FHCA 2014 Annual Conference & Trade Sho_Mikula_and_Rule.pdf · Jim Mikula, PhD, is a Clinical Neuropsychologist and a nursing home administrator nationally recognized for his pioneering

FHCA 2014 Annual Conference & Trade Show

CE Session #6 – Practical Quality Measures for Assisted Living Tuesday, July 8 – 9:30 to 11:30 a.m.

Crystal K – Assisted Living

Upon completion of this presentation, the learner will be able to:

identify facility based areas of care and services that work for meaningful performance improvement projects;

connect Florida’s ALF Risk Management and Quality Assurance Program regulatory structure with quality improvement initiatives; and

explore current national assisted living quality initiatives and review the features of quality improvement.

Seminar Description: Through a panel of assisted living administrators and nurses, attendees will explore useful and practical quality measures, learn how to make effective, facility-specific measures for quality improvement programs and review current national measures and tools. Florida’s assisted living risk management and quality improvement regulatory structure will also be assessed for its role in performance improvement projects. Presenter Bio(s): Lee Ann Griffin is the Director of Quality & Regulatory Services for Florida Health Care Association. Over a 15-year career, Lee Ann has developed extensive expertise in the rules, laws, and policy interpretations for nursing homes and assisted living facilities. Lee Ann holds a degree in Information Studies, has worked as a CNA, served as an appointee to the Florida Board of Nursing’s CNA Council and, most recently, completed the ALF Administrator’s Core Training. Kim Broom, RN is a Regional Clinical Specialist for Florida Living Options. She received her nursing degree in 1987 from Polk Community College and has worked in nursing administration for the last 18 years. In addition to nursing administration Kim has administrated Hawthorne Inn Assisted Living Facility of Lakeland for 6 years. Rosemary Carbonelli serves as the Administrator of Pines of Sarasota Assisted Living Facility. She received her Masters of Science in Health Services Administration from the University of Evansville and her Bachelor of Science from Quinnipiac University. With over 25 years of experience in long term care, Rosemary is licensed as a Nursing Home Administrator (MA) and is certified as an ALF Administrator. She serves as the ALF VP for FHCA, chairs the FCAL Committee and recently stepped down after 5 years serving as FHCA national affiliate (NCAL) State Leader. In 2011, Rosemary was named FHCA ALF Administrator of the Year. Jim Mikula, PhD, is a Clinical Neuropsychologist and a nursing home administrator nationally recognized for his pioneering efforts in care for traumatic brain

Steven Rule has been working in the Senior Care industry for over 30 years. The past 11 years have been focused in assisted and independent living settings. With increased care need demands in assisted living, he feels that practical Quality Measures are mandatory to move this industry forward. Improved Quality Measures will also ensure residents are able to reside longer in an assisted living facility rather than premature residency into a skilled nursing setting.

Practical Quality Measures for Assisted Living

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2014 FHCA Annual Conference and Tradeshow 1


Panelist Discussion

Tuesday, July 8, 2014Lee Ann Griffin

Panelists: Kim BroomRosemary Carbonelli

Jim MikulaSteven Rule

Features of a Quality Measure

1. Important

2. Sphere of control

3. Measurable

4. System or organizational process

2014 Florida Health Care Association 2


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Good or Bad

ImportantSphere of Control

MeasurableSystem Process

1823 is filled out right the first time


1823s in resident files are filled out completely

Panelist’s Pick



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National Options for QI Activities for ALFs

• NCAL Quality Initiative Recognition Program

• AHCA/NCAL National Quality Award Program

• Quality Assurance and Performance Improvement Program


Why Consider National Options for QI Activities• Recognition based

• Follows a structure

• Promotes goals of national, political interest

• Better opportunity to compare performance with others



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National Option

NCAL Quality Initiative Recognition Program

• 4 Goals • Resident centered

• 4 Tiered levels of accomplishment

• Patient Safety Organization• Cost

• Limited Protection for Submitted Material

• www.ahcancal.org/ncal


National Option

AHCA/NCAL National Quality Award Program

• 3 Application Levels• Bronze

• Silver

• Gold

• Malcolm Baldrige performance criteria

• Organization focused

• www.ahcancal.org/quality_improvement/quality_award



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National Option

Quality Assurance and Performance Improvement Program• Required by CMS for Nursing Homes (not ALFs)

• CMS must provide technical assistance to NHs

• Principles & resources of value for ALFs

• Proactive, not reactive

• www.cms.gov/Medicare/Provider‐Enrollment‐and‐Certification/QAPI/NHQAPI.html


Quality Assurance and Performance Improvement


Plan

DoStudy

ActIndividual or Community Process


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Quality Assurance and Performance Improvement

Storyboarding what the team did

1 or 2 sentences describing whether or

not and how the

change will be

adopted, adapted, or abandoned

Next Steps

1 or 2 sentences describing the result; consider a graph or

some other visual

measure

Results

List the measures

or indicators that were used to monitor

whether or not the change worked

Measures

Briefly describe

the change that was

introduced

Action

1 sentence to describe the goal of the activity

Aim

1 sentence on the problem

Problem


Panelist’s Pick



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Performance Measures of Interest for ALFs

• Falls

• Pain Management

• Pressure Ulcers

• Infection Control

• Medication Management

• Customer Satisfaction

• Hospitalizations

• Elopements

• Depression

• Advanced Care Planning

• End of Life Care

• Employee Turnover


Falls

• Number of falls in the last 30 days

• Number of residents who required admission to the hospital due to a fall within the last 30 days

• Number of residents assessed for fall risk within 4 weeks of admission



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Pain Management

• Number of residents identified reporting their daily pain is not relieved with medication


Pressure Ulcers

• Number of residents with pressure ulcers that were acquired in the assisted living facility

• New ALF regulation re: admission and discharge record will assist in capturing this measure



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Infection Control

• Number of residents:• with in‐house acquired urinary tract infections in the last 30 days

• Receiving a current season influenza vaccine

• Receiving the pneumococcal vaccine


Medication Management

• Number of residents with medication errors (all‐cause) in the last 30 days

• Medication error: any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional or consumer.

• Prescribing

• Order communication, product labeling

• Compounding, dispensing, distribution

• Administration and use

• Prevalence of off‐label use of antipsychotics in residents



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Customer Satisfaction

• The percent of positive resident and/or family member response to customer satisfaction surveys

• Willingness to recommend the community to a friend

• Anonymity

• Consistency


Hospitalizations

• Number of residents discharged from the hospital to the ALF and readmitted to the hospital, unplanned, within 30 days

• Number of overall unplanned hospitalizations in the past 6 months



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Elopements

• Number of documented cases of elopement in the last 30 days


Depression

• Number of current residents that were screened for depression within 30 days of admission



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Advanced Care Planning

• Number of current residents who have written advanced directives on file at the ALF

• New regulation supports this measure

• Number of advanced directives reviewed annually


End‐of‐Life Care

• Number of residents receiving end‐of‐life, or hospice care



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Employee Turnover

• Focus on caregiving staff

• Choose a formula and a timeframe for measuring• # of Staff Separations ÷ # of Staff Employed

• Select a goal, i.e. below 30%


Panelist’s Pick



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Hospital Care – Why the DHHS Focus?

Benefits

• Sophisticated lab tests, X‐rays

• Access to doctors and specialists

• Availability of surgery and other procedures

• Intensive Care Units

Risks

• New or worsening condition

• More time spent in bed (loss of function, muscle weakness)

• Less sleep

• Increased risk for falls, new infections


Reducing Rehospitalization in ALFs

• Population served

• Staff Capabilities

• Facility Capabilities

• Appetite for Risk

• Sensitivity to Change in Condition



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Know Thyself – and Share with Partners

• Successful entry or reentry from the Hospital to the ALF

• ALF Capability Checklist• Your audience: ER Staff, Hospital and Primary Care Physicians, Discharge Planners

• Include licensure type and what that means• Prohibition on conditions requiring 24 hour nursing

• Activities of Daily Living

• Level of Medication Management

• Availability of 3rd party services – transportation, pharmacy

• Areas of special emphasis such as dementia care

• First 72 hours2014 Florida Health Care Association 29


72 Hours after a Discharge

• High risk window requiring special focus• Nutrition• Mobility• Falls Prevention• Sleep Problems• Chronic Pain• Neurologic or Mental Health Changes• Memory or Cognitive Changes

• Coordination of Services• 3rd party services delivered as ordered• Communication

• Physician’s office• Among staff



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Changes in Condition & Rehospitalization

• Recognizing

• Gathering information about what is going on with the resident

• Communicating that information directly to someone

• Work within scope of practice and policy of ALF• When to call 911 and providing assistance to the resident



• Universal data elements always communicated to the Primary Care Physician or Nurse

• Resident’s name• Age• Current medications and recent changes to medications• Allergies• Sex• Vital signs, is possible• Responsible party• Advanced directives• Current diagnosis; some past medical history



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• Activity Change• Agitation or Behavioral• Bleeding• Blood Pressure• Breathing Problems

• Chest Pain• Cough or Cold Symptoms

• Diarrhea or No Bowel Movement

• Eating Changes• Falls• Fever• Pain• Skin Changes• Sleep Problem• Urine Problems

• Walking


Panelist’s Pick



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Risk Management and Quality Assurance Programs in ALFs • Voluntary

• Purpose• Assess

• Resident care practices

• Facility incident reports

• Deficiencies

• Adverse incident reports

• Resident grievances

• Develop plans of action to correct and quickly identify quality differences

• Internal


Protections re: RM & QA Programs in ALFs

• What’s the big deal?

• There is no specific authority for the Agency for Health Care Administration to have access to internal working incident reports and investigation papers not externally reported through AI or ANE

• Keep your external reporting system separate from your internal systems

• Agency cannot release records of a RMQA Committee (s.400.119, F.S.)



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Non‐Clinical Measures

• The Customer’s Voice


QI is Personal – Find the Right ToolQI Tool Pro Con

NCAL QI Recognition Program Nice national recognition through publications and conferences

Expense

Eventually will yield some level of national comparative data in key areas

Uncertain protection of data from external requestors

Lists specific areas of focus Lists specific areas of focus

NCAL Quality Awards Program Important national recognition Expense

Seriously creates change Commitment of time

CMS QAPI Flexible No national recognition

Free No comparative data

A good many resources Not ALF focused

Surveyor recognition

Florida RM & QA Program Voluntary Work papers may be at risk

Lists specific areas of focus Lists specific areas of focus2014 Florida Health Care Association 39


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Entry Point: Quality Improvement

• Based on facility readiness• Some degree of staff stability

• Regulations are consistently and mostly met

• Census is stable

• Leadership is interested and supportive

• Facility Capabilities are well established

2.Preliminary discussion with small group• Brainstorm possible areas of improvement

• Post brainstorming, apply filters to drill down to viable ideas

• Narrowing the field2014 Florida Health Care Association 40

Resources

1. Baldrige Performance Excellence Programhttp://www.nist.gov/baldrige/

2. www.ahcancal.org/ncal

3. www.ahcancal.org/quality_improvement/quality_award

4. AMDA’s Protocols for Change of Condition

5. www.cms.gov/Medicare/Provider‐Enrollment‐and‐Certification/QAPI/NHQAPI.html

6. Section 429.23, Florida Statutes



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ConclusionLee Ann Griffin, [email protected]

Panelists: Kim Broom

Rosemary Carbonelli

Jim Mikula

Steven Rule

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Documents

FHCA 2014 Annual Conference & Trade Sho_Mikula_and_Rule.pdf · Jim Mikula, PhD, is a Clinical Neuropsychologist and a nursing home administrator nationally recognized for his pioneering