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Achieving Quality in the Pursuit of the Silver AHCA/NCAL National Quality Award. Steve Izzo LNHA, MPH, Administrator Karen Gentile RN, Assistant Administrator/DON Meredith Weil LSW, Director of Social Services Inglemoor Rehabilitation and Care Center (IRCC) Livingston, New Jersey. Objectives.

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achieving quality in the pursuit of the silver ahca ncal national quality award
Achieving Quality in the Pursuitof the Silver AHCA/NCAL National Quality Award

Steve Izzo LNHA, MPH, Administrator

Karen Gentile RN, Assistant Administrator/DON

Meredith Weil LSW, Director of Social Services

Inglemoor Rehabilitation and Care Center (IRCC)

Livingston, New Jersey

objectives
Objectives
  • Achieving and Sustaining Performance Excellence using the AHCA quality award application
  • Applying Best Practices to achieve and sustain quality
  • Involving and Empowering Staff in Performance Improvement Initiatives
value of participating in the ahca ncal quality award
Value of Participating in the AHCA/NCAL Quality Award
  • Focus on quality awareness throughout the organization
  • Framework for our Performance Improvement program
  • Tools, resources, education to achieve and sustain performance excellence
  • Engage and reconnect with staff
tools and resources
Tools and Resources
  • Best Practices models
  • CMS’s QI Indicators
  • Advancing Excellence
  • LTC Trend Tracker
  • MyInnerview surveys
  • AHCA quality award criteria
  • CMS Five Star Rating (nursing home compare)
inglemoor s quality journey
Inglemoor’s Quality Journey
  • 2008 Bronze Award (awarded 2nd attempt)
  • 2010 Silver Award (awarded 2nd attempt)
  • 2011 Gold Award (1st attempt)
quality award application
Quality Award Application
  • Start Early do it through out the year
  • Engage entire workforce
  • Small team to write
  • Professional review
  • Resources and tools
  • Network
  • Don’t lose focus on your core competency
post acute

OVERALL SATISFACTION

RECOMMENDATION TO OTHERS

QUALITY OF LIFE DOMAIN

98

95

93

89

88

85

85

89

87

84

82

82

80

82

81

90

90

QUALITY OF CARE DOMAIN

QUALITY OF SERVICE DOMAIN

85

84

83

82

82

82

81

81

Post Acute
family

100

94

93

93

89

89

OVERALL SATISFACTION

88

RECOMMENDATION TO OTHERS

QUALITY OF LIFE DOMAIN

88

88

88

85

85

87

85

85

85

84

75

QUALITY OF CARE DOMAIN

QUALITY OF SERVICE DOMAIN

90

88

87

86

83

83

81

82

79

79

78

74

Family
employee

OVERALL SATISFACTION

RECOMMENDATION FOR JOB

RECOMMENDATION FOR CARE

95

93

92

91

87

87

87

84

84

80

80

80

80

77

73

74

69

67

WORK ENVIRONMENT DOMAIN

TRAINING DOMAIN

82

79

74

71

70

73

74

72

68

67

65

64

Employee
geographic market all nation peer group all peers metric occupancy rate percentile peer group state
Geographic Market: All (Nation) Peer Group: All (Peers)Metric: Occupancy rate Percentile Peer Group: State
best practice
Best Practice

Karen Gentile RN, BSN

Assistant Administrator/DON

best practice guidelines

Best Practice Guidelines

A best practice guideline is a “systematically developed method for statements (based on best available evidence) to assist practioner and patient decisions about appropriate healthcare for specific clinical circumstances” (Field and Lohr – 2002, p.8)

The idea is with proper processes a desired outcome can be delivered with fewer problems and complications.

the expected benefits of using initiating best practices
The Expected Benefits of Using/Initiating Best Practices
  • Improved Quality of Care and Resident Outcomes
  • Increased knowledge; evidence based practice that will support the care of our geriatric patients
  • Provides support for nurses and staff in our facilities
  • Improved quality of work life for staff

Implementing Best Practices

1. Evaluate your Facility Needs

    • Use of QI, resident/family surveys, employee surveys, complaint investigation, quarterly meetings, staff meetings
    • Identify which performance measure and evidence based practices offer the most promise for improving quality of care and life within your facility
implementing best practices
Implementing Best Practices
  • Find a well developed, evidence based best practice guideline
    • identify whether a credible organization has evaluated the guideline process
implementing best practices1
Implementing Best Practices
  • Identify and engage stakeholders
  • Identify the stakeholders who have high influence and support the implementation
implementing best practices2
Implementing Best Practices
  • Assess the environment for readiness for Best Practice Implementation
      • Identify the barriers and facilitators of implementation
implementing best practices3
Implementing Best Practices
  • Use of Implementation Strategies
    • Hold interactive educational meetings for all staff
    • Provide reminders to prompt behaviors
    • Build consensus among team
    • Provide ongoing monitoring and support during the process
implementing best practices4
Implementing Best Practices
  • Evaluate the Implementation Process
    • Provide baseline data before implementation and benchmark to current data
    • Outcome  achievement of targets and goals, adherence to Best Practice Guidelines, increased health outcomes of our patients
    • Support staff/share with staff
objective
Objective
  • Limit and/or prevent the occurrence of falls within the parameters that can be controlled through structured interventions
    • Minimize the severity of injuries sustained
    • Provide the professional staff with acceptable standards of practice that will enable them to perform effectively
    • Educate the resident, family and staff
    • Limit the liability and financial risk to the facility
key elements to a fall management program
Key Elements to a Fall Management Program
  • Assessment
    • Clinical Assessment by RN
    • Rehab Assessment
    • Pharmacological Assessment
    • Environment Assessment
key elements to a fall management program1
Key Elements to a Fall Management Program
  • Dynamic Treatment Plan
    • Multidisciplinary implementation of interventions based on results of the assessments and resident preferences
    • The IDC Team must address:
      • Resident, staff and family education
      • Room modifications
      • Residents daily routines
      • Physical limitations
      • Pain Management
      • Medication use
      • Proper and consistent use of assistive device
key elements to a fall management program2
Key Elements to a Fall Management Program
  • Evaluation
    • Post Fall Evaluation
        • Fall Management Investigation
          • Physical assessment
          • Contributing factors to fall
    • Reporting mechanism/tracking of falls within facilities
        • Facility Fall Summary
        • Action of the IDC Team
        • Collective review and analysis of trends in resident falls throughout the facility
    • Facility Protocol may include review by safety committee, QI committee
key elements to a fall management program3
Key Elements to a Fall Management Program
  • Education / Awareness
      • Falls Program in service
          • Staff members
          • Resident / Family

Content of Review:

I. Instruction and information concerning safety awareness

II. Proper uses of call bells, wheelchairs, assistive devices

III. How they can assist

key elements to a fall management program4
Key Elements to a Fall Management Program
  • Quality Improvement
    • Collect fall data
        • Post fall tool
        • Fall summary report
          • Conduct interdisciplinary analysis of information to gain knowledge
          • Review and revise Policies and Procedures

(P&P) as appropriate

- Retrain staff on new P&P

performance improvement pi cycle
Performance Improvement (PI) Cycle
  • Formal process of gathering meaningful data points
  • Data is turned into useful information through evaluation and analysis
  • The information is used to assess and determine the current system strengths and weaknesses.
performance improvement pi cycle1
Performance Improvement (PI) Cycle
  • The knowledge gained is applied to the current system in the form of action plans aimed to improve performance and outcomes.
  • Sustain deployed action plans through integration of learning from evaluation and repetition of cycles.
performance improvement tools
Performance Improvement Tools
  • Design, Measure, Assess, Improve and Control (DMAIC) Tool
  • Plan, Do, Check, Act (PCDA) Tool
  • Fishbone Diagram
  • Root Cause Analysis (RCA)
  • Cause and Effect Map
  • Failure Mode and Effects Analysis (FMEA)
  • SMART Tool
  • Pareto Analysis Chart (PAC)
performance improvement tool pdca
Performance Improvement Tool PDCA
  • Plan – Identify and target root causes of problems and develop action plan
  • Do – Pilot planned solution and implement activity
  • Check – Measure, Audit, Evaluate outcomes
  • Act – Determine if improvements have been met, refine and expand solutions, and monitor progress
inglemoor rehabilitation and care center s 2010 pi initiatives
Inglemoor Rehabilitation and Care Center’s 2010 PI Initiatives
  • Dining Experience PI
  • Callbell Response PI
dining experience pi initiative
Dining Experience PI Initiative
  • The Dining experience was identified as an area for us to improve our performance as evidenced by poor customer satisfaction survey responses in the area of quality of meals, dining experience and an increase in customer complaint forms in the same areas over the past year.
dining experience pi initiative1
Dining Experience PI Initiative

The Dining Experience PI team was chaired by a department head and line staff from various departments and levels of responsibility.

The team met and developed a resident questionnaire to identify the root causes of the problem. The team divided up the residents in house and completed the questionnaires with them, commencing the data gathering process.

dining experience pi initiative2
Dining Experience PI Initiative
  • Identified Root Causes of problem
  • Wrong food temperatures
  • Un-timely tray pass
  • Wrong food orders being given and missing items on tray
  • Poor customer service dining staff impolite
  • Lack of menu selection and repetitious menu cycles
dining experience pi initiative3
Dining Experience PI Initiative
  • Action Plans developed from gathered data
  • Complete necessary repairs to kitchen steam table to keep food hotter prior to serving
  • Tray passes started earlier and supervisor oversees timeliness of tray pass on units
  • Policy and procedure on selective menus revised to ensure they were being delivered timely and accurately.
dining experience pi initiative4
Dining Experience PI Initiative
  • Action Plans continued
  • New system developed to have a second person checking trays on the line to ensure proper food and condiments are being given
  • Extensive inservicing with dining room staff on good customer service
  • Revised menus with dietary staff to widen the variety of meals to keep up with resident expectations.
dining experienced pi initiative
Dining Experienced PI Initiative

Checking Stage

  • This stage requires ongoing monitoring of action plans to determine if they are successful
  • Evaluate outcomes through the use of resident satisfaction surveys and feedback

Acting Stage

  • We have continued to monitor our outcomes and refine and expand upon solutions. We repeat this cycle to sustain results
callbell response pi initiative
Callbell Response PI Initiative
  • Callbell Response was also identified in the same way our dining experience was identified as an opportunity for performance improvement
  • Through resident surveys and complaint forms we identified that our residents were dissatisfied with the wait time
  • We assembled a second PI team using the same method as Dining initiative
callbell response pi initiative1
Callbell Response PI Initiative
  • Data was gathered through the use of a callbell response questionnaire created by our PI team and completed with the residents
  • Once data was gathered and evaluated, the root causes for long callbell wait times were identified by the PI team
callbell response pi initiative2
Callbell Response PI Initiative
  • Identified Root Causes of problem
  • Perceived lack of staff
  • CNA’s are busy assisting other residents
  • Staff turns callbell lights off telling patients they will be right back and never return
  • Lack of oversight by nurses
  • High callbell volume during particular times of the day (AM, Shift change, etc.)
  • Staff takes extended breaks too often
callbell response pi initiative3
Callbell Response PI Initiative
  • Action Plans developed from gathered data
  • Inservice nursing staff on all shifts on approaches for improving callbell response
  • Reinforce resident’s routine and customary preferences for care by developing a schedule if possible to anticipate resident’s needs
  • Inservice ALL staff on their mandatory participation in answering callbells, especially during AM care
callbell response pi initiative4
Callbell Response PI Initiative
  • Action Plans continued

4. We created a callbell checklist for staff when answering call lights: does the resident have water pitcher, phone, callbell, tissues, tv remote in reach before staff exists room?

5. Asking “is there anything else I can do for you?” before you leave the room

6. Continued customer service training. A staff member’s positive/negative attitude can impact a resident who has been waiting for care

7. Maintain the highest staffing levels possible

callbell response pi initiative5
Callbell Response PI Initiative
  • Checking stage
  • This stage requires ongoing monitoring of action plans to determine if they are successful
  • Evaluate outcomes through the use of resident satisfaction surveys and feedback
  • Acting Stage
  • We have continued to monitor our outcomes and refine and expand upon solutions. We will repeat this cycle to sustain results
the power of an engaged and empowered workforce
The Power of an Engaged and Empowered Workforce

“No company, small or large, can win over the long run without energized employees who believe in the company’s mission and understand how to achieve it.”Jack Welch, retired CEO of General Electric

the power of an engaged and empowered workforce1
The Power of an Engaged and Empowered Workforce
  • Building a Team of Engaged Employees starts with leaders clearly stating expectations and responsibilities of work along with purposes and function of work.
  • Recruitment phase – Purpose of work must be communicated from the beginning of the recruitment phase. This ensures the employee understands the ultimate purpose and mission of the organization which should help to attract potential employees to feel like they have found a “home” and they are aligned with the vision of the organization.
the power of an engaged and empowered workforce2
The Power of an Engaged and Empowered Workforce
  • The Hiring Phase – During this phase leaders should carefully select employees. Not just hire “a warm body” to do the job.
  • The Orientation Phase – During the orientation process employers should “set the bar high” and offer the employee a significant emotional opportunity to become invested in the mission of the organization.
the power of an engaged and empowered workforce3
The Power of an Engaged and Empowered Workforce
  • The Orientation Process – Employers should talk about the culture of the organization, the strategic objectives and why they are important and relevant to the facilities mission statement. Employers must identify those employee’s who have potential to foster the growth of their organizational culture.
  • As leaders identify these employees they should invest in them and involve them in quality improvement endeavors.
the power of an engaged and empowered workforce4
The Power of an Engaged and Empowered Workforce
  • Ongoing Departmental Training – During these regular opportunities to engage with employees, leaders should reiterate expectations and responsibilities and relay “excellence is expected everyday”.

Employers should use these opportunities to reinforce and recognize employees who are engaged. Employers must be sure their employees clearly understand that their efforts will be encouraged, good work will be rewarded, and their opinions and ideas matter.

  • THE QUICKEST WAY TO DEMOTIVATE YOUR ENGAGED EMPLOYEE IS FOR THEM TO SEE THEIR LEADERS TOLERATE MEDIOCRACY OR POOR PERFORMANCES!
the power of an engaged and empowered workforce5
The Power of an Engaged and Empowered Workforce
  • Keeping Your Workforce Engaged and Empowering Them
  • Involve them! Solicit their input and opinions on major issues within the organization.
  • According to MyInnerView (MIV), “employees need to know where the bus is going”. MIV conducted a “2009 National Survey of Consumer and Workforce Satisfaction in Nursing Facilities”. The results identified consistent negative themes in their comments, foremost being that employees felt that managers did not listen or pay attention to staff issues. This included listening to employee concerns and a caring attitude among supervisors. Supervisors must ensure their employees feel like a part of the organization and that their co-workers are committed to doing a good job too.
the power of an engaged and empowered workforce6
The Power of an Engaged and Empowered Workforce
  • “Employee engagement is achieved one employee at a time; it is a marathon and not a sprint. It starts with senior management’s commitment and trickles through every management layer of the organization until every employee has a clear line of sight about what matters most and what they can do to make a difference every time they walk through the door”. (MIV Supplement, Oct. 2010)
the power of an engaged and empowered workforce7
The Power of an Engaged and Empowered Workforce

“My InnerView’s “2009 National Survey of Consumers and Workforce in Nursing Facilities” shows that nursing facilities that score higher on employee satisfaction also score higher on family satisfaction. Nursing Facilities that score higher on family satisfaction also score higher on resident satisfaction.” (MIV Supplement, Oct. 2010)

the power of an engaged and empowered workforce8
The Power of an Engaged and Empowered Workforce

The true power of an engaged and empowered workforce as a catalyst for change is astounding.

If your workforce is engaged and empowered within your organization and satisfied with their job they become the driving force behind providing excellent patient care.

Without engaged employees, change will be met with resistance and performance will suffer.

contact information
Contact Information
  • Steve Izzo, LNHA,MPH Administrator stevei@inglemoor.com
  • Karen Gentile, DON, RN Assistant Administrator don@inglemoor.com
  • Meredith Weil, LSW, Director of Social Service meredithr@inglemoor.com
  • Tisha Stellato, Director of Admissions tishaj@inglemoor.com