risk management and quality improvement in ltc karl e. steinberg, md, cmd karl e. steinberg, md, cmd...

Risk Management Risk Management and Quality and Quality

Improvement in LTCImprovement in LTC Karl E. Steinberg, MD, CMDKarl E. Steinberg, MD, CMD

Associate Medical Director,Associate Medical Director,Scripps Coastal Medical Center, OceansideScripps Coastal Medical Center, Oceanside

President, California Association of President, California Association of Long Term Care Medicine (CALTCM)Long Term Care Medicine (CALTCM)

Medical Director, Las Villas de Carlsbad HC, Medical Director, Las Villas de Carlsbad HC, Village Square Nursing Center, Hospice by the Village Square Nursing Center, Hospice by the

SeaSea

Editor-in-Chief, Editor-in-Chief, Caring for the AgesCaring for the Ages

ObjectivesObjectives Consider When to Call Doctor Consider When to Call Doctor

& What to Say& What to Say Review Notification Requirements Review Notification Requirements Importance of Informed Consent & RefusalImportance of Informed Consent & Refusal Discuss Common Documentation Discuss Common Documentation

Problems/ErrorsProblems/Errors Realistic Goals for Care Plans Realistic Goals for Care Plans Explore Issues With Unrealistic Explore Issues With Unrealistic

Residents & FamiliesResidents & Families

ObjectivesObjectivesAssociated Documentation Issues Associated Documentation Issues

& Risk Management Strategies& Risk Management StrategiesVital Signs, OVital Signs, O22 Sats SatsAssessmentsAssessmentsI/Os, Hydration, NutritionI/Os, Hydration, NutritionTurning & Repositioning, Pressure UlcersTurning & Repositioning, Pressure UlcersUTI vs. Asymptomatic BacteriuriaUTI vs. Asymptomatic BacteriuriaIssues in Diabetes, Anticoagulants, DepressionIssues in Diabetes, Anticoagulants, Depression

Recognize Current Negative Public Opinion Recognize Current Negative Public Opinion of our Industry & Strive to Improve It!of our Industry & Strive to Improve It!Compassion, Empathy, Human Touch Go a Long WayCompassion, Empathy, Human Touch Go a Long Way

Contacting the PhysicianContacting the PhysicianTrue Emergencies: Obviously, Use Most True Emergencies: Obviously, Use Most

Immediate Method (Pager, etc.) Immediate Method (Pager, etc.) May Need to Take Action without OrdersMay Need to Take Action without Orders

Significant but not truly Emergent symptoms:Significant but not truly Emergent symptoms:Consider Personal Preferences of MD/DO, Consider Personal Preferences of MD/DO, but do not compromise patient safetybut do not compromise patient safety

Moderate Symptoms, Need System to Ensure Moderate Symptoms, Need System to Ensure Follow-Up is Obtained! (& Documented)Follow-Up is Obtained! (& Documented)

Minor Symptoms (Skin Tears, Weight Minor Symptoms (Skin Tears, Weight Fluctuations, Non-Injury Falls)Fluctuations, Non-Injury Falls)Consider Fax with Printed Confirmation SheetConsider Fax with Printed Confirmation Sheet

Methods of Methods of CommunicationCommunication

Direct/Immediate (In Person, 2-Way)Direct/Immediate (In Person, 2-Way)By Telephone (Direct Conversation, 2-Way)By Telephone (Direct Conversation, 2-Way)By Voice Mail Message (Indirect/One-Way)By Voice Mail Message (Indirect/One-Way)Via Fax (Indirect/Passive, One-Way)Via Fax (Indirect/Passive, One-Way)Log Book or Communication Book (One-Way)Log Book or Communication Book (One-Way)E-mail (One-Way)E-mail (One-Way)Via EHR SystemVia EHR SystemVia Alpha Pager or Text Message (One-Way)Via Alpha Pager or Text Message (One-Way)

Different Situations Require Different Situations Require Different DocumentationDifferent Documentation

Notification of changes.

(i) A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is—

(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;

(B) A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);

(C) A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or

(D) A decision to transfer or discharge the resident from the facility as specified in §483.12(a).

Notification of changes.

• When in Doubt, Notify!• Failure to Timely (“Immediately”) Notify

Physician & Family Member May Result in Deficiencies/Citations

• Can also Result in Successful Lawsuits• Important to Document Notification• If Unsuccessful, Keep Trying

• And Keep Documenting!• Use Nursing Judgment• Call for Backup if Needed

• DON, Medical Director• Administrator/Executive Director

Other Times to Initiate ContactOther Times to Initiate Contact Abnormal Vital Signs (What Does This Mean?)Abnormal Vital Signs (What Does This Mean?) Skin BreakdownSkin Breakdown Poor Dietary or Fluid IntakePoor Dietary or Fluid Intake Weight LossWeight Loss Falls/Near-FallsFalls/Near-Falls Abnormal Laboratory StudiesAbnormal Laboratory Studies ******Family Concerns Family Concerns ******

Usually OK to let Family Know How to Contact DocUsually OK to let Family Know How to Contact Doc Usually Usually NOTNOT OK to Page Doc from Nurses’ Station for OK to Page Doc from Nurses’ Station for

Family & Hand Phone Over! (Ambush!)Family & Hand Phone Over! (Ambush!)

Other Times to Initiate ContactOther Times to Initiate Contact Resident Symptoms (Pain, Cough, Dyspnea, Resident Symptoms (Pain, Cough, Dyspnea,

Bowel Irregularities, Dysuria, Confusion, etc.)Bowel Irregularities, Dysuria, Confusion, etc.) When an Order is Not Carried Out as DirectedWhen an Order is Not Carried Out as Directed

Labs Not Drawn for any ReasonLabs Not Drawn for any Reason Medication Not Administered or Delivered (Timely)Medication Not Administered or Delivered (Timely)

Can Solicit a Substitute from E-Kit if Appropriate (esp. for Can Solicit a Substitute from E-Kit if Appropriate (esp. for Pain or when Serious Infection is Suspected)Pain or when Serious Infection is Suspected)

Refusals of Medication or TreatmentRefusals of Medication or Treatment Refusals of Turning & Repositioning or Use of Refusals of Turning & Repositioning or Use of

Splints, Adductor Pillows, Heel Protectors, etc.Splints, Adductor Pillows, Heel Protectors, etc. Unexpected Delays in Appointments for Test/ConsultUnexpected Delays in Appointments for Test/Consult

Sophie & TessaSophie & Tessa

Established Principles forEstablished Principles for Effective Communication Effective Communication

Except in Emergencies, Take Time to Prepare!Except in Emergencies, Take Time to Prepare! Do An Appropriate Assessment Before CallingDo An Appropriate Assessment Before Calling Have All Information Ready for ProviderHave All Information Ready for Provider Consider Calling Responsible Party FirstConsider Calling Responsible Party First Assess and Mention All Relevant DiagnosesAssess and Mention All Relevant Diagnoses Know the Preferred Intensity of Treatment!Know the Preferred Intensity of Treatment! It’s OK to Have an Agenda, but Be FlexibleIt’s OK to Have an Agenda, but Be Flexible Worth Having it Written Down BeforehandWorth Having it Written Down Beforehand

Consider SBAR or Similar Pre-Printed FormsConsider SBAR or Similar Pre-Printed Forms

Specific Strategies for Effective Specific Strategies for Effective Communication/NotificationCommunication/Notification

Have All Information Ready for PhysicianHave All Information Ready for Physician Chief Complaint & Associated HistoryChief Complaint & Associated History Vital Signs, Full Set, Recent! Vital Signs, Full Set, Recent!

Actually Do a Respiratory RateActually Do a Respiratory Rate Include Orthostatics if AppropriateInclude Orthostatics if Appropriate

Oxygen SaturationOxygen Saturation Results of Focused Physical Assessment Results of Focused Physical Assessment

e.g., Lung Sounds, Abdominal Exam (Bowel Sounds, Tenderness, e.g., Lung Sounds, Abdominal Exam (Bowel Sounds, Tenderness, Distention), Cardiac Rhythm/SoundsDistention), Cardiac Rhythm/Sounds

Check for Impaction, Check for Bladder DistentionCheck for Impaction, Check for Bladder Distention Assess Mental Status in Comparison to BaselineAssess Mental Status in Comparison to Baseline

Actually Assess Orientation—Residents Can Fool You!Actually Assess Orientation—Residents Can Fool You! Delirium Grossly Underdiagnosed & Carries Poor PrognosisDelirium Grossly Underdiagnosed & Carries Poor Prognosis


Have Medication List HandyHave Medication List Handy Know if Resident is on Coumadin (Antibiotic Interactions)Know if Resident is on Coumadin (Antibiotic Interactions) Know if Resident is or has been on Antibiotics recently Know if Resident is or has been on Antibiotics recently

(Increased Risk of C. diff., Yeast, Drug Reaction, etc.)(Increased Risk of C. diff., Yeast, Drug Reaction, etc.)

Have MARs with recent Blood Glucose values if Have MARs with recent Blood Glucose values if applicable, and Current Sliding Scale Coverageapplicable, and Current Sliding Scale Coverage

Know when last BM & Void Occurred, Meal IntakeKnow when last BM & Void Occurred, Meal Intake Know Hx of Previous Impaction, Retention, InfectionsKnow Hx of Previous Impaction, Retention, Infections

Consider the Use of a Standardized FormConsider the Use of a Standardized Form Can Create Facility-Specific, Symptom-Specific FormsCan Create Facility-Specific, Symptom-Specific Forms Get Medical Director to Provide Input!Get Medical Director to Provide Input!


Consult with Other Personnel if AvailableConsult with Other Personnel if Available CNA Usually Knows Resident Best! Talk to Them!CNA Usually Knows Resident Best! Talk to Them! Therapy StaffTherapy Staff Social Services or Case Manager: Is Discharge Looming? Social Services or Case Manager: Is Discharge Looming?

Talk to Resident and/or Family (if Non-Emergent)Talk to Resident and/or Family (if Non-Emergent) Know Code Status and Preferred Intensity of TreatmentKnow Code Status and Preferred Intensity of Treatment Consider Diagnostic & Therapeutic Measures In-HouseConsider Diagnostic & Therapeutic Measures In-House

Obtaining Labs/X-RaysObtaining Labs/X-Rays IV HydrationIV Hydration IV AntibioticsIV Antibiotics Respiratory Therapy (Nebulizers, Incentive Spirometry, Steroids, ORespiratory Therapy (Nebulizers, Incentive Spirometry, Steroids, O22)) More Frequent Monitoring: Vitals, Sats, Mental Status, etc.More Frequent Monitoring: Vitals, Sats, Mental Status, etc. Define Callback ParametersDefine Callback Parameters


Have Most Recent and Older Labs/XRs at HandHave Most Recent and Older Labs/XRs at Hand Important to Provide Baseline & Comparative ValuesImportant to Provide Baseline & Comparative Values

Have a Summary of Your Impressions & ConcernsHave a Summary of Your Impressions & Concerns Have an Idea of What Your Wish List for the Have an Idea of What Your Wish List for the

Situation Is—Offer it if Appropriate Situation Is—Offer it if Appropriate Must Consider Individual Practice/Personality Styles of Must Consider Individual Practice/Personality Styles of

Providers: In Some Instances, Tread LightlyProviders: In Some Instances, Tread Lightly Also Consider Individual Factors of Resident/FamilyAlso Consider Individual Factors of Resident/Family

Be an Advocate for Your ResidentsBe an Advocate for Your Residents Have a Policy Mandating Read-Back of All New Have a Policy Mandating Read-Back of All New

Orders, and Enforce It! (Safety First!)Orders, and Enforce It! (Safety First!)


If Nurse is Uncomfortable with MD/DO/NP/PA If Nurse is Uncomfortable with MD/DO/NP/PA Response—Call an Authority within the Facility to Response—Call an Authority within the Facility to Discuss (DON, Admin., Medical Director, etc.)Discuss (DON, Admin., Medical Director, etc.)

Need to Practice in Accordance with Your PrinciplesNeed to Practice in Accordance with Your Principles If Something Doesn’t Feel Right, It May Not Be RightIf Something Doesn’t Feel Right, It May Not Be Right But Also Need to Consider Your Own LimitationsBut Also Need to Consider Your Own Limitations In Some Cases, Turn Care Over to Another NurseIn Some Cases, Turn Care Over to Another Nurse

Need to Consider Your Own Professional LicenseNeed to Consider Your Own Professional License Need to Consider Facility/Corporate P&PNeed to Consider Facility/Corporate P&P Sometimes Involves Taking Alternative ActionSometimes Involves Taking Alternative Action If You Have Corporate Backup, Use It! (Consultant, If You Have Corporate Backup, Use It! (Consultant,

Regional Nursing or Risk Management Professional, etc.)Regional Nursing or Risk Management Professional, etc.)

Growth Areas for QualityGrowth Areas for Quality Hold Parameters on MedicationsHold Parameters on Medications

An Excellent Idea in Principle, Should Improve SafetyAn Excellent Idea in Principle, Should Improve Safety Needs to Be Consistently ImplementedNeeds to Be Consistently Implemented May Require More Frequent MonitoringMay Require More Frequent Monitoring Generally Physician-DrivenGenerally Physician-Driven

Most Commonly Used with Most Commonly Used with Antihypertensives, DigoxinAntihypertensives, Digoxin May Hold Antihypertensive for SBP<95-120May Hold Antihypertensive for SBP<95-120 May Hold Digoxin or Beta-Blocker for AP<50-60May Hold Digoxin or Beta-Blocker for AP<50-60 Also Consider What Also Consider What HoldingHolding Medication May Do Medication May Do

Should Consider Holding Opioids for Should Consider Holding Opioids for Excess Sedation or RR<8-10Excess Sedation or RR<8-10

Nebulizers, Sliding Scale Insulin are Grossly Nebulizers, Sliding Scale Insulin are Grossly Overutilized. Rarely Truly Necessary. Overutilized. Rarely Truly Necessary.

Dehydration a Common Problem & Cause of Change in ConditionCan Present as Lethargy, Abnormal VS (↑ HR, ↓ BP)Vicious Cycle as Intake Diminishes FurtherCNAs Often the First to Notice Subtle MS Changes, ↓ IntakeCNAs Also First Line of Defense in Prevention & TxEmpower CNAs—Encourage Communication,

Listen To & Appreciate Their Input!Snack/Hydration Carts A Good IdeaSometimes, Relative “Dehydration” is Desirable (Diuretics,

CHF)Clinical Signs of Dehydration Somewhat Unreliable

Until It is Advanced, But their Presence or Absence Should Be DocumentedSkin Turgor (Consider Forehead) Mucous Membranes, Sunken Eyes, Dry AxillaLab Work More Definitive, (Not Just BUN & Creatinine:

Sodium, Urine Specific Gravity, sometimes Urine Sodium)

Dehydration Is Sometimes Unavoidable: Document Discussion w/Responsible Party When This OccursEducate Family About OptionsWhen CHF is Present, Some Degree of Iatrogenic Dehydration Is Desirable

Dehydration Has a Bad Reputation as Cause of Death Largely Undeserved Reputation: Educate!! Enlist MD/DO/NP/PA Assistance

Consider IV Hydration in Facility, or Hypodermoclysis (Subcutaneous Infusion) …Rather Than Automatic Shipping to ER

Nutrition: ‘Therapeutic’ Diets Not HelpfulUsually Do More Harm than GoodFamilies/Residents May Need Education

Growth Areas for QualityGrowth Areas for Quality Dehydration Is Sometimes Unavoidable: Document Dehydration Is Sometimes Unavoidable: Document

Discussion w/Responsible Party When This OccursDiscussion w/Responsible Party When This Occurs Educate Family About OptionsEducate Family About Options When CHF is Present, Some Degree of Iatrogenic When CHF is Present, Some Degree of Iatrogenic

Dehydration Is DesirableDehydration Is Desirable Dehydration Has a Bad Reputation as Cause of DeathDehydration Has a Bad Reputation as Cause of Death

Largely Undeserved Reputation: Educate!! Largely Undeserved Reputation: Educate!! Enlist MD/DO/NP/PA AssistanceEnlist MD/DO/NP/PA Assistance

Consider IV Hydration or Hypodermoclysis Consider IV Hydration or Hypodermoclysis (Subcutaneous Infusion) (Subcutaneous Infusion) Rather Than Automatic Shipping to ER Rather Than Automatic Shipping to ER

Nutrition: ‘Therapeutic’ Diets Not HelpfulNutrition: ‘Therapeutic’ Diets Not Helpful

Growth Areas for QualityGrowth Areas for QualityFalls: Complete post-fall analysis before Falls: Complete post-fall analysis before

calling unless severe injury suspected or calling unless severe injury suspected or transfer requiredtransfer requiredCheck vitals including orthostaticsCheck vitals including orthostaticsFull Body CheckFull Body CheckIf unwitnessed, careful consideration of possible head injuryIf unwitnessed, careful consideration of possible head injuryFingerstick Blood Sugar if diabeticFingerstick Blood Sugar if diabeticCurrent Fall Prevention MeasuresCurrent Fall Prevention MeasuresHistory of Previous FallsHistory of Previous FallsAnticipate what an IDT would doAnticipate what an IDT would doHelp Doc Make Appropriate Choices (Add Tab Alarm, Low Help Doc Make Appropriate Choices (Add Tab Alarm, Low

Bed, Mats, Lap Buddy, etc.)Bed, Mats, Lap Buddy, etc.)If your facility is “Restraint-Free,” make sure If your facility is “Restraint-Free,” make sure

Resident/Family aware, and that other facilities may not Resident/Family aware, and that other facilities may not have that policy (Medicolegal and Liability Issues)have that policy (Medicolegal and Liability Issues)

Documentation Quality Documentation Quality IssuesIssues

Important to Individualize Charting (esp. Important to Individualize Charting (esp. Narrative)Narrative) Care Plans Are Often Highly Generic, Goals UnrealisticCare Plans Are Often Highly Generic, Goals Unrealistic Narrative Notes Should Include Some Physical Narrative Notes Should Include Some Physical

Assessment!Assessment! ““Call Light Within Reach”—A (Usually) Meaningless Call Light Within Reach”—A (Usually) Meaningless

NotationNotation ““Alert & Verbally Responsive”: Alert & Verbally Responsive”:

Not Enough! Tell More! Not Enough! Tell More! ““URI”—Usually Not Really URI”—Usually Not Really UpperUpper Respiratory Tract Respiratory Tract Alert Charting Should Actually Be On the Alert for Alert Charting Should Actually Be On the Alert for

Something!Something! Turning & Repositioning: Protocols Should Be Used and Turning & Repositioning: Protocols Should Be Used and

Documented. In High Risk Residents, Maybe Every Turn!Documented. In High Risk Residents, Maybe Every Turn! Education & Discussion of Risks, Benefits, Alternatives Education & Discussion of Risks, Benefits, Alternatives

Should Always Be DocumentedShould Always Be Documented

Basic Risk ManagementBasic Risk Management Accept That SNFs Are Viewed Negatively by Accept That SNFs Are Viewed Negatively by

PublicPublic Make an Effort to Humanize Care & CaregiversMake an Effort to Humanize Care & Caregivers Clarify HIPAA Issues Early On, Obtain Clarify HIPAA Issues Early On, Obtain

Permission to Discuss Resident w/All Permission to Discuss Resident w/All Appropriate Parties Appropriate Parties If You Don’t, There Will Be Bad Blood!If You Don’t, There Will Be Bad Blood! Don’t Be a HIPAA Zealot! Don’t Be a HIPAA Zealot! Consider Risks vs. Benefits of DiscussingConsider Risks vs. Benefits of Discussing

Help Create Realistic ExpectationsHelp Create Realistic Expectations Some Complications UnavoidableSome Complications Unavoidable Train All Staff to Be Compassionate, Train All Staff to Be Compassionate,

Empathetic & RespectfulEmpathetic & Respectful

Foster an Attitude of Compassion• Provide the kind of care you’d want your family to

get• Always greet residents/visitors and ask if they need

help• Respond promptly to phone calls and other concerns• Treat everyone in the building with respect• Have a Greeter/Receptionist (a Friendly One!)

Convene Ethics Committees when appropriate• Use Medical Director in complex or sticky situations• A Good Ombudsman Can Be a Great Asset

Avoid Value Judgment in Documentation Be complete in Documentation whenever

possible• Avoid “Charting Parties” and “Shadow Charting”

Ensure Adequate Staffing, but Avoid Registry• Good Evidence Exists that Consistency/Continuity of Staff

with Individual Residents Results in Improved Outcomes

You Know Who the Problem Families Are!• Be Proactive With These People!• Do Extra Charting, Extra Vitals, Extra Calls to Doc if

needed• Document Conversations with Resident/Family• Document Conversations with Attending Physician• Involve Ombudsman When Appropriate• Try to Work Collaboratively, Do Not Bad-Mouth Anyone• Be Caring! Or Act Like It!• Have Extra Team Meetings to Address Specific

Concerns Have People Sign Waivers When Doing

Something that’s Against Medical Advice• Even Though They Will Claim You Never

Explained It, Can Be Helpful in a Lawsuit• Get Attending MD/DO and/or Medical Director to

Assist with Documentation on Problem Residents

Growth Areas for QualityGrowth Areas for QualityPressure Ulcers are a Huge Source of Pressure Ulcers are a Huge Source of Pain, Pain, Medical Expenses & LiabilityMedical Expenses & LiabilityAlso Not All AvoidableAlso Not All Avoidable

Some Good Evidence that ‘Skin Failure’ is Some Good Evidence that ‘Skin Failure’ is Part of Part of

Dying Process, Interventions May Not Dying Process, Interventions May Not WorkWorkAlways Care-Plan & Manage Pain!Always Care-Plan & Manage Pain!

Education of Resident/Family is Education of Resident/Family is UsefulUseful

Create Realistic ExpectationsCreate Realistic Expectations

Documentation & Care Planning Documentation & Care Planning Critical (T&R!!)Critical (T&R!!)Use Specialty Mattresses, Wound Use Specialty Mattresses, Wound Consults EarlyConsults Early

Saving One Lawsuit Is Worth ExpenseSaving One Lawsuit Is Worth Expense

Make Sure Physician Kept In The Make Sure Physician Kept In The LoopLoop

Participate as a FacilityParticipate as a Facility

CAHF: QCHF & Other OfferingsCAHF: QCHF & Other OfferingsCalifornia Association of Long Term Care Medicine California Association of Long Term Care Medicine

((CALTCMCALTCM) ) www.caltcm.org Education, Advocacy, Cutting-Edge Medical Updates, Education, Advocacy, Cutting-Edge Medical Updates,

Networking, Medical DirectorshipNetworking, Medical DirectorshipAnnual Meeting July 10-12 in LA at Omni. Annual Meeting July 10-12 in LA at Omni. Save the Date!Save the Date!POLST Implementation Pre-Conference July 10POLST Implementation Pre-Conference July 10

Advancing Excellence ProgramAdvancing Excellence Programwww.nhqualitycampaign.org Multiple Goals/Parameters to Improve QualityMultiple Goals/Parameters to Improve Quality

American Medical Directors Assoc. (AMDA)American Medical Directors Assoc. (AMDA)National Organization for Medical DirectorsNational Organization for Medical DirectorsClinical Practice Guidelines, ToolkitsClinical Practice Guidelines, Toolkits

Take-Home MessagesTake-Home Messages

Transfers & Other Transitions in Care Settings Transfers & Other Transitions in Care Settings are a Major Source of Errors are a Major Source of Errors …and a Great Opportunity for Growth! …and a Great Opportunity for Growth!

Documentation is Critical: Accurate, Complete, Documentation is Critical: Accurate, Complete, Individualized, Relevant, Resident-CenteredIndividualized, Relevant, Resident-Centered

Team Approach is Optimal: Consider and Team Approach is Optimal: Consider and Respect All Opinions, Especially CNAsRespect All Opinions, Especially CNAs

Create (& Document) Realistic Create (& Document) Realistic ExpectationsExpectations

When Not Possible, When Not Possible, Document Unrealistic OnesDocument Unrealistic Ones

Take-Home MessagesTake-Home Messages Engage Medical Director, Ensure Interest & Engage Medical Director, Ensure Interest &

Participation in Education, OrganizationsParticipation in Education, Organizations Join CALTCM as a Facility: Join CALTCM as a Facility: www.caltcm.orgwww.caltcm.org Medical Director Should Consider CMD CertificationMedical Director Should Consider CMD Certification

If Medical Director Not Active, Change That!If Medical Director Not Active, Change That! Get Outside Help When AppropriateGet Outside Help When Appropriate Devise Action Plans for Building-Specific IssuesDevise Action Plans for Building-Specific Issues

Falls, Pressure Ulcers, Dehydration, Bacteriuria/UTI, Falls, Pressure Ulcers, Dehydration, Bacteriuria/UTI, Identification of Delirium are Good Places to StartIdentification of Delirium are Good Places to Start

Policies & Procedures Should Be Current, Policies & Procedures Should Be Current, Evidence-Based, and Actually Followed!Evidence-Based, and Actually Followed!

Consider Using AMDA’s Clinical Practice Guidelines and Consider Using AMDA’s Clinical Practice Guidelines and Tool Kits Tool Kits www.amda.comwww.amda.com

Take-Home MessagesTake-Home Messages

Maintain Attitude of Empathy and HumanityMaintain Attitude of Empathy and Humanity Consider Palliative Care Early When AppropriateConsider Palliative Care Early When Appropriate Our Work Is Valuable, Important, Our Work Is Valuable, Important,

Compassionate and LovingCompassionate and Loving Culture Change Is Upon Us: Let’s Culture Change Is Upon Us: Let’s

Work to Improve Public Perception of Our Industry!Work to Improve Public Perception of Our Industry! Keep Striving to Improve Quality Keep Striving to Improve Quality

and Reward Innovationand Reward Innovation Get Support and Input Get Support and Input

from Medical Directorfrom Medical Director

risk management and quality improvement in ltc karl e. steinberg, md, cmd karl e. steinberg, md, cmd...

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