putting it into practice - mmic group ppt-follow your data.… · ©pathway health 2013 the new...

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©Pathway Health 2013

Follow Your Data:

Performance Improvement Plans

that Work

Betty VanWoert RN, BSN, CPHRM, Sr. Risk and Patient Safety Consultant ,MMIC Group

Chris Osterberg RN, BSN, Senior Nursing Consultant, Pathway Health


• Review clinical data to prioritize areas for

improvement based on facility measures.

• Work with staff, residents and families closest to problems to generate effective

solutions.

• Develop simple and logical Performance

Improvement Plans to meet clinical goals.

Objectives


Putting It into Practice

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As we move into the home stretch of our journey into QAPI, there are more resources and details available to help you analyze factors & achieve resident-centered goals.

Follow the next case study, and use the QAPI skills you’ve learned so far.

Watch for underlined information to complete the QAPI recommended forms

Getting the Hang of It

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Meet Joe Wilson, NHA.

Looking over the weekend report, he found that 4 residents had been transferred to the hospital over the last 3 days- 2 admitted, one deceased, and one returned to the facility.

Aside from worry over the condition

of his residents & concerned calls

from families -

Starting at the Top

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He has doubts about the quality of care over the weekend, with staff sick calls and a frustrating conversation from the medical director, who was on call over the holiday weekend.

“What’s wrong with your nurses-calling me at all hours, no physical assessments or vitals!”

Words were exchanged…

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The team convenes. Joe listens to the census and clinical discussions, the nursing report.

The DON is particularly concerned about the changes in condition that she thinks might have been caught earlier. ‘CHF’ and ‘Sepsis’ are mentioned when discussing the hospital transfers.

Monday Morning Stand Up

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The Social Worker expressed other concerns.

“Dorothy and Bill had Advance Directives that might have prevented their transfers, did anyone catch that?”

“Bill’s daughter called me…”

“What about Advance Directives?”

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What do we know about…

Unnecessary hospitalizations?

What are the rehospitalizations

that may be preventable?

What are “early warning signs”?

How can we keep our facility in compliance with the

Affordable Care Act?

The Administrator asks…

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The new nursing home culture embraces resident self-determination & personal choice through

relationships & community.

Joe and his team are on board, but it’s unclear how well the rest of the staff has adjusted to greater

responsibilities in decision making

A Head Start

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To foster strong bonds, & strengthen ability

to notice changes in condition, the same personal care assistants, CNAs & nurses

always provide care to a resident.

Close Relationships

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Staff should have the authority, and the

necessary training, to respond on their own

to

residents’ needs.

Staff Empowerment

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The opinions & priorities of individual

residents & family members are used to:

• Identify quality of life & care issues important to them

• Provide feedback on their experiences

Residents & Family

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Mary contacts weekend staff to better understand how things happened…how decisions were made.

Her goals:

• Identify the problem and contributing factors

• Listen to staff perception and

analysis

• Solicit solutions

Problem ID

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Mary has two focus areas

• Hospitalization dates & rates

to understand patterns

• Individual cases

to analyze details

This information will guide

her actions to improve care and outcomes

Access The Information

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Using this information,

• Admission dates of individual transfers

• Return dates of individual transfers

Calculate rehospitalization rate & compare to local,

as well as national norms

Rates + Dates = Patterns

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Joe wants to calculate his average unplanned hospitalization rate for the third quarter of 2013. The census in July was 110, August 112, and September, 108.

The facility transferred a total 40 residents; one was directly admitted for a planned revision of a colostomy, a second for a scheduled hip replacement, and a third for monthly chemotherapy.

Five residents were placed into observation status. What was the average unplanned admission rate per 1000 resident days for this quarter?

3.16 – the number to beat!

Calculate Rates

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Mary does the diagnosis & case reviews as she contacts staff.

She sees that hospital transfer patterns indicate most happen on the PM and Night shifts, and more often on weekends.

She reads over 24 Hour Reports,

looks at identified risks for

individuals, notes staffing levels &

corresponding documentation.

It’s Not Just Numbers

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“I don’t hear from the nurses

until things are going bad.

Why don’t they routinely

check vitals, listen to lungs?

We could treat early fluid

overload with diuretics,

not the ER.”

“I agree-we need to re-educate to

improve assessment skills…we may

need more RNs on the evening shift.”

Frankly Speaking

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Therese Thompson, Social Worker:

“I spoke with the nurses-they aren’t always sure what the resuscitation status is, or if the family and resident agree about decision-making.”

Cathy Cook, Unit Manager: “We don’t have easy access to the

Advance Directives…and my nurses

are afraid to make mistakes about

who to send out and when.”

The Right to the Right Care

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Maintain medical stability to avoid

unnecessary hospitalizations and

emergency room visits

THE GOAL

The Challenge

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Mary looks at the areas of nurse competence she thinks need more emphasis in orientation…

Something else…she recently read the QAPI News Brief – she discovered the difference between weak, strong and intermediate solutions…

What to do?

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The Department of Veterans Affairs National Center for Patient Safety

Hierarchy of Actions

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The weakest link in the process is

implementing solutions that are centered on training & education, or asking clinicians to “be

more careful.”

The Weakest Link

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Weak actions enhance or enforce existing processes:

• Double checks

• Warnings/labels

• New policies / procedures / memoranda

• Training/education

Depend on staff to remember their training or what is written in the policy.

WEAK Actions

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These solutions don’t impact the system, & are based on two assumptions-

1. Lack of knowledge contributed to the event,

and

2. If a person is educated or trained, the mistake won’t happen again.

WHY?

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Solutions that rely on vigilance or memory are equally problematic because they create expectations for staff to remember more or be more careful.

This is not always realistic when staff are in stressful situations or when multi-tasking.

If the system doesn’t provide support, it is part of the problem.

Human Error

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Somewhat dependent on staff remembering to do the right thing, but provide tools to help staff remember or to promote clear communication.

Intermediate actions modify existing processes:

• Decrease workload

• Software enhancements & modifications

• Checklists, cognitive aids, triggers, prompts

• Read back

• Enhanced documentation & communication

INTERMEDIATE Actions

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Do not depend on staff to remember to do the right thing.

May not totally eliminate the vulnerability but provides strong controls.

Change or re-design the process - help detect & warn so there is an opportunity to correct before the error reaches the patient.

STRONG Actions

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Won’t allow the process to continue unless something is corrected or signals intervention to prevent significant harm:

• Physical changes: grab bars, nonslip strips

• Forcing functions: only O2 can be run to oxygen lines

• EMR: cannot save unless all fields are filled in

• Simplifying: unit dose

Strong Actions = Hard Stops

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The facility has just uploaded a new electronic medical record, and they are still learning all of the functions and reports.

Mary knows that she can activate INTERACT forms and decision making tools to reinforce and coach her staff to act more effectively.

She knows the Medical Records

Coordinator, a software whiz,

can help with the interface.

Prompts & Cues


Mary looks at INTERACT materials for

clinical decision making. She sees they are instructive, logical and clinically sound…no

need to reinvent the wheel…

Addressing Clinical Competence


Mary recognizes equally important members

of the team include staff who in many cases are closest to the resident –

NURSING ASSISTANTS

A Missing Link

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CNAs, especially when consistently assigned to the same residents, may be the first to recognize subtle changes in resident:

• Appearance (edema, paleness, posture…)

• Stamina (shortness of breath, weakness…)

• Behavior (confusion, restlessness, etc.)

First Responders


• Early detection means early intervention, before there is the need for more intense treatment

• Anyone who has contact with residents should have a means to report changes they may notice

All Responders


Mary completed the Root Cause Analysis, based on what she learned from staff, the medical director, and a process review…

Mary’s Homework

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Change in Condition Process

Resident change noted by nurse or reported to nurse

Assessment per nurse based on judgment of symptoms

MD notified Decision to hospitalize


• True of many clinical systems, there are many questions and concerns

and

• Opportunities for improvement

• A fishbone worksheet looks something like this

A Lot to Address


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Let’s remember the Weak, Intermediate, &

Strong interventions –

The Process Improvement Plan


Action Plan - Hospitalizations


Page 2

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There is a lot to be said for beginning with one unit, one hall, one manager, charge and CNA

• Identify enthusiastic team members

• Take a week, monitor closely and work out the bugs

• Report progress and alter the plan accordingly using –

Start Small


Plan:

• Educate staff re INTERACT forms

• Use forms for one week

• Analyze results

Plan Do Study Act


Do

• Medicare Unit,

• Hall 1,

• 1st week of the month

Plan Do Study Act

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Study

• 5 residents with change in condition

• Assessment & notification?

• 1 resident transferred to hospital

• Root Causes identified?

• Physician feedback

• Documentation review

Plan Do Study Act


Based on results of study

• Added RN notification before MD contact

• Change location of INTERACT early warning tool

• Added systems review of residents at risk to shift report

• Walking rounds

Test alterations in system for 1 week,

begin education updates & orientation enhancements

Plan Do Study Act


Work with partners along the continuum to identify potential barriers and root causes for less than expected results-HOSPITALS, CLINICS, HOSPICE, HOME CARE…

• REAL LIFE EXAMPLES PROVIDE DATA

• REAL LIFE FEEDBACK TELLS HOW YOU’RE DOING

• MANY MINDS CAN GENERATE THE BEST SOLUTIONS

• LET EVERYONE DO THEIR PART

In other words…

Case Reviews

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Use feedback from customers & partners to

find risk factors, system failures, and opportunities for improvement

Communicate!


• Include results in monthly QA data

• Maintain QAPI structure for new Process Improvement Projects

• Post project results

• Use in marketing & to attract new partners

Continue PDSA


Latest INTERACT 3.0 materials:

http://www.interact2.net/

McKnights article re QAPI requirements:

http://www.iha.org/pdfs_documents/resource_library/Stephen%20Jencks.pdf

Rehospitalization PowerPoint for MD’s:

http://www.ajas.org/Docs/Webinars/Effective-Interventions-to-

Reduce-Rehospitalizations.pdf

http://cms.gov/Medicare/Provider-Enrollment-and-

Certification/QAPI/NHQAPI.html

Resources






http://www.iha.org/pdfs_documents/resource_library/Stephen Jencks.pdf








http://www.ajas.org/Docs/Webinars/Effective-Interventions-to-Reduce-Rehospitalizations.pdf











http://cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/NHQAPI.html








putting it into practice - mmic group ppt-follow your data.… · ©pathway health 2013 the new...

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