Advancing Excellence in America's Nursing Homes (Text Version)

On September 19, 2011, Mary Lane Koren made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (2.3 MB). 

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Slide 1

Advancing Excellence in America's Nursing Homes

Mary Jane Koren, M.D., MPH
Chair, Advancing Excellence
Vice President, The Commonwealth Fund

Slide 2

 

Advancing Excellence (AE): The NH Quality Campaign Overview of the presentation

• Background.
• Description of Advancing Excellence
  • Purpose and structure.
  • Process: how it works.
• Accomplishments:
  • Evidence of impact.
  • Other achievements.
• Building on what works.
  • Using AE to test new ideas.
  • Working with the Centers for Medicare & Medicaid Services (CMS) Quality Assessment and Performance Improvement (QAPI) and the Quality Improvement Organization's (QIO) 10th Statement of Work (SOW).
  • Factors associated with why AE has been successful.

Slide 3

 

Background

Slide 4

Context for the NH Quality Campaign

Industry Characteristics	Facility Characteristics
15,800 facilities (approx. 1.68 million beds) 1.4 million residents on any given day 2.8 million discharges/yr >95% of beds are Medicare or Medicaid certified 66% for-profit, 28% not-for-profit, 6% gov't. 52% are part of a multi-facility group	110 beds average size Median occupancy 86% and dropping gradually Generally, high staff turnover CN's 71% annually Nurses 48.9% Administrative Staff 35.5% Old buildings: Average NH is over 30 years old

Slide 5

Antecedents to Advancing Excellence

• The Sioux Falls Group formed in 2000:
  • Share information about each others' initiatives and strategies.
  • Create effective coordination among themselves; and.
  • Proactively, through their respective organizations, lead important national improvement initiatives.
• IHI's 100,000 Lives Campaign 12/04-6/06.
  • "Some is not a number, soon is not a time".
  • Modeled on a political campaign.
  • Based on 6 evidence-based practices.
  • Established and promoted a set of achievable goals for US hospitals.
  • Generated unprecedented amounts of social pressure for hospitals to participate.

Slide 6

Description of AE: Purpose and Structure

Slide 7

Advancing Excellence is...

• Largest national coalition of NH stakeholders (30 organizations) working together to help NHs improve care.
• An opportunity for NHs to demonstrate their commitment to self-improvement (>47% participate) outside regulation.
• An independent organization incorporated in 2010, recognized as 501(c)(3)in 2011.
• Funded by:
  • CMS for the web-site and analytic support.
  • The Commonwealth Fund for program support.
  • Members for communications and other special needs.

www.nhqualitycampaign.org

Slide 8

 

AE functions on 3 levels

Slide 8. AE functions on 3 levels

AE functions on 3 levels

Nationally: Board of Directors

• Sets goals.
• Develops resources.
• Provides support.

Statewide: LANES

• Recruit NH's.
• Coordinate statewide activities.
• Provides support.

Facility

• Registers for AE.
• Selects 3 goals and sets targets.
• Uses AE's web based tools and resources.

Slide 9

Board of Directors

Voting Members:

• Alliance for Quality Nursing Home Care.
• Alzheimer's Association.
• American Academy of Nursing — Expert Panel on Aging.
• American Association for Long Term Care Nursing (AALTC).
• American Association of Nurse Assessment Coordinators (AANAC).
• American College of Health Care Administrators (ACHCA).
• American Healthcare Association (AHCA).
• American Health Quality Association (AHQA).
• AMDA—Longterm care.
• LeadingAge (formerly AAHSA).
• National Association of Healthcare Assistants (NAHCA).
• National Consumer Voice for Long Term Care.
• The Commonwealth Fund.
• The Evangelical Lutheran Good Samaritan Society.

Slide 10

 

Board of Directors (continued)

Voting Members: (continued)

• Association of Health Facility Survey Agencies (AHFSA)
• Foundation of the National Association of Boards of Examiners of LTC Administrators (NAB).
• Gerontological Advance Practice Nurses Association (GAPNA).
• Hartford Institute for Geriatric Nursing.
• National Association of Directors of Nursing Administration in Long Term Care (NADONA/LTC).
• National Association of State Long-Term Care Ombudsman Programs (NASOP).
• National Gerontological Nursing Association (NGNA).
• PHI.
• Pioneer Network.
• Service Employees International Union (SEIU).

Non-voting/Government Members

• Administration on Aging.
• Agency for Healthcare Research and Quality (AHRQ).
• Assistant Secretary for Policy and Evaluation (ASPE).
• Centers for Disease Control and Prevention (CDC).
• Centers for Medicare & Medicaid Services (CMS) and its contractors, the Quality Improvement Organizations (QIOs) and State Survey Agencies.
• Department of Veteran's Affairs.

Slide 11

Advancing Excellence Goals

1. Staff Turnover.
2. Consistent Assignment.
3. Restraints.
4. Pressure Ulcers.
5. Pain.
6. Advance Care Planning.
7. Resident Satisfaction.
8. Staff Satisfaction.

Slide 12

AE is Committed to Three Audiences:

• NHs:
  • AE selects meaningful issues aligned with national initiatives.
  • Provides free, practical, evidence-based resources to support organizational stability and performance improvement.
• Direct care staff:
  • AE's tools designed so workers can join in on QI efforts.
  • Solicits feedback about how they feel about their job.
• Residents and their families:
  • AE promotes open communication and participation of families and residents in care planning.
  • Encourages measurement of "customer" satisfaction as a part of the home's QI process.

Slide 13

AE Goals Compared to Other Initiatives

	AE Current Goals	QIO 10th SOW	NQF Quality Measures (* = time limited endorsement, (n) = number of related QMs)	RAI CAAs Care Assessment Areas	CMS Survey and Cert
Consistent Assignment	X	X
Staff Turnover	X	X			X (5-Star)
Restraints	X	X	X	X	X (GPRA)
Pressure Ulcer	X	X	X *	X	X (GPRA)
Pain	X		X *(2)	X
Resident Satisfaction	X
CAHPS			X *(3)
Staff Satisfaction	X
Advance Care Planning	X
Falls		X	X(2)	X
Delirium				X
Dementia				X
Visual Function				X

 Slide 14

Local Area Networks of Excellence (LANES)

• Neutral space where stakeholders can come together to build working relationships:
  • Divisive issues (e.g. 5 Star, reimbursement, the survey) are deliberately set aside or avoided.
  • Must learn to work together toward a shared goal—better care for resident.
• The aim is create ongoing learning networks or "learning communities" of stakeholders and of NHs.

Slide 15

 

Key Members of the LANE

• QIO.
• Ombudsman.
• State Survey Agency.
• Nursing Home Association Reps.
• Culture Change Coalition Rep.
• Others can include consumer advocacy groups, state Medicaid agency, health care professionals (e.g. state AMDA chapters), unions, etc.

Slide 16

Process: How it Works

Slide 17

Becoming Part of the AE Campaign

• Nursing homes register on Web site.
• Choose 3 goals minimum—1 clinical, 1 organizational plus 1 more (however, may pick all 8).
• Identify benchmarks and set targets.
• Use the web-site to access AE's resources and tools.
• Collect and monitor data using PDSA/PI methods.
• Enter data on AE Web site regularly.

Slide 18

Campaign Benefits

• Focuses on things consumers, surveyors and payers are concerned about.
• Increased staff stability: less turnover, better retention:
  • Saves money.
  • Improves performance.
  • Builds better relationships among staff and residents/families.
• Improves satisfaction (staff/resident/family).
• Lets them be part of a learning network, lets them compare their performance with others.
• Complements other initiatives:
  • QA/PI (ACA section 6102).
  • QIO program initiatives (10th SOW just starting).
  • Preparation for payment reforms.

Slide 19

Free Campaign Tools

• Evidence-based or field tested.
• Downloadable, ready to use.
• Standardized formatting, user-friendly Excel® worksheets for data collection.
• Clear, easy to understand instructions.
• Calculations, trend graphs and charting functions built-in.
• Compatible materials provided for consumers.

Slide 20

Advancing Excellence Tools

• Staff Turnover Calculator.
• Consistent Assignment Calculator.
• Pressure Ulcer Monitoring Tool.
• Restraint Monitoring Tool.
• Pain Monitoring Tool.
• Advance Care Plan Monitoring Tool.
• Suggest tools to measure Staff Satisfaction and Resident/Family Satisfaction.

Slide 21

Image: A screen shot of the Advancing Excellence Web site is shown.

Slide 22

 

Image: A screen shot of the Advancing Excellence Web site Resources by Goal page is shown.

Slide 23

Image: A screen shot of the Advancing Excellence Web site Goal 1 page is shown.

Slide 24

Image: A screen shot of the Advancing Excellence Web site Pressure Ulcers data page is shown.

Slide 25

Image: A screen shot of the Advancing Excellence Web site Instructions page is shown.

Slide 26

Image: A screen shot of the Advancing Excellence Web site Reducing Pressure Ulcers page is shown.

Slide 27

Accomplishments

Slide 28

Recruitment

• Participating nursing homes in Phase 2:+
  • 7398 (47%).
  • 4726 Charter members.
  • 1965 New participants.
• Participating consumers: 3053.
• Participating nursing home staff: 1860

September 1, 2011.

Slide 29

 

Recruitment % by State

Image: A line chart showing the recruitment % by state from highest to lowest is shown.

Slide 30

Recruitment % by State (continued)

Image: A continuation of the line chart showing the recruitment % by state from highest to lowest is shown.

Slide 31

The Relative and Absolute Number of Residents at High Risk for Developing Pressure Ulcers is Increasing

Image: A line graph showing the relative and absolute number of residents at high risk for developing pressure ulcers is shown for 2005 Quarter 3 through 2009 Quarter 3. It shows the numbers at high risk, low risk, and post-acute care.

Slide 32

Physical Restraints

Image: A chart showing the percent of physical restraints used on nursing home residents is shown from 2005 Quarter 4 through 2009 Quarter 3.

Slide 33

High Risk Pressure Ulcers

Image: A chart showing the percent of high-risk residents who develop pressure ulcers is shown from 2005 Quarter 4 through 2009 Quarter 3.

Slide 34

Campaign Progress

• Campaign participants* have improved faster than non-participants in all things measured.
• Campaign participants* improved faster in the goals they selected to work on in every case.
• Campaign participants that set targets improved the most.

*In the aggregate...

Slide 35

Accelerated Improvement Since Campaign Start
2005 Q3—2006 Q3 (year before) vs. 2008 Q3—2009 Q3 (last year)

Image: A bar chart showing Accelerated Improvement Since Campaign Start from 2005 Q3—2006 Q3 (year before) vs. 2008 Q3—2009 Q3 (last year) is shown.

Year	High Risk Pressure Ulcers		Physical Restraints
	Participants Selecting Goal	Non Participants	Participants Selecting Goal	Non Participants
Year Before Campaign	4%	4.5%	6.5%	7.5%
Last Year Phase 1 of Campaign	7%	5.5%	24%	17.5%

Percent Improvement Comparing Participants Selecting Goal and Non-Participants for the year before the Campaign and for the last year of the Campaign. Those selecting the clinical goal realized greater relative improvement than non-participants for Pressure Ulcers and Restraint use after joining the Campaign.

Slide 36

Progress Toward Campaign Goal

Image: A chart showing Progress toward Campaign Goal is shown for End of Phase 1 2009 Quarter 3.

	Non Participants	Participants Selecting Goal	Participants Selecting Goal and Setting Target
High Risk Pressure Ulcers	87%	95%	97%
Physical Restraints	125%	130%	138%
CCPain	110%	122%	127%
PAC Pain	65%	70%	75%

Slide 37

Change and Relative Improvement in National QMs: Q3 2006 to Q3 2010

Image: A bar chart showing Change and Relative Improvement in National QMs Q3 2006 to Q3 2010 is shown.

	QC 2006	Q3 2010
Restraints	7%	3% (58% improvement)
Pressure Ulcers	13%	10.1% (18% improvement)
Chronic Care Pain	5%	3% (37% improvement)
Acute Care Pain	22%	19% (12% improvement)

Slide 38

Advancing LANE Performance

21 Statewide Performance Improvement Projects in 14 States

• Increased use of Consistent Assignment.
• Decreased Staff Turnover.
• Decreased Pressure Ulcers.
• Decreased Physical Restraints.
• Increased Advance Care Planning.
• Increased Web site data entry.

Slide 39

 

Image: A map of the United States is shown. States are shown with stars depicting: 1) More than 50% nursing home participation; 2) Accelerating LANE Performance States; 3) Critical Access Nursing Home State; and 4) Changing LANEs Project.

Slide 40

Arkansas Restraint Rate 2005 Q3 through 2009 Q3

Image: A line graph showing the Arkansas Restraint Rate 2005 Q3 through 2009 Q3 is shown. The rates highlighted are 13.6% in 2006 for the national and 6.2% for Arkansas, and for 2010 Q3 3.3% for the nation and 2.6% for Arkansas.

Slide 41

Finding New Ways to Measure Quality: a New Measure for Consistent Assignment

Consistent Assignment:

• Uses a person-centered frame for the measure by asking, "How many CNAs touched the resident in the course of the month".
• Same CNA takes care of the same resident every time, all of the time.
• Optimally? Could be as low as 6—8 over the course of a month.

Slide 42

Promoting Research on the Impact of This Staffing Practice:

• Using Consistent Assignment 85% of the time associated with fewer survey deficiencies, 41 % fewer empty beds, and 31% less turnover—recent study by Dr. Nick Castle.
• Small study by Dr. Barbara Bowers on consistent assignment— currently in progress.

Slide 43

Building on What Works

Slide 44

 
The Critical Access NH Pilot: Can AE LANEs Help to Reduce Disparities in NHs?

• 18 NHs from 4 States (GA, IL, IN, OH).
• NH selection based on quality measures, number of deficiencies, % Medicaid, % minority population, geographical area, media attention, etc.
• Only one nursing home has dropped out.
• One nursing home was added at the request of the State Health Department.

Slide 45

CANH LANE Successes

• LANE members, and the NHs, stayed at the table.
• NHs were enabled to share experiences with peers.
• LANEs learned to take responsibility for overcoming impediments e.g. getting NH corporate offices to pay attention.
• CMS Region IV very engaged.
• Possible use of model following the project in at least 2 states.

Slide 46

CANH: Facility Successes

• "We used to have 5 or 6 call-outs a night. Now we only have one a week...".
• "We've gone back to Nursing 101. Instead of having the nurses call the doctor when a resident has a fever, we have empowered the nurse and allow him or her to try Tylenol, compresses and other nursing care... our hospital admissions have decreased".
• "The dietary staff that used to fight with each other all the time are now working together to help the residents...".
• DON and Administrators are doing MDS resident interviews and realize they have been "missing the boat.".

Slide 47

Quality Assurance/Performance Improvement (QA/PI)

• The Affordable Care Act, Section 6102 requires CMS to:
  • Strengthen QA requirements in nursing homes.
  • Provide technical assistance to nursing homes in order to meet new requirements.
• Law specifies implementation by December 31, 2011.
• QA/PI plans must be submitted to HHS Secretary one year later.

Slide 48

QIO 10th SOW

Aims for the 10th SOW

• C.6 Beneficiary and Family Centered Care:
  • Patient and Family Engagement Campaign.
• C.7 Improving Individual Patient Care:
  • Reduction of Health-Care Acquired Conditions.
• C.8 Integrating Care for Populations and Communities:
  • Improving Care Transitions Leading to the Reduction of Readmissions.
  • Using Data to Drive Dramatic Improvement in Communities.

Drivers for creating change: Tasks under the 10th SOW.

• C.10.1 Supporting and Convening Learning and Action Networks;.
• C.10.2 Providing Technical Assistance; and.
• C.10.3 Care Reinvention through Innovation Spread.

Slide 49

Lessons from IHI: Why Learning Networks are Important

• Engages leaders.
• Shared aims or goals.
• Welcomes everyone and harnesses energy.
• Self-conscious—participants are a part of the whole.
• Non-linear.
• Devolves control/bottom-up learning.
• Manages knowledge nimbly.
• Seeks critical mass—not total coverage.
• Values asking, not merely sharing.

Slide 50

AE is an Example of a Collective Impact Initiative

Collective impact initiatives represent ongoing commitments by key stakeholders from different sectors to a common agenda for solving a specific social problem.

• Use the LANE, often with major help from the QIOs, as the supporting infrastructure.
• Forge new partnerships across interest groups.
• Build strong working relationships among important players through continuous, ongoing communication.
• Concentrate on identifying and then addressing the common problem.
• Jointly agree on what success will look like and having a shared measurement system.
• Use mutually reinforcing activities to maximize existing resources.

Slide 51

Mary Jane Korean
mjk@cmwf.org

Or

Carol Benner
cb@leadingage.org