Task 1a NH QIOSC Quality Improvement Model

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Task 1aNH QIOSC Quality Improvement Model
Supporting Materials(Part I)

• David R. Gifford MD MPH
• AHQA Technical Conference
• February 2003

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NH Quality Improvement Presentation Overview

• QIOSC-proposed approaches for system improvement
• Statewide approach
• Intensive group approach
• Effective nursing home system
• Key features
• Material
• Implementation
• Panel discussion
• Implementation
• Q A

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Intervention Terminology

• Clinical interventions
• Provider Interventions
• QIO interventions

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QIO Selection of QMs
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Statewide Approach
QIO led
Partnership led

• Educational Programs
• Clinical topics
• Quality Improvement
• Quality Measures

• Partnerships
• Supplementary education materials on
• QM clinical topics
• MDS coding
• Other NH issues
• Support and promote QIO programs

Nursing Home

• Information dissemination
• Active (e.g. mailings)
• Passive (www.MedQIC.org)

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Statewide Approach Key Features

• Goal Education and information dissemination
• Design single episode of support
• Stand-alone (e.g. seminars or mailings)
• Regional or statewide
• Dissemination of material
• Non-tailored dissemination of material
• NH accesses materials (e.g. web)
• Utilization of partnerships

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Statewide ApproachQIOSC Materials

• Powerpoint presentations
• Educational Material
• QIOSC supported
• Non-QIOSC supported
• www.MedQIC.org/nursinghomes
• www.RIQualityPartners.org

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Statewide ApproachEducational Programs

• Clinical education on your selected 3-5 topics
• Education program can be seminar, Web,
  teleconferences, or on-site
• Each topic repeated yearly
• Thus, a seminar approximately every quarter
• Coordinate with partners
• Could be joined with intensive group activities

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Statewide ApproachInformation dissemination(opti
ons)

• Newsletter (with or without partners)
• Websites
• QIO Website links
• MDS State web page reminders
• MedQIC
• Direct mail
• Ad hoc requests
• At Seminars

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Intensive Group Approach
Team Workshop 1
Team Workshop 2
Team Workshop 3
NH team
Individual Consultation
Individual Consultation
Nursing Home
Leadership Workshop 1
Leadership Workshop 2
Leadership Workshop 3
NH Leadership
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Intensive Group Approach Key Features

• Goal achieve implementation of effective nursing
  home systems
• Longitudinal relationship with NH
• Hybrid of collaborative and consultative models
• QIO facilitates interfacility sharing

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Effective Nursing Home System
Leadership Support
Nursing Home
Organizational QI System
Clinical System
Positive Outcomes
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Leadership SupportKey Features - 1

• Understand quality improvement
• Employ a QI model
• Track performance
• Assign staff to monitor clinical care
• Involve staff in activities and problem solving
  vs. doing the work for them

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Leadership Support (2)Key Features

• Empower employees
• Promote teams (clinical and improvement)
• Set parameters of QI teams authority to make
  changes
• Support participation in QI projects
• Compensated participation in external activities
• Time on shift to participate in internal QI
  activities
• Recognize and reward quality

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Leadership SupportQIOSC Materials

• Pre-workshop checklist
• Assessing Your Quality Improvement System
• Series of workshops on role of leadership
• 3 half-day modules
• 4 hour-long segments
• Powerpoint presentations
• Team exercises

www.riqualitypartners.org/Nursing_Homes/leadersh
ip_materials.shtml
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Effective Nursing Home System
Leadership Support
Nursing Home
Organizational QI System
Clinical System
Positive Outcomes
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Clinical SystemKey Features

• Medical Model
• Policies, protocols clinical tools consistent
  with guidelines and medical literature
• Focuses on key processes of care
• Staff incorporate content of policies protocols
  into every day work
• Clinical and non-clinical staff have basic
  understanding of key processes of care

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Medical Model
Screen
YES
NO
Evaluate
Rescreen
Result
Formulate treatment plan
Initiate treatment
Monitor treatment
Revise treatment
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Medical Model Pain
Screening (e.g. Pain as fifth vital sign)
Patient complaint
- evaluate pain (severity, location, better or
worse) - evaluate cause/etiology
Evaluate complaint
Formulate non-drug medication treatment plan
include goal of pain control
Formulate treatment plan
Initiate treatment
Start treatments
Monitor treatment
Monitor pain after treatments - use pain scale
Revise treatment
Revise treatment plan if goal not achieved
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Assessment Terminology

• Screening
• e.g., asking questions to identify if someone is
  having any pain
• Evaluating
• e.g., asking series of questions to assess cause
  and severity of pain
• Monitoring
• e.g., asking residents questions about pain to
  monitor effectiveness of treatments

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Clinical SystemQIOSC Materials

• Standard package for all QM topics
• Clinical Overview
• Essential systems for quality care (e.g. change
  concepts)
• Clinical tools (screening/evaluating/monitoring)
• Annotated guidelines literature
• Facility Assessment Checklists
• Flow diagrams
• MDS items for topic
• Regulations for topic

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Clinical SystemQIOSC Materials

• Additional materials for most popular QM topics
• Clinical tools / annotated web links to tools
• Monitoring tools
• Communicating with physicians
• Process of care measures (pain and PU)
• Powerpoint presentations
• Annotated list of other resources
• e.g. professional society manuals

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Effective Nursing Home System
Leadership Support
Nursing Home
Organizational QI System
Clinical System
Positive Outcomes
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Organizational QI SystemKey Features

• Process to ensure implementation of policies
  protocols
• System to make changes when care falls below
  their target threshold of performance

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Organizational QI SystemKey Features

• Ensuring implementation
• Hold teams not just individuals accountable for
  care provided
• Identify person (champion) to monitor
  implementation of medical model (e.g. plan of
  care)
• Should not be done retrospectively or by DON
• Best done by unit or shift manager or CNA
  champion.

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Organizational QI SystemKey Features

• System to make changes
• Track performance measures
• Teach all staff basic QI principles
• Empower staff to make changes at unit-level or
  patient-level
• Establish process to spread improvement
  throughout facility

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Organizational QI System
Review Performance
YES
NO
Assess System
Result
Formulate Plan to change system
Pilot test change
Disseminate within organization
YES
Monitor change
Result
NO
Revise plan Repilot test
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Organizational QI SystemQIOSC Materials

• Facility Assessment Checklists
• Flow diagrams
• Essential systems for quality care (change
  concepts)
• QI Worksheets

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Organizational QI SystemQIOSC Materials under
development

• Process of care measures
• pain and pressure ulcers
• Quality Improvement Implementation manual
• Identifying opportunities for improvement
• Teamwork
• Problem solving

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Implementation
Ideal NH System
Nursing Home
3-5 years
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5-10 minute Break
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Task 1aNH QIOSC Quality Improvement Model
Supporting MaterialsPart II

• David R. Gifford MD MPH
• AHQA Technical Conference
• February 2003

33
Intensive Group Approach
Team Workshop 1
Team Workshop 2
Team Workshop 3
NH team
Individual Consultation
Individual Consultation
Nursing Home
Leadership Workshop 1
Leadership Workshop 2
Leadership Workshop 3
NH Leadership
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Hybrid Approach

• Hybrid of
• Modified IHI BTS Collaborative model
• Individual consultant model

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Hybrid ApproachWorkshop series component

• Two parallel series of workshops
• Quality Improvement teams
• Leadership (Admin., DONs, Med. Dir., etc.)
• Connect workshops to each other
• Homework exercises
• Follow-up from previous workshops

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Classic IHI BTS Collaborative

• Kick-off meeting
• Teams
• Collaborative faculty
• Provide change package
• Learning Sessions
• CQI - PDSA training
• Sharing opportunities
• Data collection
• Senior Leader Reports (SLR)
• Final Congress

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Challenges to Conducting Collaboratives

• Collaborative teams often not cohesive in
  beginning
• Change package often too narrow
• CQI/PDSA training too conceptual
• Workshop too didactic
• SLR burdensome, not seen of value
• Leadership loses interest in clinically-based
  projects
• Selection bias on who participates

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Hybrid ApproachModifications to Classic
Collaboratives -1

• Prepare teams before workshops begin
• Teleconferences
• Individual telephone/onsite support
• Preconf meeting as group w/ teams
• Practical hands-on workshop sessions
• use common language to describe CQI PDSA cycle
• help teams identify step-by-step approach to
  implementing PDSA and change concepts

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Hybrid ApproachModifications to Classic
Collaboratives -2

• Modify SLR to simplify tracking of ongoing
  changes that NH are testing
• Assist teams with sharing of experiences
• Keep sharing simple with little work for team
• Avoid more formal presentations
• If helpful, have QIO staff develop but NH present
• Add individual consultation between meetings
• On-site visits extremely helpful

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Hybrid Approach Workshop Series - 1Key Features

• Workshop components
• Short One didactic presentation per workshop
• Could be done in conjunction with statewide
  workshop
• May need to tailor presentations based on
  participant needs during course of project
• Team exercises and follow-up from homework
  assignments for teams
• Sharing experiences between NHs

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Hybrid ApproachWorkshop Series - 2

• Frequency
• Every month or every other month
• Size
• 10 to 15 optimal
• Group NHs by region
• Consider number of QIO facilitators available for
  team exercises

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Hybrid ApproachWorkshop Series - 3

• Materials needed
• Powerpoint presentations for didactic session
• Team exercises facilitated by QIO staff
• Practicing root-cause analysis
• Interpreting data
• Flow charting process
• Brainstorming
• Interactive report back to group (from exercises
  or homework)
• Use flip charts as necessary

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Hybrid ApproachIndividual Consultation ModelKey
Features - 1

• Frequent contact either
• On-site visits from facilitator (e.g. nurse)
• Once to twice a month but frequency may vary
  depending on needs of NH
• other method of contact
• telephone, e-mail, fax
• twice monthly but may vary

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Hybrid ApproachIndividual Consultation ModelKey
Features - 2

• Tailor assistance to individual NH needs
• Assisting NH teams implement material and
  principles from workshops

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Hybrid ApproachIndividual Consultation - 1

• Principles
• Promote staff to follow step-by-step approach
• Tailor changes and monitoring of changes to
  individual NH needs
• Start with one clinical condition
• Start with one process of care related to
  condition
• Pilot test on single unit
• Work with NH to create simple reports to track
  changes implemented and data to track changes

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Hybrid ApproachIndividual Consultation - 2

• Work with QI team to
• Evaluate current clinical practice
• Supplement clinical education where knowledge
  deficit is apparent
• Assist in pilot-testing changes
• Provide real-time monitoring of improvement
• Respond to ad hoc requests from teams when
  possible
• Recognize deficits in leadership support

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Hybrid ApproachIndividual Consultation - 3

• Work with leadership team to
• Conduct homework exercises
• e.g. Once per week talk to one CNA from each unit
• Supplement role of leadership education
• Identify barriers and solutions to assisting QI
  teams work

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Hybrid ApproachQIOSC materials

• Facility Assessment Checklists
• Essential systems for quality care
• QI System Assessment for leadership
• Quality Improvement Worksheets
• Process of care measures (pain PU)
• Clinical monitoring tools

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Using Facility Assessment Checklists -1

• Starting point for NH and individualized
  assistance
• Checklists divided into sections to follow
  medical model
• Best used one section at a time
• Helps breaks project into manageable pieces
• Proceed to next section once all areas completed

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Using Facility Assessment Checklists - 2

• Serve as a framework for QIOs to assist NH
  identifying interim monitoring measures
• Tailor NH data collection
• e.g., review 5 charts to complete item on
  checklist

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QI Worksheets

• Use worksheets as template tools for QIO to
  provide to NH to implement Organizational QI
  system in a step by step manner
• NH will need QIO assistance to implement and use
• QIOs assist NH tailor use of worksheets.
• May use all, some, or none of worksheets

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Panel Members

• Kathy Hybarger IN
• Jill Mcardle NC
• Laura Palmer CO
• Gail Patry RI
• Kevin Warren TX

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Panel Questions

• How are you balancing resources expended on
  statewide activities vs. intensive group
  activities?
• How are you working with nursing homes located
  over a wide geographic area?

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Panel Questions

• 3. How do you tailor assistance to intensive
  group nursing homes?
• 4. Are you planning onsite vs off site nursing
  home support?