© 2006 CARF International. All rights reserved.

© 2006 CARF International. All rights reserved.

Performance Improvement: A Performance Improvement: A Quality Framework for Adult Quality Framework for Adult

Day ServicesDay Services

NADSA Annual ConferenceSeattle, Washington * October 10, 2009

Janice Nestler, Executive Director, Elder and Adult Day ServicesZoie Nikov, Business Development Executive, CARF International

2 © 2006 CARF International. All rights reserved.

Session ObjectivesSession Objectives

Discuss elements of an effective measurement system to help determine your ROI in key operational areas

Discover standards that support implementation of a performance measurement framework focused on quality improvement

Learn from providers that have successfully measured ROI and implemented quality improvement initiatives


Commission on Accreditation of Commission on Accreditation of Rehabilitation FacilitiesRehabilitation Facilities

International accreditation and standards setting organization Founded in1966 Private, non-profit, independent Customer Service Units

Aging Services Behavioral Health Child and Youth Services Durable Medical Equipment Prosthetic Orthotics & Supplies (DMEPOS) Employment and Community Services Medical Rehabilitation

Accredits more than 5,500 organizations in U.S., Canada, Europe, South America, South Pacific

Over 7.2 million people served annually Field driven Peer Review Process Moral owners – persons served Process emphasizes:

Persons served Performance improvement Business aspects of human service delivery Good management process


Commission on Accreditation of Commission on Accreditation of Rehabilitation FacilitiesRehabilitation Facilities

CARF International Tucson, Arizona

CARF Canada Edmonton, Alberta

CARF-CCAC and Aging Services

Washington, DC


Aging Services Aging Services Customer Service UnitCustomer Service Unit

Adult Day Services Aging Services Networks Assisted Living Continuing Care Retirement Communities Home and Community Services (coming in

2010) Person Centered Long Term Care

Communities Dementia & Stroke Specialty


ADS CARF Accreditation TodayADS CARF Accreditation Today

2008 revised ADS standards NADSA is CARF International

Advisory Council participant Tracking Medicare ADS Act of 2009 VA explorations Currently accredit programs in 22

states in US and in Ontario, Canada


State Acceptance of AccreditationState Acceptance of Accreditation

Acceptances of accreditation in lieu of regulatory requirements:

Iowa Maine Maryland Massachusetts Missouri Montana Nebraska New Mexico North Carolina Rhode Island Wyoming

Contact us if your state is developing, updating, revising statutory provision or regulations


The Accreditation ProcessThe Accreditation Process


The Accreditation ProcessThe Accreditation Process Intent to survey Use standards for 6 months – self

assessment Survey is scheduled – 2-3 day survey Peer surveyors - Administrative,

Program Orientation Tour Interviews with persons served, staff,

leadership, families Observation of processes Review of documentation Daily “Where we are” meeting Exit Conference Very consultative throughout


Cost of AccreditationCost of Accreditation

Intent to Survey = $950 Survey Fee = $1375 per surveyor per

day Average survey: 2 surveyors for 2

days = $1375 x 4 = $5500 Total = $6450 for 3-year term

Average cost: $2150 per year

for three years


Why is Accreditation Important?Why is Accreditation Important?

CARFAccreditation


Why: Big Picture ValueWhy: Big Picture Value

Preemptive: regulations can be invasive, disjointed, excessive

Standards: cover best practices for business and service

Process: Self assessment with third-party peer review – learn your strengths and areas for improvement

Bottom line value Public accountability


Why: Standards ConformanceWhy: Standards Conformance Rights are communicated, procedure

in place for formal complaints, review of formal complaints

Emergency procedures Safety during violent or

threatening situations Tests of procedures Procedure for responding to

critical incidents Evaluation of critical incidents

Evacuation routes are accessible in all areas where people receive services

Accessibility planning Performance measurement:

Data collection system Performance analysis Sharing performance

information Technology and systems plan

Human Resources: Performance management Students and volunteers Training on diversity issues,

customer service, outcomes measurement, performance improvement

Procedures for responding to subpoenas, search warrants, other legal actions

Review of billing Risk management plan Written procedures for receiving

counseling and appealing involuntary transfer, discharge, contract termination

Written agreement includes refund policies

Policies on protection of records from damage due to water damage or fire


Why: Bottom Line ValueWhy: Bottom Line Value

2009 study found average business increases in CARF-accredited organizations:

26% increase in persons served annually 37% increase in annual budget dollars

2008-2009 surveyed accredited provider findings: 98% stated their business was improved due to CARF 88% said CARF standards were relevant to direct

quality 93% said CARF’s surveyors provided valuable

consultation 88% said on-site survey was beneficial 88% said survey report guides improvement


Measuring for Measuring for SuccessSuccess

Determining Your

Return on Investment


Questions to Consider Questions to Consider For The Organization...For The Organization...

Who are your stakeholders?

Do you know if you are meeting their needs?

Can you provide information in simple and useful way?

How do you analyze if you have met strategic goals or targets?

Do you use all the data you gather?


Questions to Consider Questions to Consider For The Organization...For The Organization...

How do you make decisions in your organization now?

What role does data play in those decisions?

Can you accurately speak about your “performance”?


Thought Provoking QuestionsThought Provoking Questions

Where is the information to respond to questions from persons served, payers, leadership and others currently available?

Who collects the information and how are they trained? What system and/or tool is used to collect the

information? Where is the information stored? Who ensures that the data has been entered correctly? How do you know how different groups respond to

questions? New vs. long-term personnel Persons served who have been part of the organization

for <1 year vs. >5 years


Data Collection StandardsData Collection Standards

Collect data Needs of persons served Needs of other stakeholders Business needs of the organization

Allow for comparative analysis Used to manage and improve service

delivery


Data Collection StandardsData Collection Standards

Fact-based, decision making model Organization demonstrates how it

addresses data: Reliability Validity Completeness Accuracy


Demonstrating ReliabilityDemonstrating Reliability

The organization plans to take steps to ensure that data are collected in a way that could be reproduced at another time or by other data gatherers. What actually happens in practice? How are people trained to administer

tools? If standardized tools are used are

they administered properly?


Demonstrating ValidityDemonstrating Validity

The organization chose indicators, measures, and data elements that reflect what it intends to measure.

Tool (s) ask appropriate questions of the population to get at information needed

Did this happen? Have things changed and do the changes reflect the indicators actually used?

Has the population changed in such a way to invalidate the tools used because tools don’t get at the right information?


Demonstrating CompletenessDemonstrating Completeness

The organization takes steps to ensure that the data used for decision making are as complete as possible No groups of persons served are omitted

from the data gathering or analysis: representative sample

No data elements or fields are constantly missing

Database is checked for completeness of records before final analyses are run and decisions made


Demonstrating AccuracyDemonstrating Accuracy

The organization takes steps to ensure that data are recorded properly and that errors are caught and corrected

Spot checks of records of persons served are done to ensure that data taken from the record are correctly entered into database

The person responsible for the database routinely reviews the data to ensure that it appears correct


Service Delivery StandardsService Delivery Standards

Data collection system: Includes characteristics of persons

served Collects data at:

— Beginning of services— Appropriate intervals— End of services— Point (s) in time following services



Measures of indicators of: Effectiveness of services Efficiency of services Service access Satisfaction and other feedback

from:– Person served– Other stakeholders


Measuring the Big Four Measuring the Big Four Domains of IndicatorsDomains of Indicators

EffectivenessOutcomes or results achieved for

persons served

Efficiency Resources used to get a result

AccessGetting into services

Feedback/satisfactionProcess and outcome



Each indicator: Whom applied to How is data collected What is the performance goal Extenuating/ influencing factors

considered for analysis


Example: FrameworkExample: Framework

Expected Outcome

Data Source/ Obtained By

Time of Measure

Who Applied To

IndicatorObjectiveType of Measure


Premises for MeasurementPremises for Measurement

Information (converted data) is available in your organization.

Information is used to Review the implementation of mission and

core values of the organization, Improve the quality of programs and services Facilitate organizational decision making and

strategic planning. Measurement is woven throughout your

organization


Information Management Information Management DefinitionDefinition

Philosophy + processes = improvement to better meet needs and expectations of persons served

Designs or activities which

improve quality or reduce

costs Eliminate waste Reduce non-value-added tasks


Don’t let your data be like socks into a dryer—

What goes in must come out!

The CycleThe Cycle


Case Studies:Case Studies:ROI Measured and Quality ROI Measured and Quality

Improvements Improvements ImplementedImplemented


Case Study #1Case Study #1

Elder and Adult Day Serviceswww.eadscares.org


Elder and Adult Day ServicesElder and Adult Day Services

Founded Feb 1984 private free standing non-profit

First Adult Day Health serving East King County Expanded from 1 to 4 centers 300 participants

Purchased Bellevue Center 1989 East King County – Issaquah 1996 South King County – Des Moines 2003 Kitsap County – Bremerton 2004 to

Bainbridge 2008 2001 first program in Wa State to achieve CARF

accreditation/currently only accredited ADH


EADS - Key MessageEADS - Key Message

Elder and Adult Day Services provides relief to caregivers by offering day health programs focused on frail seniors and

developmentally disabled adults


EADS AccreditationEADS Accreditation

Commitment to deliver Adult Day Health Services in accordance with industry standards established nationally

Dedicated to being good stewards for our resources to ensure continuous quality improvement

EADS philosophy includes persons served not only the participant and their family but also staff, vendors, funders and the community at large

History of collaboration and successful partnerships for the benefit of each person served

Mission and values driven


Implementing CARF StandardsImplementing CARF Standards

Care Process for the Person Served The program has a written philosophy

of health and wellness for the person served that:

a. Is implemented to:(1) Address: (a) Function (b) Quality of life

(2) Promote healthy aging and well being


EADS ProcessEADS Process

Talked with participants Reviewed care plans/assessed acuity Met with Parents/Caregivers/physicians Talked with Staff Review/evaluate notes from all of the above Assessed EADS current program

What’s missing? What’s needed?

Research possible programs Evidence based exercise programs Appropriate, affordable and effective


What Next?What Next?

Participants needed an improved form of exercise Increase core strength and mobility Proactive form of fall prevention instead of

reactive Increase individual self esteem

Goals Improve each persons independence Reduce the risk of falls Increase individual dignity and self reliance Secondary gain of function in their ADL’s


Staying Active and Independent for Staying Active and Independent for Life (SAIL)Life (SAIL)

SAIL = Developed by geriatricians and Physical Therapists specializing in balance disorders by the WA Department of Health with funds from CDC

SAIL first evidence based exercise program specifically designed for Adult Day Health Centers

SAIL has become a part of the public domain SAIL P.T. specialist visited EADS centers and

met with the board for final approval EADS was selected to pilot this program in WA EADS staff were trained to deliver SAIL EADS OTR trained to train trainers


SAIL begins at EADSSAIL begins at EADS

SAIL began at one center plan to include all centers

Staff collect and provide data Fitness checks every 6 months using PT

standardized assessment completed by OTR Grant provide minimal equipment for

optimum benefit SAIL participants receive a pre-test

evaluation SAIL added to participants care plan SAIL progress is charted weekly


SAIL ROI at EADSSAIL ROI at EADS

Early data indicates after almost one year using SAIL Most significant gain from seniors who

were the most frail Anecdotally congenital balance

disorders have improve Traced lower blood sugar for person

with diabetes Seniors with dementia have improved

participation Caregivers report greater independence

and sense of well being when their loved one is at home


CARF Standards for AssessmentCARF Standards for Assessment

Participant benefits related to CARF Standard are as follows: Positively affecting multiple systems that

lead to increase in health and wellness Increase in overall function Increase in general health and well being Improved self esteem In line with state initiative for falls

prevention


Implementing CARF StandardsImplementing CARF Standards

Leadership Standard

CARF accredited organizations identify leadership that embraces the values of accountability and responsibility to the individual organizations stated mission. The leadership demonstrates corporate social responsibility

Standard: The identified leadership guides the following:

a. Establishment of the mission and direction of the organization

b. Promotion of value and achievement of outcomes in the programs and services offered


EADS ProcessEADS Process

EADS Strategic Plan Foundation for direction and sets priorities for EADS

— Tactic: Increased awareness of EADS through key message and brand awareness

Development staff researched grants In line with EADS mission, values and goals Consistent with EADS partnership philosophy

Taproot Foundation grant received $50,000 in professional staff for defined scope of

work Blueprint contract approved with deliverable

outcomes EADS staff /board worked with industry professionals Process includes environmental assessment


What Next?What Next?

Taproot Team produces several versions of EADS key branding messages for various print and verbal means Presented to EADS board for final approval All staff and board given written and in person

training on appropriate use of all key branding messages

Printed on newsletter, brochure, invitations giving envelopes, website, employee ads/orientations participant and family handbook

Used in verbal presentations


Key Message ROI for EADSKey Message ROI for EADS

EADS measures effectiveness after 1 year: More appropriate referrals from

advertizing E-Newsletter # of hits “looks” and click

through Increased level of contributors at

fundraisers Recognition at United Way/Day of

Caring events Differentiate from other adult day health

centers


CARF Standard AssessmentCARF Standard Assessment

Leadership Standard: Promotion of value and achievement of outcomes and achievement in the programs and services offeredDelegation of activities,

community assessment, using the feedback and collaborating on several levels of EADS leadership


EADS Survey ExpensesEADS Survey Expenses

Survey preparations (third time around) Purchase CARF-ADS standards CARF Lead takes an online refresher

course Complete online application for survey Inform all staff and board important dates Begin by reviewing standards with key

staff Evaluate Performance Improvement

Plans Let the fun begin


EADS AccreditationEADS Accreditation

WHY?


CARF ROI at EADSCARF ROI at EADS

Overall positive effect on EADS bottom line by: National Compass for our mission and purpose Enhanced participant health, independence and

well being Improved staff retention with enhanced esteem Higher caliber Board members/easier

recruitment Identify, demonstrate and measure benefits Additional key marketing message Third party independent quality assurance for

all vendors and persons served



Senior Resource Groupwww.srgseniorliving.com


Measuring Staff TurnoverMeasuring Staff Turnover

Senior Resource Group Headquarters in Solana Beach, CA 15 communities in Arizona, California,

Florida and Oregon 1,000 employees, 2,800 persons served,

2,000 units Objective: Minimize staff turnover Domain: Efficiency Measure Target: Less than 50% annual turnover

(historical turnover rate 100%)


Measuring Staff TurnoverMeasuring Staff Turnover

Result: 100% to 60% in 5 years = 40% reduction in annual employee turnover

Learnings from analysis: implemented standards for tracking/trending, employee satisfaction survey, new employee orientation, longevity recognition program


Return on InvestmentReturn on Investment

*Track Data Before and After Implementing Standards*

Annual salary $25,000 ($10/hour) Turnover cost $37,500

Vacancy/replacement costs Recruitment costs Orientation/training costs Lost productivity costs New hire costs

Number of employees 50 Average turnover rate is 30% 15 employees X $37,500 = $562,500 annual cost Cost of accreditation $6450/3 year term of

accreditation or $2150 per year for 3 years


Bottom Line ValueBottom Line Value

Marketing: 1,450 more leads were received and 1,118 more tours given

Falls decreased by 2% Medication errors decreased by 34% Elopements decreased by 15% Vehicle maintenance decreased by $831

despite the addition of 10 vehicles Supply costs decreased on average, by

$2,700 per campus



Youngstown Ohio Area Easter Sealswww.mtc.easterseals.com


Measuring Client SatisfactionMeasuring Client Satisfaction

Youngstown Ohio Area Easter Seals Boardman Adult Day Services Warren Adult Day Services

Objective: Maintain high client satisfaction

Domain: Effectiveness Target: Overall Satisfaction 90%

(historical satisfaction high 80%)



Result: 90% and higher client satisfaction Feedback is a major driver of

programmatic changes Feedback provides support for

additional resources, equipment, space and new services



Learnings from analysis: Implemented standards in key operational

areas Low satisfaction rates for parking,

accessibility and outside space led to decision to move programs to new facilities in order to meet client needs

Responding to the feedback has a direct positive impact on client satisfaction

— Consistent 90% and higher client satisfaction


Return on InvestmentReturn on Investment

*Track Data Before and After Implementing Standards*

Reduction in marketing costs to recruit new participants

Seattle Times: $1806 for one weekday ad (black and one standard color)

Invitation/announcement costs Food and beverage cost for one open house $250 Staff cost to plan, manage and attend event

Reduction in cost for print marketing materials Reduction in staff time spent orienting participant

and family members Cost of accreditation $6450/3 year term of

accreditation or $2150 per year for 3 years


Closing TipsClosing Tips


Nothing is less productive

than to make more efficient what should not be done at all.

-Peter Drucker


Closing TipsClosing Tips

Keep it very simple Get staff on board with how this can help Measure before you begin, during and after

you implement quality improvement efforts Don’t collect more data – take a hard look at

what you collect to ensure that it brings value Integrate business and service delivery Set realistic/achievable targets


Thank YouThank You

Janice Nestler, Executive Director, Elder and Adult Day Services [email protected]

Zoie Nikov, Business Development Executive, CARF Aging Services [email protected]


Contact CARFContact CARF

CARF Aging Services866-888-1122, www.carf.org

/aging

Rebecca Best, Resource Specialist

[email protected] Amanda Birch,

Administrator of Operations [email protected]

Susan Ganson, Resources Specialist [email protected]

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50

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4th

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East

West

North

Sue Matthiesen, Managing Director [email protected]

Zoie Nikov, Business Development Executive [email protected]


Insights from ColleaguesInsights from Colleagues

“CARF is an educational experience. The surveyor’s attitude was one of cooperation and support rather than roadblocks. We enjoyed working with CARF because of the precise nature of CARF’s philosophy. I am very excited working with CARF, as I believe CARF focuses on quality, competence, and character.”

- an accredited provider “CARF has helped us focus on the needs of our

customers. By defining ourselves clearly, evaluating ourselves professionally, we can locate funding sources, and articulate our staffing needs. CARF gave us many suggestions to generate needed income for our programs.”

- an accredited provider


Insights from ColleaguesInsights from Colleagues

“You set the standards…the way standards should be set – by professional field and consumer input. I have always appreciated that surveyors work full time in the field and understand the realities of trying to do a good job (and stay in business). Thank you for all the work that you do!”


“We were very happy that the expertise of the survey team matched our agency. This is the best thing we’ve ever done as an organization to improve our system of care.”



Insights from ColleaguesInsights from Colleagues “The opportunity for an objective and standardized review

of our programs validated our focus for service delivery. The opportunity for feedback, dialogue, and exchange of ideas provided the impetus for further creativity and identified areas for improvement.”

- an accredited provider “Our involvement with CARF has benefited the people we

serve beyond belief. We have become even more customer driven and outcomes based. CARF has demonstrated that you can be rural and deliver quality care.”

- an accredited provider “The standards were very supportive of the services,

philosophy, and mission of our organizations. The standards assisted us in fine-tuning our client-oriented program and in establishing systems for accountability.”


© 2006 CARF International. All rights reserved.

Health & Medicine

Transcript of © 2006 CARF International. All rights reserved.