Stop Managing for Survey; Start Managing for Quality!

Kathy Owens, MSN, RN, NP

Donna Kelsey, MS, NHA

Objectives

By the end of this session, participants will be able to: Overview of Quality Improvement Discuss Root Cause Analysis (RCA) State the elements of the Four Step Plan of Correction Integrate RCA and Four Step Plans of Correction into the

PDSA Model Discuss how to use the Four Step Plan of Correction as a

response to a serious event Complete a sample Four Step Plan of Correction for a

clinical concern Discuss Change Management principles to guide the

implementation of the Four Step Plan of Correction into the center’s daily PI process.

Quality ImprovementDefinitionsChallenges “Survey Ready Every Day”

Strong Systems Routine Monitoring

Root Cause AnalysisDefinitionRefinement

Plan of CorrectionTraditional UsePro-Active Model for achieving

sustained results

The “Four Steps”Corrective Actions Identification of Others At RiskSystemic ChangesMonitoring

Integrating the Four Steps of the

POC into daily Quality Improvement Response to a Survey Result (2567)Making the Four Step part of the PDSA

ModelWhat centers do wellOpportunities for more effective

application

Response to a Survey ResultFamiliarReviewed in center Performance

Improvement processRequires ongoing monitoring for

sustained results

PDSA ModelBased upon an accurate Root Cause

AnalysisPlan DoStudy Act

Integration of Four Step POC into Routine PI Process

Event/ Trend Occurrence

Investigate & Corrective Actions

Working Root Cause(s)

Identify Others At Risk

Refine Root Cause

Systemic Changes

Monitor

PLAN

DO

STUDY

Expand to Entire CenterACT

Continue to MONITOR

When to Use the Four Step POC Identification of a Trend

Increase in Nosocomial Pressure Ulcers Increase in Falls

Response to a Serious Event Resident develops Stage III Pressure Ulcer Resident Falls and Fractures

Four Step Plans of Corrections: Comfort Zones for Centers

Corrective Actions Correcting the problem for the resident

involvedSystemic Changes

Education of Staff

Opportunities Emphasis on Identifying Others At Risk for

same issue Requires a systematic, documented baseline audit Results can be used to refine the Root Cause Correction of newly identified issues

Monitoring Requires disciplined, documented monitoring Results of monitoring need to be reviewed May lead to further refinement of systems changes

Embracing Serious Events as OpportunitiesThe Silver Lining of a Serious Event

Can be a “red flag” of a broken part or whole system

ExamplesUsing the “Four Step POC” as a routine

response to a serious event Examples

Documenting the ProcessPart of Performance ImprovementCreate a “paper trail” as evidence of

completion of each step of the plan of correction

Place evidence of completion in a file or binder Easily accessed if needed to produce the

documents

Topic / Opportunity / Problem

Current Measurement/

Target Action / InterventionsTarget Dates

Responsible Party

Follow-Up

    Corrective Actions :      

    Identification of Others At Risk

     

    Systemic Changes      

    Monitoring      

Performance Improvement Action Plan

Result of Root Cause Analysis:

Privileged and Confidential - Prepared for use by Quality Assurance Committee, Insurer and Corporate Counsel 42 C.F.R. 483.75(o)PI – FRM 05 Performance Improvement Action Plan Form

Response “Template” First Step: Always protect resident;

corrective actions for resident(s) involved Begin Root Cause Analysis Based upon “working” RCA, begin a baseline

audit to identify others at risk from same practice

Refine RCA, based upon trends revealed through the baseline audit

Root Cause Analysis (RCA) Initially based upon information

gathered as part of Event InvestigationMay have several “working” RCAs

Determining Others At Risk Requires a thorough baseline audit of others

who could be at risk for same deficient practice (s) Repeating assessments Review of current orders and documentation trail Review of Care Plans Review of communication of interventions

Window into the functioning of the System/Process

May lead to a refinement of the RCA

Systemic Changes Actual Systems Changes

Dependent on Root Cause (s) May require revisiting current Policies and

Procedures with no new changes needed May requires the use of a Workgroup or

Subcommittee Education of Pertinent Individuals

Staff, Residents, Families Clarify Content and Approach of Educational

Sessions Document completion of educational opportunities

MonitoringMore frequent at first, then reduce in

frequencyReview of results criticalCorrect any newly identified concernsTrends reviewed in center PI

CommitteeONGOING!

Protecting the ProcessMaintain records under the Umbrella of

Performance Improvement Process Example:

Privileged and Confidential - Prepared for use by Quality Assurance Committee, Insurer and

Corporate Counsel 42 C.F.R. 483.75(o)PI – FRM 05 Performance Improvement Action Plan Form

Success StoriesAbuseSkinFallsAdvance Directives

Responding to Substantiated Abuse AllegationScenario: Root Cause AnalysisFour Step Response

Responding to development of Nosocomial Pressure UlcersScenarioRoot Cause AnalysisFour Step Response Integration into Center PI Process

Extra Bonus: Surveyor Response “Acting as if already cited”Success Stories

Organizing for Sustained ResultsDocumentation TrailKeeping Team Focused

Falls Possible F Tag 323 ACCIDENTS AND SUPERVISION

TEACHING TOOL/ Guide for Evidence Binder Issues: Falls not reported Falls not addressed appropriately when reported Care Plans not updated Care Plan interventions not in place

CORRECTIVE ACTIONS

Copies of completed Event Report and Post Fall evaluation on sample residents and referenced falls

Updated Fall Risk Assessment for sample residents Current Fall Prevention Care Plan for sample residents Documentation of proper reporting to Family/Provider/DHS

IDENTIFICATION OF OTHERS AT RISK Root Cause for Deficient practice(s):

o Include results of PI analysis/trending (Include documentation of resolution of each identified issue)

Repeat Fall Risk Assessment for current residents Include results of residents deemed to be at risk for falls Include updated care plan for each of above residents Include results of additional assessments for above residents (e.g. PT/OT) Review recent Falls for evidence of proper reporting

SYSTEMS CHANGES Create Workgroup to review root cause (s) and determine next steps (review current

Policies and Procedures and/or make changes to existing polcieis and procedures) o Provide Education on current Policies and Procedures for Fall Risk

assessment, reporting, interventions, care planning, communication of care plan interventions, etc.

Include Content for education sessions Include sign in sheets for employees

o ___ # staff attended inservices/ Total # of staff in center

MONITORING

Blank Audit tool(s) reflecting the following items: Fall Risk being completed; Post Fall Evaluation completed; Reporting; Care Plans updated to reflect falls; care plan interventions in place

Results of completed tool(s) for above items

o Frequency o Who completes

o Separate Line for each audit to be completed o

Trends reviewed in center Performance Improvement Committee o Separate line for date of each time to be discussed in PIC o Include only Agenda in Evidence Binder/ Folder

Integration of Four Step POC into Routine PI Process

Event/ Trend Occurrence

Investigate & Corrective Actions

Working Root Cause(s)

Identify Others At Risk

Refine Root Cause

Systemic Changes

Monitor

PLAN

DO

STUDY

Expand to Entire CenterACT

Continue to MONITOR

Application ExerciseBreak into GroupsEach Group Given a Summary of a

Serious EventGroup Charge

Identify Recorder Create an Four Step Action Plan for Event

Management Identify Presenter

Group Presentations

Managing Multiple Plans of Correction

PrioritizeTrack completion of plans, and results

of ongoing monitoringTeam reviews trends and directs

continued monitoring

Now What?For things to change, somebody,

somewhere has to start acting differently

Knowledge does not change behavior

We Need to Change In the business we tend to think in two

stages plan and execute there is no learning stage or practice

stage.

“We don’t care how you do it, just

get it done.”

Integration of Four Step POC into Routine PI Process

Event/ Trend Occurrence

Investigate & Corrective Actions

Working Root Cause(s)

Identify Others At Risk

Refine Root Cause

Systemic Changes

Monitor

PLAN

DO

STUDY

Expand to Entire CenterACT

Continue to MONITOR

Plan

What does the center do now?

What change do you want?

What is holding you back?

How do you make the change?

Do

Select a leader, a champion in each center

Give clear direction, train, give examplesDemonstrate the value and what will

happen if you don’t changeStart small, “what are you going to do

differently by Tuesday”Grow your people

Study

Review Outcomes at PI

Lower fall rate

Lower incident of acquired pressure ulcers

Celebrate Success

Review the process

Provide templates

Review the Four Step action plans for completeness

Act

When change works, it tends to follow a pattern: the people who change have clear direction, ample motivation, and a supportive environment.

Questions?