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8/21/2018
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September 19, 20182:00-3:15
Mary Tellis-Nayak, RN, MSN, MPHEllen Rychlik, RN, BSN
Reducing Rehospitalizations–Part 2
716-949-3464
Ellen Rychlik, RN, BSN
Director of Outpatient Oncology,
UPMC Hillman Cancer Center
Mary Tellis-NayakRN, MSN, MPH
Vice President of Quality Initiatives
NRC Health
773-942-7525
Presentation Outline
• List three drivers of satisfaction in the subacute population
• Explain the importance of quality focused recruitment and identify key retention strategies.
• Discuss QAPI and its impact on Quality Metrics
• Identify key aspects in JV collaborations
• Who are your key stockholders and how they impact the resident experience
• List operational changes that must occur to effectively and efficiently manage the higher complexity patient/resident and prevent unnecessary hospitalization.
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Do you think satisfaction
has any relationship with
return to hospital?
Voice of Former Patient
SKILLED NURSING
Top Drivers for Recommendation to Others
Independent Living Resident Assisted Living Resident
Home-Like Atmosphere .61 Responsiveness of Management .61
Responsiveness of Management .59 Choices/Preferences .60
Commitment to Independence .58 Comparison of Charges .59
Care (Concern) of Staff .57 Competency of Staff .59
Responsiveness of Staff .56 Care (Concern) of Staff .58
Nursing Home Resident Short Stay Residents
Care (concern) of Staff .63 Care (Concern) of Staff .77
Competency of Staff .63 Competency of Staff .77
Responsiveness of Management .61 Choices/Preferences .74
Choices/Preferences .59 Responsiveness of Management .72
RV/LVN/LPN Care .58 Quality of Medical Care .72
What Matters Most in Nursing Homes
Nation’s Discharge Patients Say:
1. Care (Concern) of Staff
2. Competency of Staff
3. Choices/Preferences
4. Responsiveness of Management
5. Quality of Medical Care
Source: Skilled Nursing Discharge Patient Satisfaction Surveys collected in 2015
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SNF Discharge
Items Ranked by Percent “Excellent”
SNF Discharge
Items Ranked by Percent “Excellent” Cont.SNF Discharge
Trending Numbers
YearOverall
Satisfaction - % Excellent
Overall Satisfaction - % Excellent and
Good
Recommendation - % Excellent
Recommendation - % Excellent and
Good
2011 50% 87% 52% 87%
2012 52% 88% 53% 87%
2013 54% 88% 56% 88%
2014 55% 89% 57% 88%
2015 55% 89% 57% 88%
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SNF Discharge
Quadrant AnalysisSNF Discharge
Quadrant Analysis: Quadrant B
2 � Respectfulness of Staff
4 � Treatment by Staff
10 � RN/LVN/LPN Care
16 � Progress Toward Rehab Goals
20 � Care (Concern) of Staff
11 � CNA/NA Care
19 � Competency of Staff
SNF Discharge
Quadrant Analysis: Quadrant D
15 � Setting Discharge Goals
13 � Quality of Medical Care
18 � Commitment to Family Updates
1 � Choices/Preferences
21 � Responsiveness of Management
SNF Discharge
Quadrant Analysis: Strengths & Opportunities
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SNF Discharge
Trending Numbers
Year Response Rate
Facilities Surveys Returned
2011 26% 2475 96183
2012 26% 2500 102418
2013 25% 2484 80059
2014 27% 2308 92692
2015 25% 2003 92952
SNF Discharge
Former Patient Response Rates
SNF Discharge
National Aggregated Results for 2014
How Often is the Patient VisitedLess than once per year 1%
Once per year 0%Every 3 months 1%
Once per month 3%
Once per week 28%Almost daily 67%
Age of Patient
19 or under 0%
20 to 29 0%
30 to 39 0%
40 to 49 1%
50 to 59 7%
60 to 69 17%
Number of Communities Visited Before Deciding
None 63%
Only this one 16%
Two 13%
Three 5%
Four 1%
Five or more 1%
Current Living ArrangementsHome alone 26%
Home with family 55%Assisted living 7%
Hospital 0%
Independent living apt 6%
Other 6%
National Aggregated Results
Length of Stay
Less than 1 month 71%
1 to 3 months 25%
3 to 6 months 1%
6 months to 1 year 2%
1 to 3 years 0%
3 years or more 0%
Reason for Choosing
Convenient location38%
Good reputation24%
Doctor or hospital24%
Relative or friend 3%
Insurance requirement 4%
Other reason 6%
Person Visiting Most
Spouse 44%
Child 31%
Brother or Sister 9%
Grandchild 0%
Friend 14%
Another person 3%
Gender of Resident
Female 64%
Male 36%
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What gets measured,
gets improved.
Peter Drucker
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Toyota’s Five Important
Questions
The nurse made a medication error
The wrong medication was in the drawer
The pharmacy tech put it in the drawer
Just Ask Why
The tech read it off the computer that way
The nurse put it in the computer that way
The nurse misread the doctor’s writing as themedication was only one letter different from the oneshe thought was correct.
The nurse misread the doctor’s handwriting and entered the wrong medication on the order sheet
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Ellen Rychlik, RN, BSN
Director of Outpatient Oncology,
UPMC Hillman Cancer Center
Quality in Caring
Key Strategies in Reduction of Unnecessary
Hospitalization and Development of Acute Care
Collaborations – Part 2
Boss vs. Leader ….Retention vs. Turnover
As Leaders…we set the tonehttps://music.amazon.com/albums/B0043XDPJ8?ref=dm_sh_b4fb-ab2f-dmcp-9357-85fca&musicTerritory=US&marketplaceId=ATVPDKIKX0DER
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How do YOU define Quality
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How we work is just as important as the work we do!!
<iframe width="859" height="483" src="https://www.youtube.com/embed/tylvc9dY400" frameborder="0" allow="autoplay; encrypted-media" allowfullscreen></iframe>
• Ability to embrace change is dependent on the organizations ability to engrain the process(s) in its culture, the way we function on a day to day basis.
• Always keep a finger on the pulse. Fine line between micro-management and crisis management. (Consistent Assignment NOT Consistent Assignment with Considerable Rotation)
• Never lose touch with the front-line staff.• Key to success is to develop systems within a culture that
promotes autonomy and ingenuity in line with the organizations vision that are not dependent on a single individuals presence.
Foremost: Sustainability
• Get the right people on the bus• Peer interviewing
• Welcome and engage new staff• Mentor program
• Keep staff engaged• Flexible scheduling when possible• Decisional participation• Autonomy• Appreciation
Keys to Staffing Stability
“A chain is only as strong as its weakest link”Be a Mentor
Promote a Culture of Positivity and Engagement
An Effective Manager Keeps Staff Engaged by Recognizing and Promoting Their Value
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Turnover Dedicated Workforce
Snowvember 2014
• 88” of snow over 3 days crippling the town of Hamburg.
• State of Emergency Declared
• Driving Bans in Effect
• No interruption in High Quality Patient Care Delivery
• Staff walking to work through zero visibility and treacherous conditions keeping staffing patterns at par.
“Promise me you'll always remember: You're braver than you believe, and stronger than you seem, and smarter than you think.”― A.A. Milne Typical LTC Staffing
Model• Primarily staffed by
non-licensed/non-professional care givers
• Nurse: patient ratio’s ranging from 1:20 – 1:40
• Lack of consistency in care giver.
• Continual “floating” of staff.
• High Turnover
Primary Permanent Nursing Staff Model• Staff are permanently assigned to their
teams with the only variation occurring on PCUI (Medically Complex/Post-Surgical/Oncological Rehab Unit).
• Each unit is “closed”.
• Increased autonomy
What was, is no more, and what is meant to be is yet to come!
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In all areas surveyed the majority of the staff responded favorably to the transition in care models. One area
that is quite remarkable is when staff was questioned; is there enough staff to handle the workload? A
question that is answered typically in healthcare as NO was answered profoundly YES with Primary Care.
The following data represents staff satisfaction ratings pursuant to surveys conducted at the Nursing
Department Education Day held in April 2010. The staff responded with (1) indicating that they strongly
disagreed and (5) indicating that they strongly agreed
Quality Assurance Process Improvement
Element 1: Design and Scope, which looks at an ongoing, comprehensive program that includes all facility departments, coupled with patient driven care.
Element 2: Governance and Leadership, which focuses on facilitating input from staff, patients, and families, as well as providing adequate resources for quality initiatives.
Element 3: Feedback, Data Systems, and Monitoring, which draws data from all available resources and formalizes outcomes monitoring. (Robust CQI Program)
Element 4: Performance Improvement Projects, which utilizes enhanced subcommittee work groups to accomplish goals.
Element 5: Systematic Analysis and Systematic Action, which includes a process for in-depth identification and analysis of actual and potential care-system problems.
� “Be who you are
and say what you
feel, because those
who mind don’t
matter and those
who matter don’t
mind.”
Dr. Seuss
QAPI in Action
Recognizing the rising clinical complexity in relation to a “safe” and efficient nurse: patient ratio, an Acuity Based Staffing
Model was then incorporated into the already Primary Permanent Assignment.
“Quality is not an act, it is a habit” - Aristotle
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Work Smarter….Not Harder
Reaping the Benefits
• In 2008, we began accepting, triaging, and successfully treating hospital diversion patients from the community, via PMD’s, ER’s, and Home Care.
• Primary, Permanent Nursing was implemented facility wide in March of 2009. This model cut the nurse to patient ratio in half placing the nurse back at the bedside. Permanent Assignment had already been implemented on our sub acute unit for 4 years and saw remarkable results:1. Decreased Hospitalization.
2. Improved Patient, Family, Staff Satisfaction Ratings.3. Improved Quality Measures(both by internal and external
assessment).
Do Not Confuse Initiatives, Culture Change > Eden Alternative….miss the forest for the
trees….must meet basic human need…to be loved and have basic needs
met…Maslow……not so much environmental changes or fur and flowers but changes to
the core, i.e. staffing. When consistent assignment is viewed as part of a broader
philosophy of care, it is implemented with a variety of other intervention
components. Don’t “blend” the lines.
• Acuity assessments are done every shift and prn
• Adjustments are made to align the needs of the patients with necessary/safe nursing staff levels
• Nurses help to decreaselengths of stay, prevent illness, errors, complications and readmissions, all of which saves money for providers and health plans and adds to overall productivity.
• Staffing models should be adjusted to reflect the true time required to meet the care needs of the patients based on their acuity level.
Primary Permanent Nursing Staff Model (Acuity Based Staffing)
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• Model looks at (7) factors determining nursing time required:
• Number/complexity of medication administration • Complexity of procedures• Patient educational needs• Psychosocial issues• Intravenous therapy needs• Infection prevention protocols/needs• ADL's.
Primary Permanent Nursing Staff Model (Acuity Based Staffing)
* Exclusions = Direct Admits, Pre-plans, Trauma, Gross Bleeding, Cardiac, and Neurological Events
• Thorough Case Review is conducted on every hospital transfer evaluating the symptoms and appropriateness of treatment leading up to acute exacerbation.
• Evaluation of Nurse Triage Process, assessment of patient condition/history, dialogue with provider, critical thinking skills, suggestions in treatment possibilities
• Attempted treatment and timeliness of intervention in attempt to prevent hospitalization.
• Prevalence of Admitting Diagnosis, CHF, Sepsis, Dehydration
• Identification of Particular Care Provider, Shift
Tools to Determine Staff Educational Need QI/QA
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Patient/Resident Name
Level of CareSA/LT
Date/Timeof
TransferProvider Synopsis
Valid(Yes) or
(No)Rationale
W. C.
CHF/AFib
LTC 1/13/130315
Resident admitted to Lakewood on 3/16/12 SA from SBM s/thoracic Spine Compression Fracture – Sleep Apnea – BPH – HTN – Hypercholesterolemia – Osteopenia – AF – COPD – Hypothyroidism. On 4/25/13 resident was transitioned to LTC. On 11/29 resident was diagnosed with Atrial Fib via ECG performed for medical clearance prior to supra-pubic catheter placement. Resident on Coumadin. On 1/8/13 resident presented with a productive cough and congestion. Dr. in to assess resident with new orders to insert HT and begin infusion of Rocephin – Dounebs – Mucinex. Patient remained afebrile with remaining VS unremarkable up until 1/13 when patient presents with difficulty breathing, course audible rhales, SPO2 74% on RA which improved to 91% on 02 at 4L. VS as follows 98.3 – AP 110-130 – 19 BP=140/95. Call placed to provider with new order to transfer for evaluation. Resident admitted with CHF and AF.
NO
(No) Perhaps being the resident did have IV access an attempt could have been made to diurese the patient prior to transfer. His BP could have safely tolerated it. AFib was not a new diagnosis.
L. D.AFib/CHF/RVR
SA 1/28/132200
. 88 year old female patient admitted at 1925 s/p Respiratory Failure secondary to COPD Exacerbation – Pacemaker (Non-Functioning) - Bronchitis – History of Falls. Patient is a Full Code.Patients did have poor appetite. Was seen by NP on 1/14 with new orders to D/C Digoxin and begin Remeron. No Dig level was drawn. Vital signs = 98. – 72 – 18 BP136/80. Patient seen on 1/17 with new order to decrease Cardizem dosage. Patient seen on 1/21with Cardizem dose decreased. BP on 1/23 110/61 and AP = 87. 1/26 BP=108/86 with AP = 68. 1/27 BP = 130/98 with AP = 74. On 1/27 at 2120 patient presents with an AP = 140-170 and BP 92/50. Patient with history significant for AF. Call placed to provider with new order to transfer for evaluation. Patient admitted with diagnosis of Acute CHF related to diastolic dysfunction, AFib and RVR (D/C of Calcium Channel Blocker), Acute Hypoxic Respiratory Failure secondary to Pulmonary Edema due to acute CHF. Patient readmitted to Lakewood on Digoxin and Cardizem and placed on Palliative Care.
Yes/No
Patient with significant medical history of AF and CHF managed on Digoxin and Cardizem. Digoxin and Cardizem discontinued prior to acute onset. Although patient did present with Anorexia, there was no Digoxin level drawn prior to discontinuation of medication. Patient was readmitted to Lakewood on Digoxin and Cardizem.
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Total Transfers: 3Case Reviews: 3(Resulting Exclusion Determination, i.e. Appropriate Hospitalization –2/3)Admissions: 3Exclusions (Direct Admits/Pre-plans/Trauma/Gross Bleeding/True Cardiac and Neurological Events/Inappropriate Hospital Discharge/Family Request, Case Review Determination of Patients Requiring a Higher Level of Care)Pre-Plans/Direct Admits: 0Family Request: 1Cardiac: 1Neurological Event: 0Trauma: 0Gross Bleeding: 1Urology Consultation: 0Unnecessary Hospitalization: 12012 Transfers: 56Unnecessary Hospitalizations: 8
• Clinical Education was driven off of case review determinations and efficacy of triage processes, diagnostics, documentation logistics, etc.
• Curriculum Development with “Test Out” determinations of competency both written and lab based demonstrations.
• Critical Thinking evaluation based on response to case review scenarios.
• All licensed nurses trained in phlebotomy.
• PICC Certified Nurses
• Infusion Therapy Education provided to all nursing staff on care/assessment of various VAD’s, lab value interpretation and treatment options, i.e. TPN, Crystalloids, Diuretics, Steroids, Antibiotics, etc.
• Amalgamation with Institutions of Higher Learning, providing clinical rotation site in return for CEU opportunities for Nursing Staff
Continuing Education
• Phlebotomy Supplies
• Smart Pumps
• ECG Machine
• Welch Allyn Vital Signs Monitor’s
• Bair Hugger
• SCD’s
• Wound Vacs, etc.
Evaluating Capital Resource Investment
• Analyzing our environment for partnership opportunities
• Overcoming stigma of “nursing home”
• Educating health care continuum of our capabilities
• Demonstrating strategies in assisting “Partners” how to operationalize our complex capabilities (Directory of Services/White Paper)
• Demonstrating our competence(Hospital Case Reviews/My InnerView, Nosocomial Infection Rates, Rehospitalization Rates)
• Maintaining and enhancing staff skill levels
Collaboration Efforts
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• My InnerView “Former Patient”
• Recommendation to Others –96%*
• Overall Satisfaction – 95%*• Competency of staff – 98%*• RN/LPN Care – 99%*• CNA Care – 99%*• Quality of Medical Care – 97%*
• Staff Satisfaction – 94%*
• Staffing turnover• 20% or less consistently
• Hospitalization Rate• 4% or less consistently
(unplanned)
Key: * % Excellent/good – 2014
Proving Your Competency
In recognition of the national need, industry wide, with regard to safely meeting the needs of the incoming complex population, (in correlation with proposed CMS future initiatives) I was asked to present nationally, for the following organizations: The American Health Care Association, American Medical Directors Association, the National Research Corporation, and McKnight’s, on the innovative high quality systems and services developed and effectively implemented at our facility, via the Annual Conventions, Quality Symposiums, Educational Sessions, and Webinars.
Clinical Capabilities
and
High Quality Services Provided
H ighly skilled and compassionate staff caring for medically complex population through◦ Multi-system Clinical Management with Disease Specific Evidence Based Treatment
Pathways◦ Prevention of Acute Exacerbation through the Preventative Medicine/Nursing
Services Ensuring Thorough Assessment and Coinciding Expedited Intervention◦ Post-op Management of Surgical Patients with Multiple Co-morbidities◦ Strict Neutropenic and Disease Specific Precautions
Primary Permanent Nursing Care Model – puts nurses back at the bedside in a holistic care approach. ◦ Remarkably low Nurse/Aid:Patient Ratio (Unique to Industry)◦ Ensures continuity of care◦ Prompt identification of deviation from baseline ensuring immediate
intervention◦ Prevents acute exacerbations thus reducing potential hospital readmissions
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Medical Services◦24/7 Physician on call coverage with coinciding House MD (Intensivist)
◦24/7 NP on call coverage
PICC Certified Nurses◦Management of IVD’s (Chlorhexidine gluconate skin preparation)◦ Peripheral Intravenous Catheters◦ Midline Catheters◦ Central Venous Catheters (CVC’s)◦ Groshong◦ Hickman/Broviac◦ Leonard◦ Mediport/Slim Port◦ Peripherally Inserted Central Catheters(Facility Based Insertion)
Infusion Solutions◦ Crystalloids
0.9 NS 0.45 NS
D5W D5 ½ NS
D5 0.9 NS LR’s◦ Antibiotics/Antivirals/Antifungals ◦ Diuretics◦ Steroids◦ TPN◦ PCA◦ Ketamine
Insuflon Catheters
Tracheostomy Care
Extensive Wound Care (Wound Vac/Drains)◦ ID Consult available PRN with Board Certified Physician
Laboratory/Radiology/ECG◦24/7 stat availability◦On-site radiology through Buffalo Ultrasound
Rehabilitative Services (7days/week)◦Physical Therapy◦Occupational Therapy◦Speech Therapy
Spiritual Care Services
Discharge Planning and Social Work (Ensuring a Safe Transition Home)
The cost savings in the per diem rate, comparing the acute care setting vs. post-acute care, is significant.
The quality of care provided is consistent.
The benefit(s) of embracing the intermediary care provider are
extraordinary and the list is extensive. The proposal of an evaluation for an abbreviated acute care stay with an accompanying intermediary stay will ensure for both clinically and financially desirable patient outcomes.
The patient will be provided the same high quality services at a lower level of care which will better prepare the patient for discharge to the community and prevent re-hospitalizations.
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This can be accomplished by:
Strengthening the deconditioned patient through extensive physical and occupational therapy intervention.
Clinical oversight and management of the severely immunocompromised patient.
Wound Care
Infection Prevention via professional line management and neutropenic precautions.
Infusion services/support, i.e. infection/dehydration/pain management.
Extensive patient education and support services.
Future collaboration of care providers with regard to hospital avoidance once discharged to the community i.e. Diversion program consideration/utilization.
Utilization of LTC/SA Facilities as Intermediary/Transitional Care
Provider
What set’s you apart from your competitors?
�Proven Competencies and Integrity in Services Offered
An organizational culture that promotes, enables, and empowers our highly skilled team , of both compassionate and passionate care givers, to whole heartedly perform their jobs. This mantra has resulted in the successful provision of unwavering and exceptionally high quality patient care delivery.
In Closing…We, at …………., pride ourselves as a learning organization. Our highly skilled staff are engaged in identifying and solving problems, enabling the team to continuously change and improve. We focus on meeting all of our customers’ unique needs and exceedingtheir expectations. We have nationally recognizedsystems/tools that promote exchanges of information among our care team, which creates a more knowledgeable workforce. We, as a learning organization, exhibit flexibility because our team embraces new ideas and changes through a shared vision.
