Improving Quality in Nursing Homes: An Overview of Advancing Excellence—The NH Quality Campaign

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Slide 1
Improving Quality in Nursing Homes: An Overview of Advancing Excellence—The NH Quality Campaign

The Commonwealth Fund
Presented by:
Mary Jane Koren, MD, MPH Assistant VP, The Commonwealth Fund
2008 Chair, Advancing Excellence Steering Committee
Slide 2
Improving Nursing Home (NH) Quality: There is no "silver bullet"

Regulation and Enforcement.
Culture change.
Advancing Excellence: The NH Quality Campaign.
Slide 3
Advancing Excellence: The Campaign's Purpose

To pursue excellence in the quality of life and quality of care for the more than 1.5 million residents of America's nursing homes by establishing a system of local quality improvement networks and providing resources to help nursing homes strengthen workforce and improve clinical outcomes.
Slide 4
Campaign History

2005—2006
2005: Small group of stakeholders come together to plan Campaign.
September '06 Kick-off Summit to launch Advancing Excellence.
2007
Jan—April—Process frameworks developed for 8 goal areas.
July—Grant from The Commonwealth Fund (CMWF) to support the Local Area Networks for Excellence (LANEs).
November—Interchange 2007 first national LANE Conference.
2008
January—Pain Webinar (1100 open lines, 3,000 listeners).
February—Pressure ulcer Webinar (1800 lines, 5,000 listeners).
March—Inaugural edition of monthly newsletter.
June—Consistent assignment Webinar (1200 lines, 3500 listeners).
July—4 quarters of data show improvements; 2nd CMWF grant.
August—AHRQ Grant for Interchange 2008 approved.
September—Staff stability Webinar; Planning retreat; Web site has frontline worker guides.
December—Interchange 2008 second national LANE conference.
Slide 5
The 8 Goal Areas

Clinical Quality Goals:
Reducing high risk pressure ulcers.
Reducing the use of daily physical restraints.
Improving pain management for longer term nursing home residents; and
Improving pain management for short stay, post-acute nursing home residents.
Organizational Improvement Goals:
Establishing individual targets for improving quality (Setting Targets—Achieving Results, STAR).
Assessing resident and family satisfaction with the quality of care.
Increasing staff retention; and
Improving consistent assignment of nursing home staff, so that residents regularly receive care from the same caregivers.
Slide 6
Organizational goals are critical to achieving clinical improvement

Lay the organizational groundwork for improvement.
Stabilize your workforce: Increase staff retention (Goal 7).
Improve efficiency by letting your staff get to know their residents: use consistent assignment so that residents regularly receive care from the same caregivers (Goal 8); and
Know where you're headed: use STAR (on the Centers for Medicare and Medicaid Services [CMS] Web site) to set Quality Indicator (QI) targets (Goal 5).
Work on the really important problems.
Reduce the use of daily physical restraints (Goal 1).
Reduce high risk pressure ulcers (Goal 2).
Be sure people in your home aren't hurting: Improve pain management for short and long stay residents (Goals 3 & 4).
Find out what your "customers" think.
Ask residents and families to tell you how you're doing: measure satisfaction (Goal 6).
Slide 7
Advancing Excellence in America's Nursing Homes Campaign Organizational Chart

Chart shows the following distinct groups:
Results Workgroup.
Staffing Workgroup.
Campaign Steering Committee.
Communications Workgroup.
Technical Assistance Workgroup.
Recruitment Workgroup.
Consumer Workgroup.
Local Area Networks for Excellence (LANEs).
Participating Nursing Facilities.
Participating Consumers.
Long Term Care Professionals and Direct Care Staff.
Slide 8
National Steering Committee

Agency for Healthcare Research and Quality (AHRQ).
Alzheimer's Association.
American Association of Long Term Care Nursing (AALTCN).
American Health Quality Association (AHQA).
American Academy of Nursing.
AAHSA, AHCA and Alliance for Quality NH Care.
American Association of Nurse Assessment Coordinators (AANAC).
American College of Health Care Administrators (ACHCA).
American Medical Directors Association (AMDA).
Association of Health Facility Survey Agencies (AHFSA).
Centers for Disease Control and Prevention (CDC).
CMS.
The Commonwealth Fund.
The Foundation of the National Association of Boards of Examiners of Long Term Care Administrators (NAB).
National Association of Directors of Nursing Administration in Long Term Care (NADONA).
National Association of Health Care Assistants (NAHCA).
National Association of State Long-Term Care Ombudsman Programs (NASOP).
National Conference of Gerontological Nurse Practitioners (NCGNP).
National Gerontological Nursing Association (NGNA).
NCCNHR: The National Consumer Voice for Quality Long-Term Care.
PHI (Paraprofessional Health Institute).
Pioneer Network.
Service Employees International Union (SEIU).
The Evangelical Lutheran Good Samaritan Society.
The John A. Hartford Foundation's Institute for Geriatric Nursing.
Slide 9
Who Does What?

Campaign Steering Committee ( meets bi-weekly by phone, face-to-face quarterly) and its Work Groups.
Governance.
Policy.
National meetings—the "Interchange."
Communications.
Development of Technical Assistance Materials.
CMS Support through its Nursing Home Quality Improvement Organizations (QIOs) QIOSCs
Web site.
Data Analysis.
List serve.
STAR target setting Web site.
Limited administrative support.
Slide 10
LANES (Local Area Networks for Excellence)

Network of individuals and organizations across the state (or territory) working together to fulfill needs at local level to ensure campaign success.
A national LANE Field Director is the liaison to transmit information between the national and the state levels and works with the LANEs.
Each LANE has a "convener"—an organization which serves as point of contact.
LANE functions:
Raise awareness about the campaign.
Recruit nursing homes to participate.
Convene meetings on a regular basis.
Provide technical assistance.
Monitor statewide progress.
Communicate key campaign messages.
Respond to critical issues.
Slide 11
Major Accomplishments to Date

Recruited more than 7,000 (44%) nursing homes across the U.S.
Attracted over 1,600 consumers to join the campaign.
Established broad-based coalition of government, providers and consumers—a public-private partnership.
Demonstrated commitment of nursing homes, with homes registering for 3.7 goals (a minimum of 3 is required).
Established LANEs in 49 states.
Developed useful Web site with quality improvement resources.
Held 3 very well attended and received Webinars on goal topics.
Slide 12
Advancing Excellence Webinars Provide Useful Information

Pain Management:
1,100 nursing homes.
3,000 listeners.
85% said it was useful.
81% said they will make a change based on the presentation.
Pressure Ulcers:
1,800 nursing homes.
5,000 listeners.
91% said it was useful.
60% said they will make a change based on the presentation.
Slide 13
NH Participation in Advancing Excellence (August 14, 2008)

Map of the U.S. shows NH percent participation:
Highest—NM, NV, SD, RI, GA, ME, and AR.
Lowest—HI, AK, MT, OK, LA, IL, and NY.
Slide 14
Accelerated Improvement Since Campaign Start in 2005 Q3-2006 Q3 (year before) vs. 2006 Q4-2007 Q4 (year after)

Bar graphs indicate that participants improved more than nonparticipants with regards to pressure ulcers and restraints.
Slide 15
Acuity and Frailty Are Increasing

Line graphs indicate that people at risk are increasing with the short-stay PU denominator and the HR PU denominator, but decreasing with the LR PU denominator.
Slide 16
Progress Toward Goals

Progress Toward National Goal, By Participation and Target-Setting (Campaign results after year 1) With regards to pressure ulcers, restraints, pain in long stay, and pain in short stay, nonparticipants fared worse than participants selecting goal, who fared worse than participants selecting goal and setting target.
Slide 17
Summary of Results

Seeing ongoing improvement toward 5 Campaign goals for which there is data.
Selecting a goal is associated with faster improvement.
Setting a target is associated with even faster improvement.
Achieved national target for reducing physical restraints (Goal 2):
Objective A: restraint use at or below 5% (at 4.9%).
Objective B: 50% of homes with restraint use below 3%
Very near national target for reducing pain for long-stay residents (Goal 3).
Objective A, national average at or below 4% (at 4.2%).
Objective B, 30% below 2% (˜35% have met threshold).
Source: This material was prepared by Quality Partners of Rhode Island, the Medicare Quality Improvement Organization for Rhode Island, under contract with the Centers for Medicare and Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
Slide 18
Issues for Advancing Excellence (AE)

Measurement issues for organizational goals need to be addressed:
Resident "satisfaction" or resident "experience"?
How should consistent assignment be measured?
Data submission for the organizational goals remains a problem.
Resolution of questions about goals: Drop some? Add new ones?
Recruitment concerns—what about the other 56% of nursing homes?
Sustainability for the campaign itself.
"Seeing" change—do consumers perceive a difference in a home that participates in AE?
How can the campaign help bring consumers and providers together to improve quality?
Slide 19
General observations and implications for patient safety

Broad stakeholder inclusion is critical to Campaign success.
Stakeholder inclusion, buy-in on goals, targets, priorities.
Frequent meetings, share practices, build consensus, transparency.
Stakeholders come with a broad range of understanding of how to get to outcome:
Keep it simple: know your number, set your target.
Emphasize root cause basics: standardized process frameworks.
Aim for similar measures across settings (MDS 3.0).
Report on progress often, repetitively.
Broad stakeholder inclusion is critical to Campaign success.
Stakeholder inclusion, buy-in on goals, targets, priorities.
Frequent meetings, share practices, build consensus, transparency.
Stakeholders come with a broad range of understanding of how to get to outcome:
Keep it simple: know your number, set your target.
Emphasize root cause basics: standardized process frameworks.
Aim for similar measures across settings (MDS 3.0).
Report on progress often, repetitively.
Slide 20
General observations and implications for patient safety (continued)

Highlight the importance of operational performance to achievement of clinical improvement.
The LANEs represent a national dissemination platform for evidence-based, practice information.
The Campaign is pushing the field into the electronic age.
Signing onto AE can only be done electronically.
TA materials and links are only accessible via the Web site.
Emphasizing importance of data management for QI.
The Campaign may be able to be used to address disparities.
Current as of January 2009


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Internet Citation:

Improving Quality in Nursing Homes: An Overview of Advancing Excellence—The NH Quality Campaign. Slide Presentation from the AHRQ 2008 Annual Conference (Text Version). January 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualmtg08/091008slides/Koren.htm


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