Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
Long-Term Care Homes Quality Inspection Program (LQIP)
~ Up-date ~
South West LHIN Long-Term Care Homes Network Forum May 30, 2013
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
Overview
• Top Ten Non-Compliances • Quality Improvement
Activities • Risk and Priority Assessment
Framework
2 Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
Inspection Data
3 Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
Provincial Inspections July 1, 2010 – April 30, 2013
Inspection Type
# Inspections
(July 1, 2010 – April
30, 2013)
# Inspections
(July 1, 2010 –
April 30, 2013)
Provincial SW LHIN
Complaint Inspection
3109 444
Critical Incident Inspections
1894 365
Follow-up 703 94
Other * 538 46
RQI 112 18
TOTAL 6356
967
* Other inspections include: SAO-Initiated inspections, Post-occupancy, Special Inspection, etc
# Inspections since July 1, 2010
CIS30%
Follow -up11%
Other8%
RQI2%
Complaint49%
Complaint
CIS
Follow -up
Other
RQI
4 Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
5
Provincial Non-Compliances July 1, 2010 – April 30, 2013
Non-compliance # % of non-compliances
Written Notification (with no other action)
5,558 47%
Voluntary Plan of Correction (VPC)
4,896 42%
Compliance Orders (CO) 1,332 11%
Total * 11,786
Referral to the Director (DR) 8
*Total does not include Written Notifications associated with a VPC, CO or DR.
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
6
SW LHIN Non-Compliances July 1, 2010 – April 30, 2013
Non-compliance # % of non-compliances
Written Notification (with no other action)
471 38%
Voluntary Plan of Correction (VPC)
633 50%
Compliance Orders (CO) 148 12%
Total * 1252
Referral to the Director (DR) 1
*Total does not include Written Notifications associated with a VPC, CO or DR.
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
7
Most Common Areas of Non-Compliance
Complaint Inspections
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
8
Main Themes Top 10 Most Frequently Cited Non-Compliances
Complaint Inspections Provincially
July 1, 2010 – April 30, 2013 1. Plan of Care (4 of 10 most frequently cited)
2. Policies (2 of 10 most frequently cited)
3. Residents’ Bill of Rights
4. Nursing and Personal Support Services
5. Administration of Drugs
6. Reporting certain matters to Director
7. Complaints Procedure
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
9
Top 10 Most Frequently Cited Non-Compliances Complaint Inspections Provincially
July 1, 2010 – April 30, 2013
Rank Non-Compliance Description # of unique LTCHs
# of times issued
(% of all complaint
inspections [3324])
1 LTCHA s. 6 (1) Plan of Care ~ sets out the planned care, goals and provides clear direction
166 236 (7.1%)
2 LTCHA s. 6(7) Plan of Care ~ The licensee shall ensure that the care set out in the plan of care is provided to the resident as specified in the plan
172 232 (7.0%)
3 LTCHA s. 3 (1) Residents’ Bill of Rights 131 180 (5.4%)
4 O. Reg. 79/10 s. 8 (1)(a)
Policies ~ in compliance with the LTCHA 127 169 (5.1%)
5 LTCHA s. 6(1)(c) Plan of Care ~ clear directions to staff and others who provide care
98 132 (4.0%)
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
10
Top 10 Most Frequently Cited Non-Compliances Complaint Inspections Provincially July 1, 2010 – April 30, 2013
Rank Non-Compliance Description # of unique LTCHs
# of times issued
(% of all complaint
inspections [3324])
6 O. Reg. 79/10 s. 8 (1)(b)
Policies ~ home to comply with own policies 72 96 (2.9%)
7 O. Reg. 79/10 s. 131(2)
Administration of Drugs ~ in accordance with direction of prescriber
67 76 (2.3%)
8 O. Reg. 79/10 s. 33 (1)
Nursing and Personal Support Services ~ requirements for 2 baths per week
62 73 (2.2%)
9 LTCHA s. 6(10)
Plan of Care ~ reassessment and revision
66 72 (2.2%)
10 O. Reg. 79/10 s. 101 (1)
Complaints procedure ~ requirements for dealing with written or verbal complaints
61 71 (2.1%)
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
11
Most Common Areas of Non-Compliance
Critical Incident Inspections
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
12
Main Themes Top 10 Most Frequently Cited Non-Compliances
Critical Incident Inspections Provincially
July 1, 2010 – April 30, 2013
1. Plan of Care (3 of 10 most frequently cited)
2. Prevention of Abuse and Neglect (2 of 10 most frequently cited)
3. Reporting and Complaints (2 of 10 most frequently cited)
4. Policies
5. Residents’ Bill of Rights
6. Nursing and Personal Support Services
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
13
Top 10 Most Frequently Cited Non-Compliances Critical Incident Inspections Provincially
July 1, 2010 – April 30, 2013
Rank Non-Compliance Description # of unique LTCHs
# of times issued
(% of all CI inspections
[2016])
1 LTCHA s. 6(7) Plan of Care ~ care set out in the plan of care is provided to the resident as specified in the plan
152 197 (9.8%)
2 LTCHA s. 19(1) Duty to Protect 125 159 (7.9%)
3 LTCHA s. 24(1) Reporting Certain Matters to Director 127 157 (7.8%)
4 LTCHA s. 3 (1) Residents’ Bill of Rights 117 149 (7.4%)
5 LTCHA s. 6 (1) Plan of Care ~ sets out the planned care, goals and provides clear direction
95 123 (6.1%)
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
14
Top 10 Most Frequently Cited Non-Compliances Critical Incident Inspections Provincially July 1, 2010 – December 31, 2012
Rank Non-Compliance Description # of unique LTCHs
# of times issued
(% of all CI inspections
[2016])
6 O. Reg. 79/10 s. 36
Transferring and Positioning Techniques 94 105 (5.2%)
7 O. Reg. 79/10 s. 8 (1)(a)
Policies ~ in compliance with the LTCHA 78 87 (4.3%)
8 LTCHA s. 6(1)(c) Plan of Care ~ clear directions to staff and others who provide care
52 65 (3.2%)
9 LTCHA s. 20(1) Policy to Promote Zero Tolerance 56 63 (3.1%)
10 LTCHA s. 23(2) Reporting and Complaints ~ reporting investigation results of mandatory reports to Director
51 57 (2.8%)
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
15
Most Common Areas of Non-Compliance
All Inspections
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
16
Main Themes Top 10 Most Frequently Cited Non-Compliances
All Inspections Provincially July 1, 2010 – April 30, 2013
1. Plan of Care (3 of 10 most frequently cited)
2. Policies to be followed (2 of 10 most frequently cited)
3. Residents’ Bill of Rights
4. Reporting certain matters to Director
5. Duty to Protect
6. Transferring and positioning techniques
7. Accommodation Services
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
17
Top 10 Most Frequently Cited Non-Compliances All Inspections Provincially
July 1, 2010 – April 30, 2013
Rank Non-Compliance Description # of unique LTCHs
# of times issued
1 LTCHA s.6 (7) Plan of Care ~ The licensee shall ensure that the care set out in the plan of care is provided to the resident as specified in the plan
313 535
2 LTCHA s. 6 (1) Plan of Care ~ sets out the planned care, goals and provides clear direction
266 462
3 LTCHA s. 3 (1) Residents’ Bill of Rights 240 407
4 O. Reg. 79/10 s. 8 (1)(a)
Policies ~ in compliance with the LTCHA 238 356
5 LTCHA s.6 (1)(c) Plan of Care ~ clear directions to staff and others who provide care
165 261
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
18
Top 10 Most Frequently Cited Non-Compliances All Inspections Provincially
July 1, 2010 – April 30, 2013
Rank Non-Compliance Description # of unique LTCHs
# of times issued
6 LTCHA s. 24 (1)
Reporting certain matters to Director
186 250
7 LTCHA s. 19 (1)
Duty to protect ~ every licensee of a long-term care home shall protect residents from abuse by anyone and shall ensure that residents are not neglected by the licensee or staff
169 232
8 O. Reg. 79/10 s. 8 (1)(b)
Policies ~ home to comply with own policies 134 190
9 O. Reg. 79/10 s. 36
Transferring and positioning techniques 154 189
10 LTCHA s. 15(2)
Accommodation Services ~ cleanliness and repairs
135 165
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
19
Top 10 Most Frequently Cited Non-Compliances All Inspections SW LHIN only
July 1, 2010 – April 30, 2013
Rank Non-Compliance Description # of unique LTCHs
# of times issued
1 O. Reg. 79/10 s. 8 (1)(b)
Policies ~ home to comply with own policies
33 55
2 LTCHA s. 6 (1) (c) Plan of Care ~ clear directions to staff and others who provide care
29 47
3 LTCHA s.6 (7)
Plan of Care ~ The licensee shall ensure that the care set out in the plan of care is provided to the resident as specified in the plan
27 39
4 O. Reg. 79/10 s. 8 (1)(a)
Policies ~ in compliance with the LTCHA 24 33
5 O. Reg. 79/10 s.49 (2)
Falls prevention and management ~ assessment
17 22
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
20
Top 10 Most Frequently Cited Non-Compliances All Inspections SW LHIN only
July 1, 2010 – April 30, 2013
Rank Non-Compliance Description # of unique LTCHs
# of times issued
6 LTCHA s. 8 (3)
Nursing and Personal Support services ~ 24/7 RN
15 21
7 LTCHA s. 24 (1) 2
Reporting certain matters to Director ~ abuse 20 20
8 O. Reg. 79/10 s. 91
Hazardous substances ~ labelled and inaccessible
15 20
9 LTCHA s. 19 (1)
Duty to protect ~ every licensee of a long-term care home shall protect residents from abuse by anyone and shall ensure that residents are not neglected by the licensee or staff
16 19
10 O. Reg. 79/10 s. 33 (1)
Bathing ~ minimum 2x/week and choice 13 18
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
21
Most Common Areas of Non-Compliance
Resident Quality Inspections / RQIs
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
22
Main Themes Top 10 Most Frequently Cited Non-Compliance
RQI’s Provincially July 1, 2010 – April 30, 2013
1. Policies in compliance with LTCHA
2. Plan of Care
3. Residents’ Bill of Rights
4. Satisfaction Surveys
5. Accommodation Services
6. Safe Storage of Drugs
7. Dining and Snack Service
8. Information for Residents
9. Safe and Secure Home
10. Infection Prevention and Control Program
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
23
Top 10 Most Frequently Cited Non-Compliances RQIs Provincially
July 1, 2010 – April 30, 2013
Rank Non-Compliance Description # of unique LTCHs
# of times issued
(% of all RQIs [127])
1 O. Reg. 79/10 s. 8 (1)(a)
Policies ~ in compliance with the LTCHA 67 67 (53%)
2 LTCHA s. 6 (1) Plan of Care ~ sets out the planned care, goals and provides clear direction
62 62 (49%)
3 LTCHA s. 3 (1) Residents’ Bill of Rights
58 58 (46%)
4 LTCHA s. 85(3)
Satisfaction Survey ~ seeking advice of RC & FC in developing & carrying out Survey and acting on results
53 53 (42%)
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
24
Top 10 Most Frequently Cited Non-Compliances RQIs Provincially
July 1, 2010 – April 30, 2013
Rank Non-Compliance Description # of unique LTCHs
# of times issued
(% of all RQIs [127])
5 LTCHA s. 15(2) Accommodation Services ~ specific duties re: cleanliness and repair
52 52 (41%)
6 O. Reg. 79/10 s. 129(1)
Safe Storage of Drugs 51 51 (40%)
7 O. Reg. 79/10 s. 73(1)
Dining and Snack Service ~ minimum requirements re program elements
50 50 (39%)
8 LTCHA s. 78(2)
Information for Residents ~ minimum requirements for contents of resident information package
49 49 (39%)
9 O. Reg. 79/10 s. 17 (1)
Safe and Secure Home ~ resident-staff communication system
36 36 (28%)
10 O. Reg. 79/10 s. 229(4)
Infection Prevention & Control Program ~ staff participation in implementation
35 35 (28%)
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
25
Quality Improvement Activities at LQIP
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
Centralized Intake, Assessment and Triage Team April 1 – 30, 2013
Information Received Provincial LSAO Seeking information 66 11 Complaint 235 44 CIS Notification 1333 314 LTCH Complaint/response 69 17 Bed Refusal 350 46 Discharge 0 0 Other 16 5 TOTAL 2069 437
CIATT cont’d
• Volume management / contract positions • CIS system - challenges • 51.5% of complaints received assigned for
inspection • 9% of CIs received assigned for inspection • 21.5% of complaints related to abuse/neglect • 42% of CIs related to abuse/neglect
28
RQI ~ Process Improvement & Integrity
RQI Support Team has been formed to support CQI activities, and ensure the integrity and consistency of the inspection process.
Team will conduct RQI Process and Support Assessment of the Resident Quality Inspection (RQI) process: designated RQI Support Team members are referred to as ‘Reviewers’ for
auditing purposes embedded with the RQI team of inspectors during an RQI to assess
inspectors’ compliance with the RQI process activities a means to reinforce the inspection methodology in real time
immediate feedback with educational / supportive approach promote process integrity make recommendations for improving the RQI quality management
system. The Reviewers are RQI certified inspectors and / or certified RQI Master
Trainers.
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
London SAO Performance Indicators....
RQIs Complaints Report Delivery
#’s per year Completed within 30 business days of
intake date
Faxed within 60 days of completion of
inspection
2011 = 10 2012 = 15
2013 first quarter = 10
Meeting target 100% of the time
Meeting target 95% of the time
*Note: review target
29
30
LQIP Risk and Priority Assessment Framework Inspections, Coaching and Enforcement
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
31
The Need for Continuous Quality Improvement and Transformation
The LTCHA was implemented in 2010 Homes are reporting as required with a 31% increase in total Critical
incidents being reported since 2009. Specific types of incidents are higher:
– Improper care or treatment (56%) – Abuse/neglect (39%)
Required: – Efficient targeting of Ministry inspection resources – Support to homes to improve performance/coaching – Enforcement when supports do not work and care does not
improve
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
32
Compliance Transformation – the next wave
LTCHA Implementation
The Basics As @ July 1, 2010 LTCHA & Reg.79 Implementation Education (internal &
external) Introduction of new
inspection system
July 1, 2010
On- going Activities: Continual Education & Professional Development, System & Program Monitoring & Analysis within CQI and Risk Management, Decision Support, Communication
LQIP Implementation Setting the CQI
foundation
Fully implement inspection system
Align all inspections to RQI methodology
Design CQI and Risk Management frameworks
Determine data elements for reporting
2010 – 2012
CQI / RM Implementation
Decision Support in Action
Fully implement CQI and Risk Management frameworks
Analyze data & performance metrics to fully leverage decision support capacity
Maximize inspection resources and efforts shift to proactive inspection approach (increased #s of RQIs), focus on LTCHs w/ compliance issues
Implement Coaching Teams model
Inspection Excellence
Achieving the Gold Standard
Further enhance
CQI activities seek accreditation
status for LQIP Become go-to
inspection program setting industry performance benchmarks & gold standard for inspections
2013 Beyond 2013
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
33
Purpose of the LQIP Risk and Priority Assessment Framework
1) For day-to-day operation of LQIP, it provides: data to assist SAOs in scheduling inspections, esp. Resident Quality
Inspections (RQI) & the allocation of staff resources Provides longitudinal record of home’s performance / level of risk on key
data elements/ performance criteria 2) Continuous Performance Improvement – use as an ‘Early Warning System’:
to identify trends within LTC Homes to assist in the evaluation of strategies to assist homes that are
struggling; mentorship programs, education, enforcement strategies, etc. 3) Information can provide decision support to ministry in roll out of new
programs to LTC homes: e.g. when implementing a pilot program, can identify and utilize
consistently high performing homes
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
34
Proposed Risk Levels/Coaching Interventions Risk Level Select possible ministry actions
[Note: additional actions are available]
Level 1 Compliant/substantially compliant
Routine inspections, as required
Level 2 Non-compliant = risk issues identified, not corrected within required time frames, appear to be issues related to licensee’s ability to correct concerns
Voluntary action to acquire external coaching supports
meetings with SAO and licensee
Level 3 Non-compliant = moderate to high risk issues identified, high risk orders re-issued, ongoing inability to rectify the concerns
Coaching/management support required
Can issue a Mandatory Management Order – need to validate that the licensee is unwilling or unable to resolve issues themselves
Level 4 Continued non-compliance with Orders in high risk areas; on-going evidence of serious risk
Licence Revocation
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
35
Current Risk Assessment of LTC Homes [as @ Fall 2012]
No. of Homes in each Level
Level 1 510
Level 2 88
Level 3 4
Level 4 1
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
36
Data elements
Compliance / inspection: # of inspections # of findings of non-compliance or violations resulting in any sanction
(WN, VPC, DR, CO, WAO) # of findings of non-compliance or violation resulting in orders # complaints with findings of non-compliance or violations # CIS with findings of non- compliance or violations
RAI-MDS: Incidence of worsening pressure ulcers Incidence of worsening pain Incidence of worsening resident behaviour
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
37
Data elements (cont’d)
LSAA Report: Identifies any home that triggers the LSAA Compliance Indicator which is: An order that has been issued in a high risk area on two successive
occasions. Risk indicators:
Injury that results in transfer or admission to hospital Medication Incidents Missing resident Environmental hazards Infection Control Pressure ulcers Alleged/actual abuse/assault Presence of daily physical restraints Weight loss management Continence care and bowel management Falls
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
38
Data elements (cont’d)
Qualitative data:
High leadership turn-over (ex. DOC, Administrator)
Financial Challenges (i.e. information from creditors, banks, risk of receivership)
Reports from governmental bodies / agencies (e.g. Office of the Fire Marshal, Min. of Labour)
other
Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care
Thank you!
39
40
Questions…..
Jasper