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Developing Quality Systems and Personnel

Developing Quality Systems and Personnel. Putting the Pieces Together. Developing Quality Systems. Objectives Identify components of quality validation review process Identify how to schedule and make assignments Identify how to review findings with team

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Developing Quality Systems and Personnel

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  1. Developing Quality Systems and Personnel Putting the Pieces Together

  2. Developing Quality Systems Objectives • Identify components of quality validation review process • Identify how to schedule and make assignments • Identify how to review findings with team • Identify how to monitor progress

  3. Impetus for change • Average number of deficiencies per standard survey increased • Number of immediate jeopardy citations increased • QIS survey process

  4. Quality Validation Review • Proactive • Process oriented • Collaborative • Initiated 6 months prior to anticipated standard survey • Follows 7 survey tasks • Uses Critical Elements from QIS survey

  5. Annual Timeline

  6. Quality Validation ReviewScheduling and Attendance • Scheduling Six (6) months prior to anticipated standard survey Twice a year for higher risk centers

  7. Quality Validation ReviewScheduling and Attendance

  8. Quality Validation ReviewAssignments

  9. Quality Validation ReviewProcess • Entrance conference • Assignment review and completion target • Follows 7 survey tasks • Uses Critical Elements, QM/QI validation tools • Preliminary exit with administrator, DON • Conference with facility and regional or divisional management team • Quality Milestone Action Plan development

  10. Critical Element

  11. QM/QI Validation Tool

  12. Summary of findings • Grouping of like findings by F tag • Team conference Agreement on: Citation or concern F tag Scope and severity Responsibility for POC & QMAP • Calculation of SFF points

  13. Plan of Correction Development

  14. Quality Milestone Action Plan

  15. Monitoring • Responsibility of facility to assure completion of plan of correction • Regional consultant follow-up and assistance with education and audits • Re-validation 90 days later (STAT)

  16. Survey Training and Tools • Re-validation of plan of correction from Quality Validation Review “Clear” previous citations Identify new citations • Preparation of survey expandable file • Education of staff regarding survey process

  17. QVR to STAT to Survey QVR STAT SURVEY

  18. Facility Perspectives Views from a facility team: Administrator – Matthew Baad Director of Nursing – Fran Brown

  19. Developing Quality Personnel Objectives • Identify components of the licensed nurse orientation program • Identify the process steps needed for implementation • Identify components of the preceptor training program

  20. Before… Turnover Rates 2007 • Licensed Nurses = 51%!!! YIKES

  21. Getting Ready for Change Infrastructure • Human Resources • Regional Nurse Educators • Preceptors

  22. Human Resources Considerations: • Role definition • Education calendar • General orientation schedule • Mastering Caring Leadership • Turnover and retention tracking system

  23. Regional Nurse Educators Considerations: • Site selection • Clinical skills labs • Classroom settings • Equipment and Supplies • Skills validation process

  24. Preceptors Considerations: • Compensation model • Training sites • Selection process • Training • Follow-up

  25. Putting it all Together

  26. …After Turnover Rates • Licensed Nurses = 15%!!! yippee

  27. Facility Perspectives Views from a facility team: Director of Nursing – Henrietta Makowski Regional Nurse Educator – Rose Zlotecki

  28. Thank You! Questions

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