health facility evaluation and quality improvement september 21, 2010

Health Facility Evaluation and Quality Improvement

September 21, 2010

““The Indiana State Department of Health supports Indiana’s The Indiana State Department of Health supports Indiana’s economic prosperity and quality of life by promoting, protecting, economic prosperity and quality of life by promoting, protecting,

and providing for the health of Hoosiers in their community.”and providing for the health of Hoosiers in their community.”

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Outline

• Nursing Home Evaluation Process and Quality Measures

• Healthcare Quality Improvement Initiatives and Their Outcomes

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Indiana Nursing Home Evaluation Process and Quality Measures

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Overview of Long Term

Care Facilities

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Overview of Indiana Long Term Care Facilities

Long Term Care Facility Types Comprehensive care facility – nursing home

– Skilled nursing facility (SNF)– Nursing facility (NF)– Non-certified comprehensive care (State only)– Residential care beds

Residential care facility Assisted living facility Intermediate care facility for the developmentally disabled

(ICFDD) – group home

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Number of Indiana Long Term Care Facilities

Certified comprehensive care facilities (nursing homes) – 502 facilities

Non-certified comprehensive care facilities - 3

Comprehensive care facilities with residential care beds – 110

Freestanding residential care facilities – 109

Source: ISDH Data September 2010

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Indiana Long Term Care Beds

Certified comprehensive care facilities (nursing homes) – 48,636 comprehensive care beds

Certified comprehensive care facilities with residential care beds – 8,256 residential care beds

Non-certified comprehensive care – 1165 comprehensive beds Non-certified with residential beds – 304 residential care beds Freestanding residential care facilities – 8,861 residential beds Total residential beds: 17,421 beds

Source: ISDH Data September 2010

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Survey Process and Findings

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Overview of Nursing Home Survey Process

Survey Frequency

State licensing and federal certification surveys conducted every 9-15 months– Indiana has met that standard

State and federal complaint survey conducted for all complaints based on a priority tier – Indiana has met that standard

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Overview of Nursing Home Survey Process

Number of Nursing Home

Surveys Completed (2009)

Number of Annual Licensing / Certification Surveys (2009) – 533

Number of Complaint Surveys (2009) – 1,459 Number of Annual Life Safety Code Surveys

(2009) – 533

Source: CMS Casper Report

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Indiana Nursing Home Survey Findings

Most Cited Deficiencies (2010) F282: Services provided by qualified persons in

accordance with care plan – 43% of providers F323: Facility is free of accident hazards – 33% F272: Comprehensive assessments – 33% F514: Clinical records – 29% F157: Inform of significant changes – 28% F441: Infection control – 25%

Source: CMS Casper System

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Most Cited Immediate Jeopardies (2010) F323: Facility is free of accident hazards – 5 F224: Facility prohibits abuse, neglect – 3 F441: Infection control – 2 F225: Facility does not employ persons guilty of abuse – 2 F314: Pressure ulcers – 2 F223: Residents right to be free from abuse – 2

Source: CMS Casper System

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Outcomes: Deficiency free surveys

2005: 47 facilities 2006: 47 facilities 2007: 51 facilities 2008: 59 facilities 2009: 57 facilities 2010: 66 facilities (through Sept. 13)

Source: CMS OSCAR quarterly reports

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Outcomes: Deficiency free surveys (% of facilities with no deficiencies)

Indiana Region V National

Q4 2006: 10.60% n/a 8.20% Q4 2007: 11.70% 10.41% 8.30% Q4 2008: 10.78% 9.09% 7.60% Q2 2009: 12.25% 8.77% 7.83%

Source: OSCAR quarterly reports

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Outcomes: Immediate jeopardy findings

2006: 91 – Indiana 3rd highest 2007: 106 – Indiana 5th highest 2008: 76 - Indiana 13th highest (68 surveys) 2009: 46 – Indiana 17th highest (35 surveys) 2010: 25 (through September 13)

Source: CMS CASPER data

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Outcomes: Immediate jeopardy findings(% of facilities with IJ)


Q4 2006: 4.50% n/a 2.20% Q3 2007: 5.64% 3.36% 2.17% Q2 2008: 5.08% 3.75% 2.58% Q2 2009: 2.77% 3.23% 2.89%


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Average Number of Deficiencies Per Survey Indiana Region V National

2006: 1.7 1.5 1.5 2007: 2.7 2.4 2.0 2008: 3.0 2.5 2.1 2009: 2.7 2.5 2.1 2010: 2.5 2.2 2.0

Source: OSCAR quarterly reports through Sept 13, 2010

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Data Variability Between States

Percent of surveys timely completed Whether state citing all deficiencies Whether citing associated tags

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Differences in Surveys BetweenProvider Types Acute Care

– Compliance based on status at time of survey– Regulations based on facility policy

Long Term Care– Compliance determination goes back to previous

annual survey– Regulations based on descriptive requirements

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Reporting of Survey Findings

ISDH Nursing Home Consumer Report– All survey reports and plan of corrections will be

added in 2010 to Consumer Report

CMS Nursing Home Compare

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Healthcare Quality Issues Identified Through the Survey Process

Common Root Causes

Appropriate admissions / placement Timely and accurate assessments Care transition and coordination Staff education, training, & sufficiency Negative health care culture

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Healthcare Quality Issues Identified Through the Survey Process

Quality of Care Issues Pressure ulcers Healthcare associated infections Medication errors / patient safety Falls / wandering Behavior management Abuse and neglect

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Health Care Staffing

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Staffing

Staffing Initiatives

Leadership Conference

Staffing Strategies

September 17, 2009 (funded by Civil Money Penalty Fund)

Staffing Study of Long Term Care Facilities (funded by the ISDH Civil Money Penalty Fund)

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Staffing

2009 Long Term Care Staffing Study

Number of administrator changes per facility over past three years – 2.5

Number of director of nursing changes per facility over past three years – 2.8

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Staffing

2009 Long Term Care Staffing Study

Turnover rate for Registered Nurses (RN) – 74.1% (46% nationally)

Turnover rate for LPN – 67% (43% nationally)

Turnover rate for certified nurse aides (CNA) – 98.1% (64% nationally)

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Staffing

ISDH Senior Staffing for Survey Program

Three Division Directors (Acute Care, Health Care Education, Long Term Care) and all seven long term care area supervisors are new within the past three years

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CMS Quality Indicator

Survey System

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Health Care Survey System

Survey Program Quality Improvement

Implement CMS Quality Indicator Survey (QIS) system – Kick-off for QIS system occurred in August 2010– Training of surveyors for QIS surveys to begin in

January 2011

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ISDH Healthcare Quality Improvement Initiatives

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Goals

Promote health care quality and health literacy through educational initiatives

Increase public awareness and focus on a state health issues

Protect the public through oversight of quality of care provided by health care facilities

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Healthcare Quality Improvement Principles

Principles for Improvement

Summarize evidence into checklistsIdentify and mitigate local barriers to

implementationMeasure performanceEnsure all patients reliably receive the

intervention

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Healthcare Quality Competing Interests

OUTCOMESScientificFoundation

Regulatory

Feasibility

Health Care Culture

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SUCCESSFUL AGING

Rowe & Kahn, 1998

AVOIDING DISEASE

&DISABILITY

MAINTAININGHIGH

COGNITIVE& PHYSICAL

FUNCTIONING

ENGAGEMENTWITHLIFE

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Quality Improvement Themes

Evidence-based

System-based

Incorporate care coordination principles

Incorporate assessment tools

Incorporate culture change principles

Include patient and family centered care principles

Measurable outcomes

Plan for continuity after the initiative

Indiana Health Care Quality Improvement Initiatives

Survey-based Initiatives

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Survey-based Initiatives

CMS Special Focus Facility Program– Adding a facility in October 2010– Will be five special focus facilities– Funded by CMS and state funds

ISDH Consultant Program– Offered to facilities with substandard quality of care findings– Funded through ISDH Civil Money Penalty Fund

CMS Critical Need Nursing Home Project (Through Quality Improvement Organization – Health Care Excel)– Pilot program for 4-5 facilities in northwest Indiana– Funded by CMS grant to Health Care Excel


Addressing Immediate Jeopardy Level Deficiencies

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Improving Survey Findings

The Challenge

In 2007, Indiana had the 5th highest number of immediate jeopardy findings on nursing homes surveys

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Quality Improvement Activities

Monthly meetings with provider associations to review findings

Quarterly meetings with advocate organizations to discuss quality of care concerns

Collaborative quality improvement initiatives with healthcare organizations

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Quality Improvement Activities: CMS and ISDH consistency workgroups

Review of all immediate jeopardy findings by provider associations

ISDH implemented a biweekly long term care newsletter in January 2008 (funded through ISDH Civil Money Penalty Fund)

Implemented collaborative healthcare quality improvement initiatives

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Outcomes: Immediate jeopardy findings

2006: 91 – Indiana 3rd highest 2007: 106 – Indiana 5th highest 2008: 76 - Indiana 13th highest (68 surveys) 2009: 46 – Indiana 17th highest (35 surveys) 2010: 25 - Through September 13

Source: CMS CASPER data

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Outcomes: Immediate jeopardy findings(% of facilities with IJ)


Q4 2006: 4.50% n/a 2.20% Q3 2007: 5.64% 3.36% 2.17% Q2 2008: 5.08% 3.75% 2.58% Q2 2009: 2.77% 3.23% 2.89%



Indiana Healthcare

Leadership Conferences

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Healthcare Quality Leadership Conferences

Joint conferences for long term care providers, organizations, associations, and surveyors

Two conferences per year Each conference covers one topic Conferences serve as kick-off for quality

improvement initiatives Funded through the ISDH Civil Money Penalty

Fund

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Previous Conferences June 2007: Falls October 2007: Pressure ulcers March 2008: Restraints and behavior management September 2008: Emergency preparedness March 2009: Incontinence September 2009: Staffing March 2010: Healthcare Associated Infections

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Planned Conferences

Alzheimer’s and Dementia Care – October 14, 2010 Nutrition and Hydration – March 31, 2011 Abuse and Neglect – Fall 2011 Patient Safety / Medical Errors – Spring 2012

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Conference Checklist Attend conferences

Use information and resources to develop education and training program in facility

Implement quality improvement project in facility

Celebrate quality accomplishments


Indiana Pressure Ulcer Initiative

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Participating Facility and Agencies

Phase 1 Phase 2 Total

Home Health / Hospice 27 13 40 Hospitals 41 7 48 Nursing Homes 94 62 156 Totals 162 82 244

Funded through ISDH Civil Money Penalty Fund

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Indiana incidence of pressure ulcers in long term care facilities

– Q4 2003 – 9.5% (Ranked 36th in US)– Q4 2004 – 9.2%– Q4 2005 – 8.6%– Q4 2006 – 8.4%– Q4 2007 – 8.1%– Q4 2008 – 8.3% (Ranked 36th in US)

Source: CMS GPRA Data

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Initiative Components

Three In-person Learning Sessions Toolkits Six Online education modules –

www.in.gov/isdh/24558.htm Consumer brochure

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Initiative Outcomes: Pressure UlcerRates for all Indiana Nursing Homes

Q1 2008: 8.5% (34th) Q4 2008: 8.3% (36th) Q1 2009: 8.0% (29th) Q2 2009: 7.6% (28th) Q3 2009: 7.3% (26th)


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Initiative Outcomes: Number of NursingHome Residents with a Pressure Ulcer Q1 2008: 2992 Q3 2008: 2867 Q4 2008: 2899 Q2 2009: 2618 Q3 2009: 2506 Q4 2009: 2664 Q1 2010: 2574 - 14% Statewide Decrease

from Q1 2008Source: CMS GPRA Data

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Initiative Outcomes: One Year CostSavings for Indiana Nursing Homes

300-400 fewer pressure ulcers per quarter

Average cost of over $10,000 per pressure ulcer to heal

For 300 residents, savings of over $12 million in one year


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Initiative Outcomes: One Year CostSavings for One Unit of One Hospital 2008: 14 pressure ulcers with some stage 3 or 4

2009: 0 pressure ulcers

Average cost of over $30,000 per pressure ulcer to heal

For 14 patients at one hospital, savings of over $420,000 over one year


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Pressure Ulcer Deficiencies

Year Deficiencies Immediate Jeopardies

2007 195 182008 186 52009 157 42010 96 2 (to Sept. 13)

Source: CMS CASPER Data


Indiana Healthcare Associated Infection Initiative

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Infection Control Deficiencies

Year Deficiencies Immediate Jeopardies

2009 170 02010 137 2 (to Sept. 13)

Source: CMS CASPER Data

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Healthcare Associated Infections

Catheter associated bloodstream Catheter associated urinary tract Clostridium difficile Methicillin-resistant Staphylococcus aureus

(MRSA) Surgical site Ventilator associated pneumonia

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Indiana will focus on two infections

Catheter associated urinary tract infections

Clostridium difficile infections

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Goals of Initiative

Develop a state infection plan

Develop and implement an infection surveillance system

Implement a prevention initiative focusing on two of the infections

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Participating Facilities

Ambulatory Surgery Centers - 3 Dialysis (ESRD) Clinics - 2 Home Health and Hospice Agencies - 13 Hospitals - 48 Nursing Homes - 134

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Initiative Funding

Centers for Disease Control and Prevention (CDC) Grant

ISDH Civil Money Penalty Fund


Reducing Restraints

CMS GPRA Target

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Restraint Reduction in Nursing Homes

CMS GPRA Restraint Data

Q4 2003: 6.2% (27th rank) Q4 2004: 5.8% (26th) Q4 2005: 5.8% (30th) Q4 2006: 5.4% (30th) Q4 2007: 4.4% (32nd)


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Quality Improvement Activities

ISDH Leadership Conference on Restraint Reduction in March 2008 (funded by ISDH Civil Money Penalty Fund)

Quality Improvement Organization (QIO) focus on restraint reduction (funded by CMS)

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CMS GPRA Restraint Data

Q1 2008: 4.0% (32nd rank) Q2 2008: 3.6% Q4 2008: 3.1% (27th) Q1 2009: 2.8% Q4 2009: 2.3% (22nd) Q1 2010: 2.2%


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Other Civil Money Penalty Fund Quality Improvement Initiatives

Alzheimer’s and Dementia Care Initiative– Development of 10 education modules– Creation of Alzheimer’s and Dementia

Certification Program– Provided scholarships

Bladder Scanner Study for Incontinence Care

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Quality Improvement Initiatives in Progress

Aide Curriculum Review ProjectHealthcare Quality Resource CenterImplementation of New Regulations

– Life safety code– Infection control – Sept 2009

Implementation of MDS 3.0Care Transition and Coordination


Medical Error Reporting System

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Indiana Medical Error Indiana Medical Error Reporting SystemReporting System

Based on National Quality Forum’s 27 (now 28) reportable events

In 2002 NQF identified 27 events that are serious, largely preventable, and of concern to the public and providers

Indiana was the second state to use these reporting standards

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Indiana Medical Error Reporting System

Most Reported Events

Stage 3 or 4 pressure ulcers acquired after admission

Retention of a foreign object in patient after surgery

Surgery performed on the wrong body part

Death or serious disability associated with a medication error

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Indiana Medical Error Reporting System

Outcomes Pressure ulcer data as top reportable event

resulted in Indiana Pressure Ulcer Initiative and decrease in pressure ulcers

Increased awareness of medical errors Allocation of resources to patient safety Increase in number and activity of state and

regional patient safety coalitions


Patient Protection and Affordable Care Act

- Long Term Care Initiatives

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Affordable Care Act Initiatives

Affordable Care Act Includes NursingHome Quality Improvement Activities

Facilities required to implement a Quality Assurance & Performance Improvement Program (QAPI)

Posting of survey reports and plan of corrections on consumer-oriented Website

Disclosure of ownership

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Affordable Care Act Initiatives

Affordable Care Act Includes NursingHome Quality Improvement Activities

CMS Nursing Home Compare to include criminal violations

Improved reporting of staffing

Sanctions for inadequate notice of facility closure

Reduced civil money penalties for some self-reported deficiencies

health facility evaluation and quality improvement september 21, 2010

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