Pathway to Performance Excellence

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Pathway to Performance Excellence
NASVH 2009 Summer Conference Asheville, NC

• Bernie Dana, LTC Management Consultant
  Associate Professor of Business, Evangel
  University, Springfield, MO BDanaMQM_at_sbcglobal.ne
  t
• Cheryl Maitland, Administrator, Oregon Veterans
  Home, The Dalles, OR CherylM_at_oregonveteranshome.c
  om
• Melissa Temkin, American Health Care Association,
  Washington, DC mtemkin_at_ahca.org

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About AHCA

• A non-profit federation of state affiliates that
  represent more than 10,000 non-profit and
  for-profit nursing and assisted living facilities
  that care for more than 1.5 million elderly and
  disabled individuals nationally, including
  veterans.
• AHCA currently represents 25 of state veterans
  homes nationwide.
• AHCA represents the largest number of not for
  profit nursing facilities nationwide over 2,500
  facilities.
• 2nd largest health care PAC at average 1 mil per
  year.

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AHCA Support State Veterans Homes

• Legislative and Regulatory Advocacy
• In-depth education Annual convention and other
  events
• National Quality Recognition

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Legislative and Regulatory Advocacy

• Over 80 full-time regulatory, legislative,
  research and other staff based in Washington, D.C.

• 5 full-time lobbyists
• VA liaison works on issues that affect state
  veterans homes and civilian homes that serve VA
  beneficiaries
• Not for Profit Council NASVH is a member
• Committee structure addresses the broad spectrum
  of LTC issues quality, HIT, life safety,
  disaster preparedness, etc.

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Educational Opportunities

• Annual Convention
• Over 70 sessions in 13 focus areas, including
  quality, care practice, workforce and leadership
  issues
• Keynotes Cal Ripken, Jr. and Dr. Bob Arnot
• October 4-7, McCormick place in Chicago
• Annual Quality Symposium February 9-10, 2010 at
  the Marriott Baltimore Waterfront
• Congressional Briefing June 8-9, 2010

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Pathway to Performance Excellence

• Bernie Dana
• Cheryl Maitland

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Program Objectives
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The Need and the Opportunity

• Rising costs cannot be fully offset by increasing
  revenue
• Regulatory compliance does not increase customer
  satisfaction
• Inconsistent performance causes employee
  dissatisfaction
• Traditional management systems are reactive
  rather than proactive and visionary
• Person-centered culture change will not be
  sustained without systems change

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There is a Better Way!

• Act on a vision for what can be
• In all situations, lead by example
• Let customer expectations define the quality
  standard
• Engage and empower employees
• Develop a quality management system to sustain a
  focus on performance
• Develop a structure to fulfill the quality
  journey
• Commit to continuous learning and growth

Source Mapping the Road to Quality Results,
Olson, Dana, and Ojibway, Provider, Apr 2005
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Leadership and Culture Change

• Create a vision for performance excellence
• Change to systems thinking
• Its the system how organizations approach
  getting things done
• Does caring and compassion trump system thinking?
• Systems create behaviors
• My people wont do what your people do
• 85 of people problems are systems problems

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Sharing the Right Vision

• Paradigm shift needed compliance vs. customer

• Grasp your current reality
• Commit to innovation
• Vision sharing takes time and new system
• New language
• New tools
• Engage all in CQI

• LTC research found common theme they chose to
  act on a vision for what can be.

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How Vision Developed

• New leadership young or from other professions
• Education programs
• Pioneer Network, Eden Alternative, etc.
• Quality award program and similar models
• Never from regulatory change or survey enforcement

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Get a Vision Exercise

• 3 minutes total
• Work individually or as a group from the same
  facility
• Develop a headline that you would like to see
  about your community in 5-7 years
• Headline should reflect a measurable result (i.e.
  Veterans Home staff satisfaction at 96 --
  highest in nation)
• Write on handout

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The Philosophical Principles of Quality
Management

• Quality is meeting or exceeding customer
  expectations.
• Quality is everyones job.
• Quality is systems and statistical thinking.
• Quality is continuous learning and improvement.
• Quality requires effective leadership.

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Definition of LTC Quality Is...

• The totality of service features and
  characteristics that meet or exceed customer
  needs and expectations.1
• Requires the provider to
• Comprehend individual and collective expectations
• Provide services and facilities that meet
  expectations
• Achieve a high level of performance and
  reliability in systems and processes used to
  deliver services

1Source Defining Quality in Long Term Care,
Dana, Provider, Aug 2004
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An Essential Measure of Quality Is

• Customer Satisfaction
• Customers may not always know what is best for
  them but they have right to be fully informed,
  respected, and in control of decisions regarding
  their service.

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Customer

• External Customer Ultimate user of the service
• Internal Customer Anyone we hand off work to
  within the organization

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Customers View of Quality (Kano)

• What comes first?
• Shift in expectations

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Customer Realization Challenges

• We care a lot, but then assume we know what is
  best
• Learn to differentiate key customer groups
• Empower staff to respond
• Recognize every encounter as a quality moment for
  the customer

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Remove Blame from the System

• Get the right people on the bus
• Believe that everyone wants to do a good job and
  have fulfillment from their work

• Write personnel policies to encourage your best
  rather than to control your worst
• Confront poor performance when it happens rather
  than at the annual evaluation
• Build trust by response, fairness, transparency
• Learn to ask why instead of who when
  something goes wrong
• Train staff how to continuously improve their
  work

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Empowerment

• Parameters and Empowerment

Parameters set by vision, goals and resources to
maintain the focus on improvement and alignment
with organizational purpose

• Employees are EMPOWERED when they
• Know what is expected of them
• Have the skills and resources to meet
  expectations
• Receive continuous feedback to know how they are
  doing
• Can adjust work processes to achieve desired
  result

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Most Important Exercise

• 2 minutes total
• Meet with someone next to you
• Identify the three most important individuals or
  groups of employees

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The Managers

• Gallup research People leave managers, not
  organization

• Managers not effective employees not effective
• LTC managers selected from ranks for work skills,
  loyalty, and compliance

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Managers Need Development

• Basic management skills
• Communication styles
• Conflict resolution
• Performance evaluation
• Coaching
• Team meeting skills, idea generating tools,
  consensus building tools, process management,
  improvement tools

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Systems View of Quality
Design Quality
Performance Quality
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Cost of Quality

• Prevention Cost - Activities designed to prevent
  poor quality
• Appraisal/Inspection Cost - Assessing conformance
  to a standard
• Failure Cost - Correcting non-conformance to a
  customers requirement
• Cost increases as problem gets closer to customer

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Does Inspection Work?
Do both of the lines have an equal amount of bend
in them?

• Dependent on the inspectors and their paradigms
• Managers add inspection steps when something goes
  wrong

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Classifying Work

• Value-Added Work - External customer sees benefit
• Required Work - Needed to keep organization
  operating
• Rework - Something was not done properly the
  first time
• Wasted Work - Not required and no value
• No Work - Authorized leave/waiting time

20 15 30 10 25
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Do We See the Opportunity?

• Waste and Rework Cost
• Number of full-time equivalent employees
  100
• Average annual hours worked by each employee
  1,950
• Total hours worked annually
• Estimated rate of waste and rework (20)
  .2
• Total waste and rework hours
• Average hourly pay rate (including benefits)
  12.00
• Total cost of waste and rework

195,000
39,000
468,000
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Process and System

• Process - Interrelated work activities producing
  a specific outcome
• System - A combination of related processes
• Process characteristics
• Can be divided into a series of tasks
• Tasks can be put into order
• Performance can be measured
• Need standardized process

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Variation

• Two Basic Kinds of Variation
• Common Cause Variation
• predictable and inherent in all processes
• Special Cause Variation
• not predictable
• often unsatisfactory
• assignable to a cause should be investigated

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Example of Process Variation

• Sample food temperatures of meal entrees over a
  10 day period from two facilities
• Average is the sameare both processes performing
  the same?

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Organize for Quality

• Performance accountability continues with
  day-to-day leadership structure

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Process Management Cycle

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Selecting a Process to Improve

Team?
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Keep Score that Matters

• Performance is everything
• Efforts will earn you sympathy
• Compassion doesnt cover up poor results
• If not getting results, change something
• Know key success factors, then
• Learning to measure quality is not easy

BHAGs ? Strategies ? Action Plans ? Feedback
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Principles of Measurement

• Measure the process, not the person
• Measure to improve, not to blame
• Keep simple, understandable, believable,
  accurate, and useful
• Measure performance against a customer-focused
  standard
• Measure the key process indicators
• Make comparisons meaningful (best, not average)

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Is Alarm Disconnected?
We have disconnected the alarm on chronic
quality failures because the failures are so
familiar and expected that we no longer are
surprised or even offended by them.
Dr. Joseph Juran
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The Tools of Quality Management
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Nature of Problems

• Problem Any situation/issue that separates you
  from your mission, vision, and goals
• Two primary categories
• Strategic problems - organizational performance
  gaps
• Process problems - work process failures
• Responsibility for problems
• Management responsible for all strategic problems
  and all process problems if
• process handed down or tweaked by management
• employees are not empowered to correct

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Key Root Cause Concepts

• Ask why rather than who
• Ask why at least five times
• Investigate the facts

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Find the Root Cause

• Problem 1 Resident and daughter upset that
  expensive slip purchased for mother had
  returned from laundry in frayed condition.
• Symptoms - Clothing damaged
• - Laundry chemical costs increased
• Why Expensive booster chemical being added
  to every load
• Why Laundry staff feel it is need to
  prevent rewash
• Why Laundry supervisor directed
• Why Vendor had not provided training.
• Why Administrator did not include
  laundry supervisor in
• decisions and got too busy
  to schedule training
• Solution Provide training, develop
  measurements, empower

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Develop a CQI Methodology

• Helps create objectivity
• Can be adjusted to fit your QMS
• Provides a roadmap to solving problems
• Requires discipline to follow steps
• Everyone needs to be trained to use it

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Sample CQI Methodology

• Identify the process and the customers
  requirements
• Collect and analyze process data
• Describe the current process (flowchart)
• Select opportunities to improve and determine
  root causes
• Develop and implement potential solutions
• Hold the gains

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PDSA Cycle of Improvement
1. What are you trying to change? What idea are
you testing? What will you measure? Plan your
change.
4. Revise plan/retest. Spread/expand test.
Implement change on a larger scale
PLAN
ACT
DO
STUDY
3. What happened? Summarize what you learned.
2. Pilot your test. What were the results?
Document the results.
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Display and Analysis

• Learn to use the right tools to measure, analyze
  information and data

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Models of Quality Management

• Baldrige National Quality Award Program
• State Quality Awards
• Six Sigma, Lean Enterprise, Etc.
• AHCA/NCAL National Quality Award Program

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(No Transcript)
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Steps Toward Mature Processes
(1) Reacting to Problems

• Characterized by activities mostly responsive to
  immediate needs or problems rather than by
  processes
• Goals are poorly defined

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Steps Toward Mature Processes
(2) Early Systematic Approaches

• Beginning stages of using operating processes
  with repeatability, evaluation, improvement, and
  coordination
• Strategy and quantitative goals are being defined

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Steps Toward Mature Processes
(3) Aligned Approaches

• Systematic processes in place that are regularly
  evaluated for improvement
• Learning from processes shared
• Organizational units are coordinated
• Processes address well defined strategies and
  goals

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Steps Toward Mature Processes
(4) Integrated Approaches

• Systematic processes in place that are regularly
  evaluated for change and improvement in
  collaboration with other affected organizational
  units
• Efficiencies across units sought and achieved
  through analysis, innovation, and sharing
• Processes and measures track progress on key
  strategic and operational goals

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AHCA/NCAL Quality Award

• Step 1 - Commitment Organizational Profile with
  mission and demonstration of ability to improve
  (5 pages met/not met no IJ)
• Step 2 Achievement Address how core values of
  quality are embraced with good results (18 pages
  team of examiners No IJ and 3 year weighted
  average above state)
• Step 3 Excellence Address all of Baldrige
  criteria with superior results 55 pages team of
  master examiners, No IJ and 3 year weighted
  average above state)

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Benefits of Quality Award Model

• Develops providers ability to improve services
  and internal processes
• Peer and public recognition as a quality champion
• Examiner feedback identifies strengths and
  opportunities for improvement
• Creates disciplined learning curve
• Webinars and other support resources available

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Benefits of Quality Award Pathway

• Begins change in thinking
• Gives focus to the real customer
• Requires continuous learning at all levels
• Creates pride/celebration in achievement Requires
  long term commitment
• Creates shift in management style

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QUESTIONS?
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Resources

• Multiple resources for quality improvement listed
  at AHCA website http//www.ahcancal.org/quality_
  improvement/quality_first_initiative/Pages/QF_Tool
  sResources.aspx
• Developing a Quality Management System The
  Foundation for Performance Excellence in Long
  Term Care, Dana, AHCA revised 2008 (Order through
  AHCA bookstore listed at above website)
• Guidelines for Developing a Quality Management
  System (Free download) http//www.ahca.org/quality
  /qf_qms_guidelines.pdf
• A Guide to Nursing Facility Performance Measures
  (also for MR/DD providers) (Free download)
  http//www.ahca.org/quality/qf_nf_perform_measure.
  pdf
• Good to Great, Collins, HarperCollins, 2001
• First, Break All the Rules, Coffman and
  Buckingham, Simon and Schuster, 1999
• Zapp! Empowerment in Healthcare, Bynam, Random
  House, 1993
• The Deming Management Method, Walton, Perigee
  Books, 1986