Sometimes we feel like we’re spinning our wheels in correcting problem areas in our facility. What can we do to ensure ongoing compliance in problem areas?
You can use the survey process to help you in the correction of areas needing improvement. The process includes the following four steps:
What corrective action will be accomplished for those residents found to have been affected by the deficient practice?
What other residents have the potential to be affected by the same deficient practice and what corrective action will be taken?
What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur?
How will you monitor the performance to ensure that solutions are sustained, evaluated for efficacy and integrated into the facility’s quality assurance program?
Internally, you can follow the same process in improving outcomes within your Quality Assurance Performance Improvement process. First, look at the residents who triggered the issue (e.g. falls). Determine the root cause of the falls and take appropriate action to minimize the risk for those residents.
Second, look at other residents at risk for the same issue (i.e., high risk for falls) and make sure appropriate interventions are in place to reduce their risk of falls or risk of injury from falls.
Third, look at your policies and procedures and systemic processes to see if any changes need to be made. Re-educate staff in those processes.
Fourth, set up a QAPI mechanism so that you are monitoring indicators on a regularly scheduled basis. With ongoing monitoring you will see any negative trends and be able to respond to them promptly.
From the February 01, 2015 Issue of McKnight's Long-Term Care News
