Kenneth Daily, LNHA Elder Care Systems Group Kenn@qissurvey

1. What is CMS Up To? Who Defines Quality? Kenneth Daily, LNHA Elder Care Systems Group Kenn@qissurvey.com

2. MyCare Ohio Implementation • MyCare Ohio program will be delayed for one month, with the earliest effective date for coverage to be May 1, 2014. • Several other changes and clarifications: • A dual eligible beneficiary’s ability to sign up for MyCare voluntarily and get coverage one to three months early (depending on region) is being eliminated. • Coverage effective date will be July 1 for west central Ohio

3. Enrollment • Importantly, passive enrollment into MyCare initially will be for Medicaid only. Dual eligible beneficiaries may choose to join the program for Medicare as well ("opt in") but will not be passively enrolled. Previously, passive enrollment applied to both programs from the beginning. • The department is not issuing new “friendly letters,” but the 60 day enrollment letter will be pushed back to February 28 or later, depending on region.

4. Quality Pressures Value Culture Change Accountability SNFs Use of Technology Aging Population Quality and Transparency

5. Quality Care or Compliance?

6. The Five Erroneous Assumptions Quality means goodness, elegance Quality is intangible, not measurable The “economics of quality” are prohibitive, not relevant Quality problems originate with the workers Quality is the responsibility of the quality department Quality is conformance to requirements Quality is measured by the cost of nonconformance It is cheaper to do things right the first time Most problems start in planning -development Quality is shared by every function and department

7. Quality AssurancePerformance Improvement S&C Memo 13-05-NH December 14, 2012

8. Comparison of QA and QI

9. QAPI as a Foundation • For person-centered care • Relies on the input of residents and families • Measurement of not only process but also outcomes • For defining quality as ‘how work is done’ • Broad scope – entire organization (all staff and all depts) • Leadership expected to be a model • For systems thinking • Proactive analysis • Data and measurement driven • Supported by tools

10. QAPI Background • Mandated in the Affordable Care Act, enacted March 2010 • Legislation requires the Centers for Medicare & Medicaid Services (CMS) to establish QAPI program standards and provide technical assistance to nursing home providers. • CMS identified training needs for long-term care surveyors. • Demonstration projects are ongoing now and tools are coming.

11. QAPI • According to CMS, this initiative “significantly expands the level and scope of required QAPI activities to ensure that facilities continuously identify and correct quality deficiencies as well as sustain performance improvement” • QA is a process of meeting quality standards and typically set to comply with regulations. • PI is a pro-active and continuous study of processes with the intent to prevent or decrease the likelihood of problems. Fix underlying causes of persistent/systemic problems.

12. QAPI Must… According to CMS, this initiative “significantly expands the level and scope of required QAPI activities to ensure that facilities continuously identify and correct quality deficiencies as well as sustain performance improvement” Involve all NH services Prove that “priorities” were identified and chosen for PI activities Focus on indicators Take actions to demonstrate improvement and are sustainable Maintain documentary evidence of it’s operation and be able to demonstrate this to CMS Developed, implemented and maintained Effective, ongoing, nursing facility-wide – that is both clinical and non clinical indicators of quality to be measured Data driven

13. 5 Elements of QAPI • Element 1 – Design and scope • Element 2 – Governance and leadership • Element 3 – Feedback, data systems and monitoring • Element 4 – Performance improvement projects • Element 5 – Systematic analysis and systemic action

14. CMS QAPI Efforts • Nursing home quality improvement questionnaire • Development of QAPI tools and resources • Development of QAPI website • QAPI demonstration project: • Test tools/resources • Conduct learning collaboratives • Online resource center for demo participants

15. Phase 3 Roll-Out • Provider Materials • Process & Topic Tools • Online Learning Sessions • Focused Webinars • Surveyor Training Needs: • Understanding Systems Thinking • Evaluating Plans of Correction • Surveyor Worksheet • Prompts surveyors throughout survey process • Helps identify systems issues to be investigated during QAPI review • Consumer Information

16. Root Cause Analysis • Finding the real cause of the problem and dealing with it rather than simply continuing to deal with the symptoms • Asks why, why, why at each level • Interdisciplinary- involves those closest to the situation • Identifies changes that need to be made • Identifies risks and how they contributed • Leads the team to potential process improvements • Move beyond a culture of blame

17. Tools for RCA

18. WHY Analysis Resident fell last night It was dark and tripped going to bathroom No staff member helped Resident pushed called light Resident always just gets up even though not steady Therapist told resident to be more independent • Dark bathroom • Staffing • Toileting

19. Now What??? • Have active and effective QAPI program • Auditing, rounding and accountability • William Deming • Plan, Do, Study and Act • Planning is the identifying of hazards and risk • Do is the implementing of interventions to reduce risks and hazards • Study is the monitoring of effectiveness • Act is the effectiveness and modifying as necessary

20. Y-ers X-ers Boomers Matures

21. F Tags Quality Corp Compliance MDS 3.0 5 Star Life Safety Code Special Focus Audits Disasters QAPI Quality Measures • Immediate Jeopardy Culture Change K Tags • QIS

22. Culture Change is More Than Eden Alternative, Green Houses, Small Houses and Pioneer initiatives Or the superficial displays of culture change: Having mailboxes and front doors yet no one knocks or takes seriously the privacy it is meant to offer Fin, fur and feathers Food line buffet Memory boxes Brag board All these efforts are important but these do not deliver culture change

23. Health Promotion New Practice Institutional Care Individualized Care Old Practice Risk Prevention Culture Change

24. Quality Improvement is Key • The QIS offers each facility with the tools and concepts necessary to maintain and enhance each facility • Do the QIS • Conduct sample interviews, record reviews and observations • Conduct resident, family and staff satisfaction surveys • Improve communications with staff • Recognize that the process relies a lot on empowerment and satisfaction

25. The QIS Process The Quality Indicator Survey process is a revised survey process that changes how surveyors determine a facility's compliance Phase I Collected comprehensive set of resident sampling data consisting of standardized questionnaires, specific observations and record reviews which is used to determine a facilities Quality Indicators Phase II Once the quality indicators are determined surveyors investigate items which exceed CMS thresholds Goes beyond previous traditional survey process by measuring quantifying quality of life aspects of care

26. Citations and Survey Time Nat’l QIS OH QIS Average Number of Citations/ Survey 7.8 4.9 Deficiency free 6.9% 9.6%

27. “Trigger” Responses QIS rates for: • Resident Observation 16.6% • Resident Interview 19.4% • Family Interview 19.6% • Staff Interview 18.6% • Census Clinical Record 15.2% • Admission Clinical Record 17.8%

28. Triggered Care Areas • Frequently Triggered (> 60% of surveys) • Accidents and Falls, Pressure Sores, Community Discharge • Commonly triggered (30%-59% of surveys) • Dental status, personal property, ROM, activities, Abuse/Abuse Prohibition, Environment, ADLs, Death, Sufficient staffing, personal funds, choices dignity • Less Frequently Triggered (< 20% of surveys) • Incontinence, participating in care planning, food quality, pain, skin (non-pressure), privacy, restraints, notification of change, positioning and social services

29. Deficiency Rates – Mandatory Tasks • Unnecessary Med Use 39% • Kitchen 36.2% • Infection Control 35.8% • Dining 25.5% • Med Storage 23.7% • Med. Admin 14.3% • Liability Notices 11% • Resident Council 7.5% • QA & A 6.7% Rates = # cited divided by # investigated (not total # of surveys)

30. Deficiency Rates TRIGGERED Tasks • Environment 69% • Abuse Prohibition 23.9% • Adm, Transfer, Discharge 22.4% • Personal Funds 24.6% • Sufficient Nursing Staff 9.4% Rates = # cited divided by # investigated (not total # of surveys)

31. Frequency of Citations • High frequency when investigated in stage II (>50%) • Positioning (F309) • Environmental conditions (F253) • Physical restraints (F221)

32. Frequency of Citations • Commonly cited (25%-49%) • ADLs (F312-13) • Pain (F309) • Catheter (F315) • Accidents and falls (F323) • Social services (F250) • Pressure sores (F314) • ROM (F312-13) • Dental (F411-12) • Food Quality (F365) • Nutrition (F325)

33. Leading Deficiencies • Assessment F272 • Care Planning F279 • Professional Standards of Care F281 • Accident/ Hazards F323 • Quality of Care F309 • Unnecessary Medications F329 • Infection Control F441 • Bowel/Bladder function F315 • Dignity F241 • Food Handling F371 • Pressure Sores F314 • Environment F253 • Notify of change F157 • Resident Abuse F223-26 • Staffing F353

34. Disasters

35. CMS Actions • On December 31st CMS released draft rules related to CMS covered facilities to develop comprehensive disaster management program. • Mitigation, Preparedness, Response and Recovery • Policies, Hazard Vulnerability, Incident Command, Training, table top exercise

36. Disaster Cycle Mitigation - Minimizing the effects of disaster. Examples: building/LSC: risk/vulnerability analyses Preparedness - Planning how to respond including preparedness plans; emergency exercises/training; warning systems Response - Efforts to minimize the hazards; Examples: search and rescue; emergency relief Recovery - Returning the community to normal; providing care, rebuilding, return to normal or better

37. Mitigation • Create an All Hazards Plan to consider various hazards and disaster scenarios • Risk/Hazards Analysis is the possibility of loss, damage or any other undesirable event. • Process used to identify hazards • Which hazards get attention • Priorities • Resources • Maintaining Life Safety Code requirements • People – Assigned to the right tasks including • Triage • Tracking • Transport • Treatment

38. Emergency Management Program ??? • Prepare for disruption of essential services • Heating and cooling • Medications • Shelter • Utilities • Food • Supplies • Equipment

39. What is anAll Hazards Approach? • SNF’s plan addressing a wide variety of disasters through the implementation of a unified approach and Incident Command • Top potential events which could activate the Disaster Plan: • Fire • Utility Failure • Severe weather • Flood

40. WHY DO WE BOTHER TO TRAIN? • Because we are required to! • A plan on paper is meaningless • Must be useable, realistic, applicable • How do you know it works? • Because people react the way they were trained • Partner with others to obtain grants, share costs • Look for consultants and training programs that “Train the Trainer” • Command (management) needs to “buy in” • If you don’t make improvements from “lessons learned’’, don’t bother

41. NHICS • System for managing emergent and non-emergent situations • Provides SNFs with required tools to address the event • NHICS initiated by an internal/external event and is scalable and flexible • Every disaster assumes an Incident Commander

42. NH Incident Command System A standardized, all-hazard approach to incident management; usable to manage all types of emergencies, routine or planned events, by establishing a clear chain of command Organization Safety Achievement of objectives Effective use of resources

43. NHICS Functions Identified Command structure Management by objectives Command (Leader) Operations (Doers) Planning (Planners) Logistics (Getters) Finance/Administration (Money) Common terminology Resource management Integrated communications

44. Incident Command

45. The Quality Puzzle • When should the pursuit for quality begin? • Cannot wait for the government regulation or customer expectations to change before paying attention to quality management • We must put quality management procedures into place to improve quality in spite of imperfect specification.

46. Start Small What can you do by next Tuesday?

47. Kenneth Daily, LNHA Elder Care Systems Group kenn@qissurvey.com Consulting and education focusing on quality improvement, survey compliance, and facility management. Comprehensive Traditional and QIS technical assistance, Mock surveys and audits Standard/traditional and QIS preparation Directed Plan of Correction development and implementation Immediate Jeopardy Assistance Quality/Performance Improvement Program development and implementation Corp Compliance Plans