up and assistance with education and audits
Re-validation 90 days later (STAT)
Responsibility of facility to assure completion of plan of correction
Regional consultant follow-up and assistance with education and audits
Re-validation 90 days later (STAT)
Survey Training and ToolsSurvey Training and Tools
Re-validation of plan of correction from Quality Validation Review
“Clear” previous citationsIdentify new citations
Preparation of survey expandable file
Education of staff regarding survey process
Re-validation of plan of correction from Quality Validation Review
“Clear” previous citationsIdentify new citations
Preparation of survey expandable file
Education of staff regarding survey process
QVR to STAT to SurveyQVR to STAT to Survey
QVR STAT SURVEY QVR STAT SURVEY
2007 Average SFF points 181 92 51
2007 RangeSFF points 28 – 386 18 – 312 0 - 74
2008 AverageSFF points 153 53.6 23.04
2008 RangeSFF points 19 – 419 14 – 208 0 - 94
Facility PerspectivesFacility Perspectives
Views from a facility team:
Administrator – Matthew Baad
Director of Nursing – Fran Brown
Views from a facility team:
Administrator – Matthew Baad
Director of Nursing – Fran Brown
Developing Quality PersonnelDeveloping Quality Personnel
Objectiveso Identify components of the
licensed nurse orientation program
o Identify the process steps needed for implementation
o Identify components of the preceptor training program
Objectiveso Identify components of the
licensed nurse orientation program
o Identify the process steps needed for implementation
o Identify components of the preceptor training program
Before…Before…
Turnover Rates 2007
o Licensed Nurses = 51%!!!
Turnover Rates 2007
o Licensed Nurses = 51%!!!
YIKES
Getting Ready for ChangeGetting Ready for Change
Infrastructureo Human Resources
o Regional Nurse Educators
o Preceptors
Infrastructureo Human Resources
o Regional Nurse Educators
o Preceptors
Human ResourcesHuman Resources
Considerations:o Role definitiono Education calendaro General orientation scheduleo Mastering Caring Leadershipo Turnover and retention tracking
system
Considerations:o Role definitiono Education calendaro General orientation scheduleo Mastering Caring Leadershipo Turnover and retention tracking
system
Regional Nurse EducatorsRegional Nurse Educators
Considerations:o Site selection
o Clinical skills labso Classroom settings
o Equipment and Supplieso Skills validation process
Considerations:o Site selection
o Clinical skills labso Classroom settings
o Equipment and Supplieso Skills validation process
PreceptorsPreceptors
Considerations:o Compensation modelo Training siteso Selection processo Trainingo Follow-up
Considerations:o Compensation modelo Training siteso Selection processo Trainingo Follow-up
Putting it all TogetherPutting it all Together
Day Task Location
1 General Orientation Facility of hire
2 Mastering Caring Leadership Regional training center
3 Disease Management & Physical Exam Series
Regional training center
4-5 Clinical Skills Validation Regional training center
6 Preceptorship – Classroom Facility of hire
7-10 Preceptorship – On-the-unit Facility of hire
…After…After
Turnover Rates
o Licensed Nurses = 15%!!!
Turnover Rates
o Licensed Nurses = 15%!!!
yippee
Facility PerspectivesFacility Perspectives
Views from a facility team:
Director of Nursing – Henrietta Makowski
Regional Nurse Educator –Rose Zlotecki
Views from a facility team:
Director of Nursing – Henrietta Makowski
Regional Nurse Educator –Rose Zlotecki
Thank You!Thank You!
Questions Questions
