Department of Health Care Finance (DHCF) and Comagine Health
Nursing Facility Quality Improvement Collaborative
National Nursing Home Quality Improvement Campaign (NNHQIC) Part 1: Overview May 14, 2019
Qualis Health & HealthInsight have joined forces to do great things.
Together, we’re reimagining health care.
Presenters
David Reynolds, Project Manager, National Nursing Home Quality Improvement Campaign
Linda Kolpin, RN, Clinical Quality Improvement Specialist, National Nursing Home Quality Improvement Campaign
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Learning Objectives
1. Know how to access your organization’s NNHQI Campaign account
2. Understand how to choose a Campaign goal
3. Understand how to use the circle of success to conduct a PDSA cycle
4. Understand how to use QI data to monitor the project and make adjustments as needed
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About the Campaign
The National Nursing Home Quality Improvement Campaign (NNHQIC) (formerly known as Advancing Excellence)
• Supports long-term care providers, consumers and their advocates, and quality improvement professionals
• Provides easy access to evidence-based and model-practice resources
• Established in 2006 with a group of stakeholders including CMS, CDC, VA, the Joint Commission, AHCA, Leading Age, and many others
• Today, the Campaign is funded through CMS and operated by Telligen
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Account Access
• There are several types of accounts: – Provider accounts
– Long-term care staff accounts
– Consumer accounts
– Educator/coach accounts
Provider accounts enable nursing homes to track their data
• Over 60% of Nursing Homes have an account with the Campaign
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Account Access
Does your organization already have an account?
I’m not sure Check whether your organization appears in our list of registered organizations.
Yes Email us at [email protected] to gain access. Include your organization name and 6-digit Medicare/Medicaid provider number.
No Go to the provider registration page to create a new provider account.
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Circle of Success
www.nhQualityCampaign.org
SEVEN
SIMPLE
STEPS
TO
SUCCESS
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Step 1- Select a Goal
Not sure where to start?
• Gather your key staff
• Input from multiple resources
• Use survey findings, complaints,
satisfaction surveys
• Prioritize potential improvement areas
• QAPI Prioritization Worksheet
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Organizational Goals
Staff Stability
Consistent Assignment
Person-Centered Care
Hospitalizations
Clinical Goals
Pain
Pressure Ulcers
Mobility
Infections
Dementia Care &
Psychotropic
Medications
9 GOALS
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Step 2 - Identify Baseline and Set Target
Goal chosen
Time to Gather your Data…
• Start with a manageable small group
• Download your Data Tracking tool
• Collect and enter data to determine baseline
• Set a target
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Step 3 - Examine Process
Examine your current processes
• Ask Why, Which, What Questions
• What are we doing now?
• What is and isn’t working?
• What are factors?
Times, shifts, halls
• Where should you focus?
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Step 4 - Create Improvement
• Decide on the steps you need to take
to make improvements
• Make a small change, test it, and then
continue to tweak it to make it better
• Use Quality Improvement Methods to
help you on your way
• "Best practice” resources have been
identified for each of the goals
• Use a PDSA (Plan Do Study Act) cycle
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PDSA Cycle
Plan
Do
Study
Act
AIM
Measure
Change
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PDSA Cycle
Plan = What are we trying to accomplish?
• Using multidisciplinary team
• Set Objective
• Ask questions/make predictions
• Decide who-where-when
• Aim Statement (SMART)
• “Let’s increase/decrease something by (this much)
by (this time)”
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• Carry out your plan
• Start with small steps…
• “What tests can we complete by
next Wednesday?”
• Document observations
• Record your Data
• Start to analyze
PDSA Cycle
The Do = Testing Changes
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PDSA Cycle
Study = What happened with the Test
• Complete the analysis of data
• How did we measure up?
• Were there changes?
• Compare data to your predictions
• Summarize what was learned
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PDSA Cycle
Act = Where should I go now?
• Did this change work?
• Does something need tweaked?
• What changes can be implemented for the next cycle?
• Does something else need to be tested?
• Can the change be implemented full scale yet?
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Repeated Use of the PDSA Cycle
Changes That
Result in
Improvement
A P
S D
A P
S D
Very Small
Scale Test
Follow-up
Tests
Wide-Scale
Tests of Change
Implementation
of Change
Hunches, Theories,
Ideas, Action Plans or
Interventions
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Step 5 - Engage
• Encourage everyone to be involved
including residents and staff
• Use the Campaign Fact Sheets to help
• Meet regularly with those involved
• Let everyone know how it’s going
• Post and discuss progress,
challenges, and success
• Continue asking for input and getting
feedback
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Step 6 -Monitor and Sustain
• Continue to collect and submit your data
using the tracking tools
• The Excel workbooks calculate monthly
outcomes to track your progress
• View your trend graphs
• Continue your PDSA cycles, make
changes or tweak to help improve
outcomes and ensure your
improvements are continuing to work
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Step 7 - Celebrate Success
CELEBRATE!
• Even small steps are worth celebrations!
• Keeps positive momentum and continued engagement
• Celebrations Create a Spirit of Community
• Give visible or tangible appreciation
• Acknowledge those that go the extra mile
Share your success story!
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How to Track Your Data
1. Choose a Campaign goal
2. Download the Tracking Tool and start tracking your home’s data
3. At the end of each month, transfer your outcomes data from the Tracking Tool to the website
4. Get trend graphs of your data
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How to Track Your Data
1. Choose a goal
ORGANIZATIONAL GOALS
Consistent Assignment
Hospitalizations
Person-Centered Care
Staff Stability
CLINICAL GOALS
Dementia Care & Psychotropic Medications
Infections
Mobility
Pain
Pressure Ulcers
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How to Track Your Data
2. Download the Tracking Tool
Click the “Get Tracking Tools” icon from the home page
Choose your goal, then download the Tracking Tool (Excel file) and save it on your computer
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How to Track Your Data
2. …and start tracking your home’s data
On the page where you download the tool, each Tracking Tool has step-by-step instructions
The Tracking Tool is just an Excel file, but all the formulas are already built for you
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How to Track Your Data
3. At the end of each month, transfer your outcomes data from the Tracking Tool to the website
Click the “Enter My Data” icon from the home page
Manually enter the numbers that appear on your Tracking Tool’s “Data for Website Entry” tab into the website
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How to Track Your Data
4. Get trend graphs of your data
Click the “View My Progress” icon from the home page
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Quality Measure Trend Graphs
MDS 3.0 Quality Measure Trend Graphs are automatically available if you are logged in to your home’s account
Click the “Quality Measure Trends” button from the home page
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Summary
• Access your organization’s NNHQI Campaign
account
• Choose a Campaign goal
• Use the Circle of Success to conduct a PDSA
cycle
• Use QI data to monitor the project and make
adjustments as needed
Questions???
Nursing Facility Quality Improvement Collaborative Schedule of Events
• Action Period 1 (March – May 2019) • In-Person Training - April 19, 2019 • Webinar #1 - National Nursing Home Quality Improvement Campaign
(NNHQIC) Part 1: Overview - May 14, 2019 (1:00 – 2:00 PM) • Senior Leader Reports • Individual TA to be scheduled with each facility (April-June)
• Learning Session 2 - June 26, 2019 (8:00 am – 12:30 pm)
• Action Period 2 (June - August 2019) • Webinar #2 - National Nursing Home Quality Improvement Campaign (NNHQIC)
Part 2: Staff Stability - July 9, 2019 (1:00 - 2:00 PM) • Webinar #3 - August 2019 • Webinar #4 - September 2019 • Senior Leader Reports • Individual TA to be scheduled with each facility (July-September)
• Outcomes Congress – October 22, 2019 (8:00 am – 12:30 pm)
Nursing Facility Quality Improvement Collaborative Schedule of Events
This is DHCF’s new
Nursing Facility Quality
Improvement
Collaborative website.
At this site you will find
resources for the
Collaborative, including
the Collaborative
Handbook, PowerPoint
presentations and LS1
handouts.
https://dhcf.dc.gov/node/1390591
Contact Information
Gazelle Zeya
Comagine Health
Phone 1-800-949-7536 Ext. 2992hone XXX
Derdire “De” Coleman
Department of Health Care Finance
202-724-8831
