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Mary Tess CrottyVP, Quality – Genesis HealthCare
Northeast Division
The survey team finds no surprises on your annual survey.
The state receives no family complaints about your facility.
Your staff love their jobs and don’t want to move.
Your residents and family don’t blame you for any problems.
You have a waiting list for new residents.
Is a comprehensive system to manage all your strategic and operational areas.
Balances the auditing and monitoring activities with a continual focus on making large scale improvements across your facility.
Involves all your staff and encourages involvement of patients, residents and families
More than existing QA&A Aligns with the AHCA Quality Award Criteria
at Silver and Gold levels Easily incorporates most common quality
systems, such as Lean and Six Sigma Provides a full operational focus – no need
to compartmentalize An action planning system for achieving all
your organizational goals
What is your Performance Improvement model now?◦ Self-assess and reorganize as needed
How engaged are your leaders, all your staff, and your patients, residents and families?◦ Introduce new approaches or commit to existing ones
How do you plan and prioritize? How do you monitor? How do you support improvement activities?
The Team Model
Culture Change Excellence
Team
Clinical ExcellenceTeam
Staff ExcellenceTeam
Customer ExcellenceTeam
Business ExcellenceTeam
Performance ImprovementCommittee & Excellence
Teams
Safety ExcellenceTeam
The Committee Model
The Unit/Neighborhood Model
Audits for other units? Audits for other departments? Routine audits built into care processes? Process measures? Where are goals displayed? Where are results displayed?
Small changes, n=1 Neighborhood/Unit huddles Teams respond to missed targets Resident/Family involvement Large change/improvement projects – using
PDCA, DMAIC, Lean methodologies Projects pursuing strengths vs. deficiencies Visual participation – inviting everyone to
participate in improvement process
Who can identify an area to assess or improve?
What data and processes do you use to prioritize and set targets?
What performance levels trigger a response?
What tools do staff use to respond to misses and near-misses?
How does everyone know where you’re going and how you’re doing?
QAPIThe Regulation
Included as statutory language in the Accountable Care Act (ACA) for all CMS providers: regulation and technical assistance
Will be located at Tag 520, QA&A LTC is the last provider to write the regulation-
providers will have a year to implement from the regulation publication date
Technical assistance began over three years ago, including a two-year pilot with about 30 nursing facilities
Five Elements1.Design & Scope2.Governance & Leadership3.Feedback, Data Systems, and Analysis4.PIPs – Performance Improvement Projects5.Systematic Analysis and Systemic Action
Guides and worksheets for every component
Self-assessment Training modules for each Element,
including scripts, powerpoints and handouts Newsletters from pilot facility activities Video and public relations campaign
featuring AHCA and LeadingAge Quality Leaders (both geriatricians)
Think INPUT versus meeting attendance Use large visual displays to get input – such
as the multivoting example Develop a “P.I. huddle” style meeting for
staff, residents and family – a stand-up meeting, in a private area, to generate ideas for improving targeted issues. Keep the huddle to 5-10 minutes.
Establish Learning Circles on prioritized topics or solutions you are considering – include a mix of staff, residents and family
Prioritized Ideas•Make lunch more affordable for staff•Have mini fridges available on each wing for staff lunches•Offer PB&J in break room if someone needs some food•Be respectful, don’t take it if it’s not yours
Action Initiated• Payroll deductions for meals from the kitchen – all
shifts. Weekly offerings include a salad, sandwich or hot item.
• Mini Fridges in the LNA charting rooms for closer monitoring
• Free popcorn always available in the break room, made hot each day in the popcorn maker
Focus on the areas where residents, families and staff will find the most benefit
Get cross-department involvement in auditing for compliance
Make sure your “quality assurance” is built into staff’s daily routines
Have fun and celebrate with your PI Projects.
Share the success with everyone.
