A measure of success

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Facilities should adapt QAPI plans that are comprehensive and address their full range of care and services. Technicians can help by gathering feedback or analyzing trends.
Facilities should adapt QAPI plans that are comprehensive and address their full range of care and services. Technicians can help by gathering feedback or analyzing trends.

If a computer asks you a question as you're leaving the dining room at one of Benedictine Health System's sites in St. Paul, MN, stop to give your opinion. 

Whether your eggs were cold or your coffee perfect, your feedback might help administrators shape their next quality improvement initiative.

Nursing homes are still awaiting the official launch of the CMS Quality Assurance and Performance Improvement era, but many are already ramping up their data collection efforts.

No longer is it enough to measure clinical outcomes. Successful initiatives will influence all aspects of facility operations, from infection control to resident satisfaction. Figuring out how to prioritize specific goals, however, requires reliable data and employees with the time and knowledge to analyze trends.

“We feel very prepared for QAPI,” says Denise Vaughn, vice president of clinical services for Benedictine, which operates about 60 nursing homes and senior living communities in the Midwest. “It's part of our culture. It's built into our framework.”

Carol Benner is interim executive director for the Advancing Excellence in Long-Term Care Collaborative. She says other care providers — particularly hospitals — have found success by adopting that same attitude.

Once the final rule is passed, CMS says facilities must adopt plans that are “ongoing, comprehensive and address the full range of care and services provided by the facility.”

In other words, boilerplate initiatives won't work.

Programs must address all systems of care and management; hit clinical, quality of life and resident choice areas; use evidence to define and measure indicators of quality and set goals; and reflect a facility's unique resident make up and services.

The rule's data collection component seems to be getting the most attention, and software companies are offering more measurement tools than ever before.

But even innovators in the world of electronic health records acknowledge that nursing homes without leadership and employee cooperation will fall short of their targets. Meaningful analysis requires a human touch.

“The success of an initiative has to be driven by the top down and have a voice from the bottom up,” says Kirby Cunningham, vice president of clinical strategic initiatives for AOD Software. “We've built a platform where any single person in a community — even housekeeping — can input data into a system that can be analyzed in real time.”

Benedictine's nursing homes use the MatrixCare platform, Vaughn says because the point-of-care data entry lets managers spot emerging problems rather than waiting for compliance or reimbursement triggers to make something obvious.

Benedictine also uses supplemental programs for financial analysis, a PointRight program for its therapy services, and interview tools to get instant feedback from residents and families. On-site quality management coordinators use the numbers to enact system-wide quality directives and hone facility-specific goals that go beyond the regulatory level.

“With QAPI, there's a deeper dive,” Benner notes.

Drilling down

Ten years ago, nursing home data was often limited to national statistics.

And some key indicators — like the Five-Star quality ratings that feed Nursing Home Compare — need to remain part of every facility's global plan, says Kris Mastrangelo, president and CEO of the consulting firm Harmony Healthcare International.

But facilities that have specific goals in mind and need better ways to measure improvements efforts are in luck. Many vendors are building their repertoire to become one-stop shops. This fall, for instance, MatrixCare announced the acquisition of MealTracker and AOD and a corporate partnership to develop research programming focused on quality measures in memory care.


“Data is just critical,” says Denise Wassenaar, BSN, MSN, chief clinical officer at MatrixCare. “It's about finding the data points to know whether your programming is successful.”

Having multiple data sets and reliable sources of comparison allows individual facilities to better understand how they match up on specific goals or amongst regional peers, says Brad Shiverick, senior vice president for Healthcare at Team TSI. Large chains also can see weaknesses and strengths within divisions.

TSI's quality management suite can track trends such as spikes in infections, accidents or grievances. It also allows facilities to customize data entry points, then translates that data into easy-to-read reports.

One way to manage multiple data sets is through integration. Most electronic programs populate data across systems — meaning a dosage recording for a patient would be included in his medical record, reimbursement systems and any separate files set up to track medication-related goals.

Shiverick says having multiple data points displayed on a single computer dashboard enables managers to keep multiple informational plates spinning.

Sometimes just collecting the data can help move you toward a goal, notes Lori Elrod, marketing manager for skilled nursing and senior living at PointClickCare. She points to initiatives to reduce re-hospitalizations using her company's E-interact program, which connects and continuously monitors patient data.

“Having information embedded allows a nurse to have a better conversation with a physician,” Elrod says. “If they don't have a complete picture at their fingertips, the physician might be more cautious and say, ‘Let's just send them back.' ”

Those without electronic records or limited resources to purchase new measurement tools will likely find themselves at a disadvantage with QAPI, though experts agree that great free resources exist, such as through Advancing Excellence.

Additionally, the culture — devoted staff, resources and training — come into play. No matter how a facility collects data or its standards of comparison, consistency is necessary.

Many areas of concern can be computed differently. How one measures average length of stay might change depending on whether median or mean calculations are used. CMS won't necessarily dictate how facilities calculate improvement, but changes in method will likely be red flags that cause facilities to miss their goals.

“Calculation consistency is quite important, but it's also been a burden on the industry,” says Mastrangelo.

Written plans should include specifics like calculation methods so that they outlast changes in technology or staff.

Finding the cause

Once a facility has set up its data collection program, needed improvements might be obvious. Often, they're still determined by deficiencies.

But facilities should also strive to be forward-focused, thinking of goals that help clients but also reflect the move toward bundled payments and performance within diagnostic-related groups that can lead to more (or less) business, Cunningham says.

Some software now incorporates enterprise analytics, which can categorize information based on needs and improvement plans.

But how to determine what those initial plans are?

If they don't rise to the top of mind immediately, rely on staff and strategic processes to help identify needs.

In a CMS update last March, officials highlighted the need for an interdisciplinary team to meet at least quarterly to review quality assurance activities and goals. Much of the time they spend should be spent asking why problems are happening and determining a formula that will actually net results for residents. 

Benner favors a method she calls the “five whys.”

She illustrates it through the example of a Maryland nursing home that rarely had a deficiency. But after a move to the suburbs, the turnover rate jumped substantially.

“They pulled together a team, they brainstormed and they used what we call ‘the five whys' to find out why it was happening,” Benner says.

The team connected the turnover to an increased number of disciplinary write-ups. When they asked why more employees were being written up, they found many were late for their shifts. Eventually, they asked why enough times to realize that the new location wasn't on a bus line. The solution was simple and results-oriented: The facility started a van service to get employees to and from the closest stop at shift changes.

Electronic records that reveal factors contributing to individual resident outcomes will be invaluable in years to come. John Ederer, president of American Data, says QAPI should ultimately force nursing homes to focus more on the patient than their numbers.

“A good EMR should let the facility drill down anywhere they want to in the patient record,” Ederer says. “If monitoring of stats is focused on how each patient is doing, the facility stats will take care of themselves.”

The team implementing the plan — including the DON, an administrator and the MDS coordinator — should be tasked with identifying breakdowns, viable work-a-rounds and duplicated efforts to fine-tune it.

Mastrangelo points out that clients are sometimes surprised to learn that setting lofty goals can yield “nuggets of success” even if the exact target isn't met.