krystal hays, msn, rn, rac-ct great plains quality ... · 7/22/2015 1 gpqcc update krystal hays,...
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7/22/2015
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GPQCC Update
Krystal Hays, MSN, RN, RAC-CT
Great Plains Quality Innovation Network
Quality Improvement Advisor
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Great Plains Quality Care Collaborative
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Collaborative Support
Corporate Consultants
Leading Age Nebraska
Nebraska Healthcare Association
Nebraska LANE
Nebraska Culture Change Coalition
State Survey Agency
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11 SOW QIN-QIO Map
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Make-Up of the Great Plains QIN
These four states choose to work together because of: • commonalities of Medicare
consumers • provider characteristics • rural and frontier issues • similar corporate
philosophies and general approaches to the QIO work
These common factors are strengths in working cohesively
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Great Plains Quality Care Collaborative Model
18 Months x 2 Recruit: nursing homes,
stakeholders and peer coaches
Pre-work: beginning 2-3 months prior to Learning Session 1
Collaborative Learning Session 1 face-to-face session
Action Period
Learning Session 2
Action Period
Action Period
Learning Session 3
Collaborative Outcomes Congress
Project wrap-up, celebrate successes
and sustainability planning session.
Sustainability Phase
Email & List Servs, Peer Coaches, Educational Webinars, Technical Assistance
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Learning Session Objectives
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Learning Session 1 • Get ideas • Get methods • Get started
Test and implement
changes. Collect data to measure
impact of changes.
Action Period 1
Learning Session 2 • Get more ideas • Get better at
methods • Get a “stride”
Test and implement
changes, collect data to
measure impact of changes.
Action Period 2
Learning Session 3 • Continue to learn
from one another • Celebrate
successes • Get ready to
sustain and spread
Test and implement
changes, collect data to measure
impact of changes.
Action Period 3
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Staff Stability 26%
Consistent Assignment 12%
Res/Family
Engagement 7%
Team Building 21%
Communication 22%
Effective Leadership 12%
Systems Topic Needs
Data as of 6/16/15
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Avoidable
Readmissions 10%
Pain Management 14%
Fall Prevention 22%
Vaccinations (Flu/Pneum) 2%
Infection Prevention
10%
B&B Management 13%
Pressure Ulcers 8%
Reduce Weight
Loss 8%
Reduce s/s depression
12%
Other 1%
HAC Topic Needs
Data as of 6/16/15
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Basic 23%
Tools 38%
Culture 38%
Other 1%
QAPI Training Needs
Data as of 6/16/15
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Not Started 12%
Just Starting 45%
On Our Way 30%
Almost There 9%
Doing Great
4%
Initial QAPI Self-Assessment Tool Overall Progress
Data received as of 6/16/15
Webinar Preference
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Tuesdays – 51%
Thursdays – 49%
Morning – 50%
Afternoon – 50%
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NH Quality Composite Score
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Goal: 6.00 or less
13 Long-Stay Quality Measures
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13 Long-Stay Quality Measures
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13 Long-Stay Quality Measures
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NH Quality Composite Score Tools & Resources
Webinar: What’s Your Number? Understanding the Quality Measure Composite Score
http://greatplainsqin.org/wp-content/uploads/2015/05/F-NEMUMBER043015.wrf
Composite Score Calculator
http://greatplainsqin.org/initiatives/hac-nh/
Individualized Technical Assistance
• Contact Krystal Hays at 402.476-1399 (Ext. 522) or via email [email protected]
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Nursing Home Peer Coach Recognition
Achieved National Nursing Home Quality Composite Score of 6 or below and in the top 10% of state
Other factors considered
Nursing Home Compare Five Star Rating
Facility Antipsychotic Rates
Participating in the Great Plains Quality Care Collaborative
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Heritage Care Center - Fairbury
Beth Block, Administrator – [email protected]
Maggie Spilker, Director of Nursing – [email protected]
Phone: 402.729.2289 19
Hilltop Estates - Gothenburg Scott Bahe, Administrator – [email protected]
Serina Sladky, Director of Nursing - [email protected]
Phone: 308.537.7138
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Wilber Care Center - Wilber
Barb Dreyer, Administrator – [email protected]
Michele Vana, Director of Nursing - [email protected]
Phone: 402.821.2331
National Nursing Home Quality Care Collaborative Change Package (v 2.0)
CMS visited 10 Nursing Homes across the country
5,000+ Nursing homes in NNHQCC 2013-2014 expanded and added depth to version 2.0 (March 2015)
Developed from themes in quality approach and carried out work
Seven Strategies
Change Concepts
Actionable Items
Three Change Bundles
Promote avoidance of antipsychotic medications in residents living with dementia
Promote resident mobility
Prevent healthcare acquired infections
Referred to in the GPQCC News & Tip of the Week and throughout the Collaborative
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Change Package Strategies
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Great Plains Quality Care Collaborative Milestones
Recognizes your organization’s efforts toward Quality: QAPI in Action
Five milestones
You decide how your organization makes quality improvement
Test quality improvement techniques
Improve resident care
You track your progress
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Copper Milestone
Signed participation agreement for GPQCC
Formed a project team
Completed pre-work assessment/webinar Team information
Educational Needs Assessment
QAPI Self-Assessment Tool
Completed educational needs assessment
Know your Quality Measure Composite Score
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Templates Provided
PDSA Cycle Template Improvement Success Story
**Acceptable to submit own PDSA Cycle form & success story. The templates are provided if you wish to use them.
Bronze Milestone
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Chose a QI project and began a PDSA cycle
Started storyboard and/or a success story
Know your Quality Measure Composite Score
Attended 2 GP QIN educational offerings
1. Learning Session 1
2. Title of event (ie. Quality Forum) or Webex
viewed (may be live or recording)
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Silver Milestone
Complete and submit first PDSA worksheet
Shared first success story
Know your Quality Measure Composite Score
Attended 3 more GP QIN educational offerings (for a total of 5)
3. ________________________
4. ________________________
5. ________________________
Gold Milestone
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Repeated QAPI Self-Assessment Tool
Complete and submit second PDSA worksheet
Shared second success story
Know your Quality Measure Composite Score
Attended 3 more GP QIN educational offerings
(for a total of 8)
6. ________________________
7. ________________________
8. ________________________
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Platinum Milestone
Complete and submit third PDSA worksheet
Shared third success story and/or storyboard at a face-to-face learning session and/or present on a call or webinar
Quality Measure Composite Score has reached a score of 6.0 or lower during the Collaborative cycle **starting April 2015
Attended 4 more GP QIN educational offerings (for a total of 12)
9. ________________________
10. ________________________
11. ________________________
12. ________________________
When Milestone Completed
Submit by fax to 402-476-1335 or by scan/email to [email protected]
Copy of milestone checklist
PDSA worksheet
Success story
**PDSA and Success Story may be in an email format, your facility form, or templates in the Milestones Booklet.
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GPQCC Listserv
GPQCC News & Tip of the Week
• Educational Opportunities
• Tip of the Week
• QAPI in Action
• Collaborative Information
Sharing amongst Peers
• Collaborative members
• Share ideas, problem solve, policies & procedure
Upcoming Educational Opportunities
July 9 @ 2 p.m. CT – Promoting Mobility
July 16 @ 12:30pm CT - Dementia Support Across
the Continuum
August 13 @ 2 p.m. CT – Non-pharmacological Interventions
September TBA– Antipsychotic Reduction and Behavior Meetings
October 8 @ 2 p.m. CT – Leadership as a Supervisor
November – TBA – Learning Session 2
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Contact Information
Krystal Hays, RN, MSN, RAC-CT
1200 Libra Drive, Suite 102
Lincoln, Nebraska 68512
P: 402.476.1399 ext. 522
F: 402.476.1335
This material was prepared the Great Plains Quality Innovation Network, the Medicare Quality Improvement Organization for Kansas, Nebraska, North Dakota and South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-GPQCC-NE-C2-33/0615