learning session 3: welcome - great plains qin · learning session 2 collaborative outcomes...

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Learning Session 3: Welcome

Krystal Hays, RN, MSN, RAC-CT

Great Plains QIN - CIMRO of Nebraska

Quality Improvement Advisor

Great Plains Quality Care Collaborative 152 Nursing Homes

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Peer Coach Nursing Homes

Heritage Care Center, Fairbury • Beth Block, Administrator – bblock@vhsmail.com

• Carol Schmidt, Director of Nursing

• Phone: 402.729.2289

Hilltop Estates, Gothenburg • Scott Bahe, Administrator – hilltopadm@qwestoffice.net

• Serina Sladky, Director of Nursing – donhilltop@qwestoffice.net

• Phone: 308.537.7138

Wilber Care Center • Barb Dreyer, Administrator – administrator@wilbercare.com

• Michele Vana, Director of Nursing - mvana99@hotmail.com

• Phone: 402.821.2331

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Collaborative Support

Nursing Home Consultants

Leading Age Nebraska

Nebraska Health Care Association

Nebraska Local Area Network of Excellence

Nebraska Culture Change Coalition

State Survey Agency

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Quality in YOUR Home

Krystal Hays, RN, MSN, RAC-CT

Great Plains QIN - CIMRO of Nebraska

Quality Improvement Advisor

Great Plains Quality Care Collaborative Aims

Support the National Nursing Home Quality Care Collaborative (NNHQCC) objectives to instill quality and performance improvement practices, eliminate healthcare acquired conditions and improve resident satisfaction by:

• Working with nursing homes to attain a composite score of 6.00 or less

• Reduce the use of unnecessary antipsychotic medication in dementia residents

• Reduce avoidable hospital readmissions

• Improve the rate of mobility

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Recruit: nursing homes, stakeholders and peer coaches

Pre-work: beginning 2-3 months prior to Learning Session 1

Collaborative Learning Session 1 face-to-face session

Learning Session 2

Collaborative Outcomes Congress

Project wrap-up, celebrate successes

and sustainability planning session.

Sustainability Phase

Great Plains Quality Care Collaborative Model

18 Months x 2

Collaborative I – 4/1/15 to 9/30/16 Collaborative II – 4/1/17 to 9/30/18

Email & Listservs, Peer Coaches, Educational Webinars, Technical Assistance

Action Period

Action Period

Action Period

Learning Session 3

Learning Session Objectives

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Learning Session 1 • Get ideas • Get methods • Get started

Learning Session 2 • Get more ideas • Get better at

methods • Get a “stride”

Learning Session 3 • Continue to learn

from one another • Celebrate

successes • Get ready to

sustain and spread

Test and implement

changes. Collect data to measure

impact of changes

Action Period 1

Test and implement

changes, collect data to

measure impact of changes

Test and implement

changes, collect data to measure

impact of changes

Action Period 2 Action Period 3

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Sustainability

Period of sustaining the quality improvement

Between Collaborative I and II

New ways of working and improved outcomes become normal

Adapt the change to areas or residents other than the pilot group

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Measuring Success

NH Quality Measure Composite Score – Goal: 6.00 or less • 13 NQF-endorsed publically reported, long-stay QMs

Falls with major injury Urinary Tract Infections Self-reported moderate to severe pain High-risk residents with pressure ulcers Low-risk residents with loss of bowel or bladder Residents with catheter inserted or left in bladder Physically restrained residents Residents needing increased help with ADLs Weight loss Residents with depressive symptoms Residents receiving antipsychotic medications Residents given Influenza vaccine** Residents given Pneumococcal vaccine** **Not found on CASPER report

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How does your Composite Score Compare?

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Composite Score goal of 6.0 or less

Your nursing home’s Composite Score Ranking compared to all NE nursing homes

Composite Score ranking of all NE nursing homes

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Shift to the Left is Good!

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6.0 or less - 6.23% increase 6.01 to 7.99 - 4.15% increase

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Just Around the Corner. . . Antibiotic Stewardship,

Clostridium Difficile Monitoring and Prevention

National Spotlight on LTC Infection Prevention

March 2015 –White House releases National Action Plan for Combating Antimicrobial Resistance

July 2015 – CMS proposes new Federal Regulations for Long-term care facilities including infection prevention and antibiotic stewardship activities

September 2015 – CDC releases the Core Elements of Antibiotic Stewardship for Nursing Homes

October 2015 – CMS announces the C. difficile Infection (CDI) Reporting and Reduction project within the nursing home 11th Statement of work for Quality Innovation Networks- Quality Improvement Organizations (QIN-QIO)

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CMS Proposed Regulations for Infection Prevention and Control (IPC) Programs

Facility risk assessment of resident population

Integrating IPC into QAPI activities

Required review and update of IPC program, policies/procedures

Antibiotic use protocols and monitoring included in IPC and pharmacy services

Designated IPC officer with specific training

IPC-specific education and training for all staff

Why the Focus on CDI Reporting and Reduction?

CDC Report – February 2015 In 2011, approximately half a million infections in US and 29,000 deaths

OIG Report: National Incidence Among Medicare Beneficiaries, February 2014

70% of CDI-related harm was considered PREVENTABLE in SNF’s studied

HHS National Action Plan to Prevent HAI’s: Road Map to Elimination, April 2013

Need 5% of nursing homes to report to NHSN for obtaining consensus on goal setting

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CDI Reporting & Reduction Project

Identify geographic areas and communities with high CDI rates

Determine state and national CDI baseline

Decrease CDI state and national rate by June 2019

Increase reporting to the National Healthcare Safety Network (NHSN) by nursing homes • NHSN is the CDC database for infection data

• Currently 236 NHs report data nationwide

Benefits of Collaboration

Receive an onsite assessment by the Infection Control Assessment and Promotion Program

Technical assistance with NHSN and CDI prevention

Evidence-based guidance

TeamSTEPPS LTC communication strategies and techniques

Collaborative CDI prevention efforts

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How to Get Involved!

Watch for your

facility’s invitation to

participate in the

CDI Reduction Project.

More information is

coming soon!

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Weekly E-Newsletter

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Upcoming Educational Opportunities

June 15 @ 3 p.m. CT – We Got Softer Toilet Paper and Other Low-Cost Ways to Engage, Retain and Recruit Staff – Dr. David Farrell, MSW, LNHA July 7 @ 2 p.m. CT – Dying from Dirty Teeth – Angie Stone, RHD, BS Three Part MDS Series: Lisa Hohlbein & Judi Kulus of AANAC July 21 @ 3 p.m. CT – MDS Section GG: What You Need to Know About

Coding the New Section GG

August 25 @ 3 p.m. CT – MDS Sections C, D, F and J: Capturing the Resident Voice Through Resident Interview

September 22 @ 3 p.m. CT – Understanding Quality Measures and Avoiding Common Pitfalls

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Questions?

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Contact Information

Krystal Hays, RN, MSN, RAC-CT

krystal.hays@area-a.hcqis.org

1200 Libra Drive, Suite 102

Lincoln, Nebraska 68512

P: 402.476.1399 ext. 522

F: 402.476.1335

This material was prepared the Great Plains Quality Innovation Network, the Medicare Quality Improvement Organization for Kansas, Nebraska, North Dakota and South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-GPQIN-NE-74-/0615