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Indiana Healthcare Leadership Conference: Improving Nutrition
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Review of Quality of Care Initiatives
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Nursing HomeQuality Status: 2007
High number of immediate jeopardy violations (5th highest)
High number of deficiencies per standard survey (7.6 compared with national average of 6.9)
Above average number of deficiency free surveys (11.7% compared with national rate of 8.3%)
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Quality Improvement Efforts: Studies
Medical error reporting system (2005)
Staffing study (2009)
Bladder scanner study (2009)
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Quality Improvement Efforts: Education Programs
Alzheimer’s and dementia care training programs (2005)
Leadership Conference (2007)
Consultant program (2004)
Healthcare Quality Resource Center (2009)
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Quality Improvement Efforts: Communications
ISDH LTC Newsletter (2008)
Monthly meetings of provider associations and ISDH (2008)
Regular meetings with consumer organizations to discuss quality of care concerns (2005)
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Quality Improvement Efforts: Survey Process
Implemented MDS 3.0 (2010)
Implemented CMS Special Focus Facility Program (2008)
CMS and ISDH consistency workgroups (2008)
Review of immediate jeopardy surveys with provider associations (2008)
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Quality Improvement Efforts: Collaborative Initiatives
Indiana Pressure Ulcer Initiative (2008 – 2010)
Indiana Healthcare Associated Infection Initiative (2009 – 2011)
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Quality Improvement Efforts: Regional Projects
Health Care Excel (QIO) statewide support of CMS GPRA goals (2004)
Health Care Excel pilot of CMS care coordination project in Evansville (2009)
CMS Critical Need Nursing Home Project Pilot in northwest Indiana (2010) coordinated by Health Care Excel
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Quality Improvement Efforts: New in 2011
Community Foundation of St. Joseph County Regional Nursing Home Collaborative (2011)
ISDH Survey Report System (2011)
ISDH Posting of Surveys (2011)
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OUTCOMES TO QUALITY IMPROVEMENT EFFORTS
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Indiana Pressure Ulcer Initiative
CMS GPRA Initiative – 2005 – 2007
Indiana Healthcare Leadership Conference on Preventing Pressure Ulcers – October 2008
Indiana Pressure Ulcer Initiative – August 2008 – November 2010
Quality Improvement Organization ongoing projects with providers
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Indiana Pressure Ulcer Initiative: Outcomes
Source: CMS GPRA data from PDQ
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Indiana Restraint Reduction Initiative
CMS GPRA Initiative: 2005 –2007
Indiana Healthcare Leadership Conference on Restraints and Behavior Management: March 2008
Quality Improvement Organization ongoing projects with providers
Focus by provider associations
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Indiana Restraint Reduction Initiative: Outcomes
Source: CMS GPRA data from PDQ
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Indiana Healthcare Associated Infection Initiative
Overview– Collaborative initiative – Two-year initiative from Sept 2009 – Dec 2011– 130 participating facilities (80 nursing homes)
Priorities – Catheter associated urinary tract infections
(CAUTI) – Clostridium difficile (CDI)
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Indiana Nursing Homes: Deficiency Free Surveys
2006: 33 facilities - 7.0% 2007: 47 facilities - 9.6% 2008: 55 facilities - 11.0% 2009: 56 facilities – 10.7% 2010: 51 facilities - 10.3%
Source: ISDH QAMIS
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Outcomes: Average Number of Deficiencies per Standard Survey
Indiana National Region V (fewest is 1st)
Fed FY 2007 7.6 6.9 4th Fed FY 2008 8.0 6.9 5th Fed FY 2009 7.2 6.8 4th Fed FY 2010 7.1 6.3 4th
Source: CMS data from CASPER 11/8/2010
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Outcomes: Percent of LTC with a “J” or Higher on Standard Surveys
Indiana National Region V (lowest is 1st)
Fed FY 2007 5.0 2.1 4th Fed FY 2008 4.6 2.9 5th Fed FY 2009 1.8 2.7 2nd Fed FY 2010 2.9 2.5 2nd
Source: CMS data from CASPER 11/8/2010
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Outcomes: Number of Immediate Jeopardy Findings on all LTC Surveys
Indiana Region V (lowest is 1st)
Fed FY 2007 68 5th Fed FY 2008 50 5th Fed FY 2009 35 3rd Fed FY 2010 33 3rd
Source: CMS data from CASPER 11/8/2010
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Outcomes: Average Number of Onsite Survey Hours on Standard Surveys
Indiana National Region V (lowest is 1st)
Fed FY 2010 83.7 105.6 1st
Source: CMS data from CASPER 11/8/2010
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COMING QUALITY IMPROVEMENT PROJECTS
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Coming Initiatives for 2011
Healthcare Associated Infections
Three online learning modules designed for staff and consumers
Consumer brochure
In-service programs
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Coming Initiatives for 2011
Education programs for wound care and infection prevention leading to increased staff certification
Updated aide curriculum
Long Term Care Bed Tracking System
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Coming Initiatives for 2011
Leadership Conference on care coordination and transition
Complete 50% of training for Quality Indicator Survey (QIS) Process
Develop a care coordination and transition initiative for 2012 implementation
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Improving Nutrition
Conference Checklist
Provide an in-service on information and resources provided at today’s conference
Develop a plan for improving nutrition
Identify and implement 3 activities for improving nutrition
