learning session 3: welcome - great plains qin · learning session 2 collaborative outcomes...
TRANSCRIPT
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Learning Session 3: Welcome
Krystal Hays, RN, MSN, RAC-CT
Great Plains QIN - CIMRO of Nebraska
Quality Improvement Advisor
Great Plains Quality Care Collaborative 152 Nursing Homes
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Peer Coach Nursing Homes
Heritage Care Center, Fairbury • Beth Block, Administrator – [email protected]
• Carol Schmidt, Director of Nursing
• Phone: 402.729.2289
Hilltop Estates, Gothenburg • Scott Bahe, Administrator – [email protected]
• Serina Sladky, Director of Nursing – [email protected]
• Phone: 308.537.7138
Wilber Care Center • Barb Dreyer, Administrator – [email protected]
• Michele Vana, Director of Nursing - [email protected]
• Phone: 402.821.2331
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Collaborative Support
Nursing Home Consultants
Leading Age Nebraska
Nebraska Health Care Association
Nebraska Local Area Network of Excellence
Nebraska Culture Change Coalition
State Survey Agency
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Quality in YOUR Home
Krystal Hays, RN, MSN, RAC-CT
Great Plains QIN - CIMRO of Nebraska
Quality Improvement Advisor
Great Plains Quality Care Collaborative Aims
Support the National Nursing Home Quality Care Collaborative (NNHQCC) objectives to instill quality and performance improvement practices, eliminate healthcare acquired conditions and improve resident satisfaction by:
• Working with nursing homes to attain a composite score of 6.00 or less
• Reduce the use of unnecessary antipsychotic medication in dementia residents
• Reduce avoidable hospital readmissions
• Improve the rate of mobility
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Recruit: nursing homes, stakeholders and peer coaches
Pre-work: beginning 2-3 months prior to Learning Session 1
Collaborative Learning Session 1 face-to-face session
Learning Session 2
Collaborative Outcomes Congress
Project wrap-up, celebrate successes
and sustainability planning session.
Sustainability Phase
Great Plains Quality Care Collaborative Model
18 Months x 2
Collaborative I – 4/1/15 to 9/30/16 Collaborative II – 4/1/17 to 9/30/18
Email & Listservs, Peer Coaches, Educational Webinars, Technical Assistance
Action Period
Action Period
Action Period
Learning Session 3
Learning Session Objectives
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Learning Session 1 • Get ideas • Get methods • Get started
Learning Session 2 • Get more ideas • Get better at
methods • Get a “stride”
Learning Session 3 • Continue to learn
from one another • Celebrate
successes • Get ready to
sustain and spread
Test and implement
changes. Collect data to measure
impact of changes
Action Period 1
Test and implement
changes, collect data to
measure impact of changes
Test and implement
changes, collect data to measure
impact of changes
Action Period 2 Action Period 3
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Sustainability
Period of sustaining the quality improvement
Between Collaborative I and II
New ways of working and improved outcomes become normal
Adapt the change to areas or residents other than the pilot group
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Measuring Success
NH Quality Measure Composite Score – Goal: 6.00 or less • 13 NQF-endorsed publically reported, long-stay QMs
Falls with major injury Urinary Tract Infections Self-reported moderate to severe pain High-risk residents with pressure ulcers Low-risk residents with loss of bowel or bladder Residents with catheter inserted or left in bladder Physically restrained residents Residents needing increased help with ADLs Weight loss Residents with depressive symptoms Residents receiving antipsychotic medications Residents given Influenza vaccine** Residents given Pneumococcal vaccine** **Not found on CASPER report
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How does your Composite Score Compare?
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Composite Score goal of 6.0 or less
Your nursing home’s Composite Score Ranking compared to all NE nursing homes
Composite Score ranking of all NE nursing homes
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Shift to the Left is Good!
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6.0 or less - 6.23% increase 6.01 to 7.99 - 4.15% increase
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Just Around the Corner. . . Antibiotic Stewardship,
Clostridium Difficile Monitoring and Prevention
National Spotlight on LTC Infection Prevention
March 2015 –White House releases National Action Plan for Combating Antimicrobial Resistance
July 2015 – CMS proposes new Federal Regulations for Long-term care facilities including infection prevention and antibiotic stewardship activities
September 2015 – CDC releases the Core Elements of Antibiotic Stewardship for Nursing Homes
October 2015 – CMS announces the C. difficile Infection (CDI) Reporting and Reduction project within the nursing home 11th Statement of work for Quality Innovation Networks- Quality Improvement Organizations (QIN-QIO)
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CMS Proposed Regulations for Infection Prevention and Control (IPC) Programs
Facility risk assessment of resident population
Integrating IPC into QAPI activities
Required review and update of IPC program, policies/procedures
Antibiotic use protocols and monitoring included in IPC and pharmacy services
Designated IPC officer with specific training
IPC-specific education and training for all staff
Why the Focus on CDI Reporting and Reduction?
CDC Report – February 2015 In 2011, approximately half a million infections in US and 29,000 deaths
OIG Report: National Incidence Among Medicare Beneficiaries, February 2014
70% of CDI-related harm was considered PREVENTABLE in SNF’s studied
HHS National Action Plan to Prevent HAI’s: Road Map to Elimination, April 2013
Need 5% of nursing homes to report to NHSN for obtaining consensus on goal setting
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CDI Reporting & Reduction Project
Identify geographic areas and communities with high CDI rates
Determine state and national CDI baseline
Decrease CDI state and national rate by June 2019
Increase reporting to the National Healthcare Safety Network (NHSN) by nursing homes • NHSN is the CDC database for infection data
• Currently 236 NHs report data nationwide
Benefits of Collaboration
Receive an onsite assessment by the Infection Control Assessment and Promotion Program
Technical assistance with NHSN and CDI prevention
Evidence-based guidance
TeamSTEPPS LTC communication strategies and techniques
Collaborative CDI prevention efforts
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How to Get Involved!
Watch for your
facility’s invitation to
participate in the
CDI Reduction Project.
More information is
coming soon!
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Weekly E-Newsletter
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Upcoming Educational Opportunities
June 15 @ 3 p.m. CT – We Got Softer Toilet Paper and Other Low-Cost Ways to Engage, Retain and Recruit Staff – Dr. David Farrell, MSW, LNHA July 7 @ 2 p.m. CT – Dying from Dirty Teeth – Angie Stone, RHD, BS Three Part MDS Series: Lisa Hohlbein & Judi Kulus of AANAC July 21 @ 3 p.m. CT – MDS Section GG: What You Need to Know About
Coding the New Section GG
August 25 @ 3 p.m. CT – MDS Sections C, D, F and J: Capturing the Resident Voice Through Resident Interview
September 22 @ 3 p.m. CT – Understanding Quality Measures and Avoiding Common Pitfalls
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Questions?
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Contact Information
Krystal Hays, RN, MSN, RAC-CT
1200 Libra Drive, Suite 102
Lincoln, Nebraska 68512
P: 402.476.1399 ext. 522
F: 402.476.1335
This material was prepared the Great Plains Quality Innovation Network, the Medicare Quality Improvement Organization for Kansas, Nebraska, North Dakota and South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-GPQIN-NE-74-/0615