Achieving Quality in Nursing Homes

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Achieving Quality in Achieving Quality in Nursing Homes Nursing Homes Barbara Bowers, PhD, RN, FAAN University of Wisconsin-Madison School of Nursing

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Achieving Quality in Nursing Homes. Barbara Bowers, PhD, RN, FAAN University of Wisconsin-Madison School of Nursing. T he S tatus of Nursing Home Quality. Varying measures of quality Deficiencies, QIs, hospitalizations Improvements in past decade Serious and ongoing issues - PowerPoint PPT Presentation

Transcript of Achieving Quality in Nursing Homes

Page 1: Achieving Quality in Nursing Homes

Achieving Quality in Achieving Quality in Nursing HomesNursing Homes

Barbara Bowers, PhD, RN, FAAN

University of Wisconsin-MadisonSchool of Nursing

Page 2: Achieving Quality in Nursing Homes

The Status of Nursing Home The Status of Nursing Home QualityQuality

• Varying measures of quality

– Deficiencies, QIs, hospitalizations• Improvements in past decade

• Serious and ongoing issues

• Quality of life and care; raising the bar

• A long way to go……..

Page 3: Achieving Quality in Nursing Homes

Nursing Home Care Quality Nursing Home Care Quality ProblemsProblems• Unnecessary hospitalizations

• Unrelieved pain

• Poor end of life care

• Missed change in condition

• Preventable outcomes

• Preventable functional decline

• Poor quality of life

Page 4: Achieving Quality in Nursing Homes

Reasons for Quality Reasons for Quality ProblemsProblems• High turnover

• Insufficient capacity

• Workforce composition

• Staffing Levels

• Working to capacity/role clarity

• Organizational culture

• Technology

• Ineffective transitions

• Funding/resources

• Orientation/Education

Page 5: Achieving Quality in Nursing Homes

Turnover RatesTurnover RatesWorker Type Average Annual TurnoverCNA 85-105%

LPN 45-60%

RN 55-70%

DoN 40-5o%

NHA 53%

Page 6: Achieving Quality in Nursing Homes

Consequences of TurnoverConsequences of Turnover

• Relationships with staff are significant resident quality indicator

• Familiarity with residents improves care quality

• Residents are more satisfied with committed workers (Bishop et al, 2008)

• Infection and hospitalization rates

• Agency staff use

• Turnover

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Causes of TurnoverCauses of Turnover• Lack of training/mentoring

• Low wages (80%)

• Lack of Opportunities

• Higher education

• Medicaid census

• Supervisors (most important)

Page 8: Achieving Quality in Nursing Homes

Turnover Rates by Leadership Turnover Rates by Leadership Type Type (Donoghue, Castle, 2009)(Donoghue, Castle, 2009)

Donoghue & Castle studyShareholder Autocrat Consultative Consensus

RN 44.3 18.5 8.4 6.5

LPN 57.1 26.0 13.7 5.4

NA 74.3 71.4 56.8 47.4

Page 9: Achieving Quality in Nursing Homes

The Importance of The Importance of SupervisorsSupervisors• Impact on work stress and health of

staff

• Turnover, most important factor

• Capacity building of staff

• Implementation of new practices

• Preparation to supervise

Page 10: Achieving Quality in Nursing Homes

Staff MixStaff Mix

• Inconsistent evidence

– Overall staffing related to outcomes– RNs are associated with better outcomes

• Functional level/ADL• Mortality• Infections • Pressure Ulcers

– Trends decreasing RNs

Page 11: Achieving Quality in Nursing Homes

Advanced Practice and LTCAdvanced Practice and LTC

• Decreased hospitalizations 50%

• Falls

• Behavioral symptoms

• Activity level

• Pressure ulcers

• Staff development

• Recommended by IoM report

Page 12: Achieving Quality in Nursing Homes

Staffing LevelsStaffing Levels

• "...sufficient nursing staff to attain or maintain the highest practicable ... well-being of each resident..." HCFA, 2001

• Many states have minimum

• Minor increases in staffing levels, drop in RN

• IoM report, 90% insufficient levels

Page 13: Achieving Quality in Nursing Homes

Quality areas most affected Quality areas most affected by Staffing by Staffing • Independence in ADLs

• Toileting

• Walking

• Pressure ulcers

• Catheter use

• UTIs

Page 14: Achieving Quality in Nursing Homes

CapacityCapacity

• “Adequacy is not just a number, it is capability” (IoM, 1986)

• Basic geriatric knowledge(preparation)

• Communication effectiveness (families, physicians, each other)

• Supervisory skills

• Ongoing education

• CQI experience and training

Page 15: Achieving Quality in Nursing Homes

The OrganizationThe Organization

• Resources

• Use of CQI

• Decision making participation

• Supervisor/manager support

• Team work

• Safety culture

• Support for serious/end of life care

• Learning culture

Page 16: Achieving Quality in Nursing Homes

CQI in Nursing HomesCQI in Nursing Homes

• Lag behind hospitals

• Adopters

– Responding to regulations– Had information systems– Flexible use of personnel– Manager had CQI training– Improvement orientation– Rantz study of adopters – APNs

Page 17: Achieving Quality in Nursing Homes

Safety CultureSafety Culture(Handler, et al, 2006)(Handler, et al, 2006)

• Lowest scores

– Nonpunitive culture– Open communication– Feedback related to errors– Organizational learning/improvement

Low commitment to detecting errors and developing systems

Page 18: Achieving Quality in Nursing Homes

Hospitals and Nursing Hospitals and Nursing Homes: Culture of SafetyHomes: Culture of Safety(Handler et al, 2006)(Handler et al, 2006)

NH HospitalOpenness of communication

41.7% 61%

Feedback 38% 52%

Non Punitive 10.6% 43%

Organizational learning

54% 71%

Page 19: Achieving Quality in Nursing Homes

Shared Decision MakingShared Decision Making(Scott-Cawiezell, 2006)(Scott-Cawiezell, 2006)

Item Strongly AgreeNurse leaders use input 4.5%

Expectations clear 10.9%

Not necessary to check accuracy of information

1.5%

Good cross shift communication 3.0%

Page 20: Achieving Quality in Nursing Homes

IMPROVING QUALITY IN IMPROVING QUALITY IN NURSING HOMESNURSING HOMES

Page 21: Achieving Quality in Nursing Homes

OBRA 1987 Nursing Home OBRA 1987 Nursing Home Reform ActReform Act• Quality of life

• Maintain and improve functioning

• Resident assessment and care plan

• Freedom from restraint

• CNA training and certification

• Resident councils

• Inspections and new ‘remedies’

Page 22: Achieving Quality in Nursing Homes

IoM, 2001IoM, 2001

• Increase RN cover to 24 hours

• Adjustment of pay to support RN hours

• Use of geriatric specialists in direct care and leadership positions

• Enhanced training for CNAs

• DoN education

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Culture Change in Long Term Culture Change in Long Term Care Care • Focus of initiatives

– Person centered– Relationships– Environment– Clinical care– Worker

empowerment

• Pioneer network 1997

• Eden Alternative 1997

• Wellspring Alliance 1998

• Action Pact

• Green House

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Person Centered CarePerson Centered Care

• Resident choice and autonomy

– Time to wake– Time to bed– What, where, when and with whom to have a

meal– Leaving the building– Amenities– Caregivers– Activities

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RelationshipsRelationships

• Relationships with staff (CA)

• Relationships with other residents

• Continuation of past relationships

– Family– Friends

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EnvironmentEnvironment

• Community

• Relationship fostering

• Home like environment

• Neighborhood

• Small house

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Empowering Direct Care Empowering Direct Care StaffStaff• Prevent turnover

• Decision maker closest to the resident

• Participant in decisions about care

• Self directing in most activities

– Need skill development to function effectively

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Pioneer NetworkPioneer Network

• Group of nursing homes with common values

• Elder at center

• Relationship focused

• More home like

• Many models of care

• Strong and expanding movement

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Eden AlternativeEden Alternative

• Bill Thomas

• Bring life into the home

• Warmth and caring

• Improved clinical outcomes

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WellspringWellspring

• 11 nursing homes in Wisconsin

• Improved clinical care

• Advanced practice nurse consultants

• In house champion

• Empowered staff

• Clinical teams

• Workshops on clinical topics

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Green HouseGreen House• Small house

• Home environment

• Guide supervising direct care staff

• Self managed teams

• Nurse consultant

• Family meals

• Private rooms and baths

• Workers assigned to house

Page 32: Achieving Quality in Nursing Homes

Culture Change and QualityCulture Change and Quality• Staff turnover down

• Absenteeism down

• Familiarity increased (GH example)

• Collaboration between nurse and direct care staff increased

• Quality of life, choices up

• Meals more social/weight gain

• More family visiting

• Less ADL decline

Page 33: Achieving Quality in Nursing Homes

Improving Long Term CareImproving Long Term Care

• Blend of quality of life and care quality

• Appropriate skills of staff

• The right mix of providers

• Leadership/supervisory skills

• New job skills for direct care staff

• Educational preparation of new nurses

Page 34: Achieving Quality in Nursing Homes

Advancing ExcellenceAdvancing Excellence

• National Campaign

• Wide range of stakeholders

• Local Area Networks for Excellence

• Quality improvement goals and support

• 41% of Nursing homes

Page 35: Achieving Quality in Nursing Homes

Advancing Excellence Advancing Excellence GoalsGoals• Reduce turnover

• Increase consistent assignment

• Decrease restraint use

• Improve pain management

• Improve advance care planning

• Improve resident and staff satisfaction

• Improve staff satisfaction