Optimizing Outcomes and Ensuring Quality Care Clinical and Management Issues

Medical Direction Pearls March 17, 2006 3:30-5:00 AMDA 29th Annual Symposium

Optimizing Outcomes and Ensuring Quality Care

Clinical and Management Issues

Optimizing Outcomes and Ensuring Quality Care

Clinical and Management Issues

Leo J. Borrell, MDMedical Director of

Senior PsychCare in affiliation with Senior Psychological CareHouston and San Antonio

Senior PsychCare in affiliation with Senior Psychological Care

“A Better Quality of Life Through Integrated Mental Health Care”

Faculty Disclosures:Faculty Disclosures:

Dr. Leo J. Borrell

Forest Laboratories: Speakers Bureau

Bristol-Myers: Honoraria

Janssen Laboratories: Honoraria



Quality Care Is In The Eye Of The Beholder

Clinical Issues

Quality Care Is In The Eye Of The Beholder

Clinical Issues

Patient Quality ChainPatient Quality ChainGet to &

from hospital

Deal with stress

Find out patient status

Pay Bills

Provide post d/c

careValue

-Loss of Income While Visiting-Little Help Available-Unfamiliar, Complex Activities-Costs

Value Chain Problems-Location-Language-Financial Situation

-May not have Support at Home-Few “in-hospital” support systems

-Difficult to Talk to Attending Physician-Conflicting Statements from Multiple Sources-Unfamiliar Vocabulary & Concepts

Get to and From Hospital

Deal With

Stress

Find Out Patient Status

Pay Bills

Give PostDischarge Care

-Bills are Difficult to Understand-Insurance is Difficult to Understand-Insufficient Resources



RegisterPatient

Care Discharge Marketing Service Value

ValuePhysician

Pharmacy

Nursing

DiagnosticImaging

Lab

PhysicalTherapy

General Quality ChainGeneral Quality Chain

Nursing Quality ChainNursing Quality Chain

Assess Care ProvideCare

Discharge Planning

Document Value

Value Chain Problems

-All Manual-Increasing requirements from JCAHO-Everything must be documented

Assess

CarePlans

ProvideCare

DischargePrep

Document

-Shortage of nurses-Documentation is time-consuming

-Time-consuming-Not used as a communication tool-Supplemented with oral

-Not enough equipment-Not enough time and nurses-Nurses do non-nursing tasks-Manual documentation takes time

-High acuity makes coordination difficult

Physician Quality ChainPhysician Quality ChainLocate

Patient

Make Diagnosis

Orders and results

Treat patient

Documentin chart Value

Value Chain Problems

-Must go to hospital for dictation-Paperwork required for JCAHO, legal dept., HCFA-Reimbursement and coverage paperwork

Locate patient

Make diagnosis

Orders& results

Treat patient

Documentin chart

-Privileges not clarified-Get the wrong room-Bed unavailability-No coverage or restricted coverage

-Delays in obtaining medical records-Delays in getting consultants

-Delays in waiting for test to be performed-Results not delivered on time

-Scheduling conflicts for treatment rooms-Medications not given on time

Quality From Medicare’s Perspective Documentation Guidelines

Quality From Medicare’s Perspective Documentation Guidelines

• 15501 B– Medical necessity a must– Documentation must support level of service

given

• 15509.1– Will pay for visits necessary for Medicare

required assessments– For psychiatric visits, patient must be able to

benefit, must NOT be suffering from a severe enough cognitive impairment to prevent effectiveness of service



Documentation - Timing of VisitsDocumentation - Timing of Visits

• Medicare will only pay for necessary and reasonable preventive/routine care.

• Necessary and reasonable defined as what is needed, according to the attending physician, to professionally “assess, plan, manage and monitor the health care of a resident or patient in the facility” within accepted principles of medical practice.



General Principles of DocumentationGeneral Principles of Documentation

Medical Records Criteria– Complete and legible– Include date of service, a plan for care– Include past and present diagnoses– Include progress, response to treatment, and

compliance– Written plan with treatment, frequency of

visits, and medications & dosage– Support level of evaluation performed

MUST DOCUMENT NECESSITY OF SERVICE



Quality from a Surveyor Perspective Quality Indicators of Validity

Quality from a Surveyor Perspective Quality Indicators of Validity

• Prevalence of Indwelling Catheter• Bladder/Bowel Incontinence• UTIs• Infections• Inadequate Pain Management• Pressure Ulcers• Late-loss ADL Worsening• ADL Worsening• Locomotion Worsening• Improvement in Walking• Worsening Bladder Incontinence



Quality Mental Health Care From A Medical Director Perspective

Quality Mental Health Care From A Medical Director Perspective

1. Understanding Implications of F Tags for The Mental Health Team

2. Qualifications of Mental Health Care Professionals

3. Responsibilities for Documentation

4. Understanding The Biosocial Approach: Communication, Collaboration, Evaluation, Education (Psychotherapy Requires MMSE >10)

5. Quality Is in The Eye of The Beholder



Quality from A Medical Director and Primary Care Physician

Perspective

F329, F429 Tags

What It Means for Psychiatrists and Mental Health Practitioners

Quality from A Medical Director and Primary Care Physician

Perspective

F329, F429 Tags


1 2 3 4 5 6 7 8

90

80

70

60

50

40

30

20

10

0

PROGRESSION OF SYMPTOMS BY YEARS

Jost BC, et al. Journal of American Geriatric Soc. 1996;44:1078-1081.

Depression

Diurnal Rhythm

Social Withdrawal

Anxiety

Paranoia

Suicidal Ideation

Agitation

Wandering Aggression

Hallucinations

Socially Unacceptable

Peak of Occurrence (% Patients)

Frequent Fluctuation of Symptoms of Alzheimer Disease Progression Requires

Weekly Monitoring and Medication Adjustment



Necessary Drug Protocol-F329Necessary Drug Protocol-F329

• Eliminate Unnecessary Drugs – Potential for Severe Adverse Reactions (F329)

• Review Drug Regimens – Potential for Less Severe Adverse Reactions (F429)

• No Excessive Doses• Must Use Only As Long As Necessary to

Achieve Outcome• MUST BE MONITORED AND

DOCUMENTED



Necessary Drug Protocol (cont.)Necessary Drug Protocol (cont.)

• Must Have Indications for Use

• No Long-Acting Benzodiazepines– Short Acting Agents Must Be Attempted First– Exception: Use Retains Functional Status

No Use of Hypnotics

• Must Limit Dose of Antipsychotics



Necessary Drug Protocol-F429Necessary Drug Protocol-F429

• Pharmacist MUST review each resident’s drug regimen once a month

• Pharmacist must report irregularities to physician and DON

• Reports require notification of MD and acknowledgement, but not action, agreement, or provision of rationale from MD



Cardiac Safety with Psychotropic Antipsychotics

Cardiac Safety with Psychotropic Antipsychotics

• Prolong QT Syndrome (Mellaril)• Thioridiazine 35.8 m.sec• Geodon 20.6 m.sec• Seroquel 14.5 m.sec• Least Effect Haldol 4.7sec (Haloperidol)

– Electrocardiograph

• Approximately 25% of patients Taking Pherothiazine have ABNORMALITIES.



Controlling Risk of Diabetes with Atypical Antipsychotics

Controlling Risk of Diabetes with Atypical Antipsychotics

• Screen all patients for history of diabetes.– Those with DM or impaired fasting glucose must have

antipsychotics chosen carefully

• Monitor patients on atypical antipsychotics for any symptoms of diabetes. – Educate those at risk and run a baseline fasting

glucose, repeating it quarterly.

• Any abnormalities should be referred to PCP.– Only consider changing meds after consulting patient

and other caregivers.



Survey Process-Quality IndicatorsSurvey Process-Quality Indicators

Psychotropic Drug use• Frequency of antipsychotic drug use• Frequency of antianxiety or hypnotic drug

use– Hypnotics used more than 2 times in previous

week,then regular and psychotherapy

Quality of Life• Use of daily physical restraints• Little or no activity for resident



Quality Mental Health Care A Nursing Home Perspective

Focus Areas

Quality Mental Health Care A Nursing Home Perspective

Focus Areas

Environment

TherapeuticActivities

Quality ofLife

ManagingBehavior

Dementia Special

Care

Quality of Care

Culture of Care



Goal of Quality Mental Health CareA Psychiatrist’s PerspectiveGlobal States of Well-being

Goal of Quality Mental Health CareA Psychiatrist’s PerspectiveGlobal States of Well-being

Sense of Worth

Sense of Agency

SocialConfidence

Hope



Quality - A Patient PerspectiveEnhancing Quality of Life

Quality - A Patient PerspectiveEnhancing Quality of Life

Identity

BelongingAnd

Inclusion

IntimacyAndLove

Self-Esteem

Psycho-Social Needs

MeaningAnd

Purpose

Dignity

SenseOf

Control

SenseOf

Security



Benefits of Quality Well-beingBenefits of Quality Well-being

• Assert Desire • Exhibit Self-respect

• Experience & Express

Emotion

• Evidence Humor• Evidence Creativity

• Initiate Social Contact • Evidence Self-expression

• Show Affection • Evidence Pleasure

• Show Social Sensitivity• Exhibit Helpfulness

• Accepts Others with

Dementia

• Able to Experience Relaxation



Facilitating Well-beingFacilitating Well-being

• Recognize each person as unique

• Give residents choices

• Stress “working together”, not “doing for”

• Interact and express self spontaneously

• Stimulate the senses

• Celebrate task accomplishment

• Allow resident to give reciprocally to staff



Factors Contributing to Poor ComplianceFactors Contributing to Poor Compliance

Illness-Related• Paranoid ideation• Negative symptoms/reduced motivation• Depression• Demoralization• Lack of insight• Cognitive impairment• Substance abuse• Grandiosity




Treatment-Related• Inadequate therapeutic alliance• Side effects• Inconvenient regimen• Multiple drugs• Cost• Lack of psychoeducation• Misperception of therapeutic effect• Ineffective treatment




Environment-Related

• Lack of psychocosial support

• Isolation

• Stress

• Stigma



Quality From an Administrator Perspective

Quality From an Administrator Perspective

Average resident: No behavioral and psychological symptoms in dementia (BPSD), requires only verbal cues from staff for behavior.

Baseline Resident Cost

Resident with non-aggressive BPSD Baseline

+ $1800

Resident with AD and aggressive BPSD Baseline

+ $5300



Annual Cost of TherapyAnnual Cost of Therapy

Depakote ER 500 mg QD $ 588Depakote 500 mg + 250 mg $ 912Depakote ER 500 mg – 2 tabs $1174Risperdal 2 mg QD $1596Risperdal 0.5 or 1.0 mg QD $ 960*Risperdal 0.5 or 1.0 mg BID $1920Zyprexa 5mg QD $2052Zyprexa 10 mg QD $3120

*50% Risperdal RXs BID AWP 12 Months RX



Quality Care for Dementia Makes Dollars and Sense

Quality Care for Dementia Makes Dollars and Sense

Annual Costs of Caring for Residents with and without AD

– 26.4% had documented dementia

– Average additional 229 hours of care per year

– Average additional $4700 per patient with dementia per year

•Problem behaviors add costs to LTC•Cholinesterase inhibitors may reduce this cost•Residents with this medication, $49.60 a day•Residents who discontinued it, $55.16 a day

Patients who continued donepezil incurred $6.90 less per day, cost savings of over $2500 per year!



Total Cost Savings From Quality CareTotal Cost Savings From Quality Care

Management of Aggressive Behavior Cost SavingsPer Year

Utilizing medications and psychotherapy $3500/year

Utilizing Depakote rather than atypical antipsychotics

$2500/year

Maintaining a use of Donepezil $2500/year

Total Cost Savings

Per Patient Per Year$8500/ year



F501 Tag


F501 Tag




Short Term Goal:Establish Responsibilities

Short Term Goal:Establish Responsibilities

• Provide appropriate resident care

• Make periodic visits to the facility

• Provide medical orders

• Provide coverage

• Provide support for transfers

• Provide documentation

• Collaborate with other members of Treatment Team defining Treatment Goals



Short Term Goals to Comply with 501Core Areas to Establish

with Policy and Procedures

Short Term Goals to Comply with 501Core Areas to Establish

with Policy and Procedures

• Develop criteria/policies relating to care• Set standards for appropriate physician and

mental health professional services• Review credentials of all professionals & CME• Review performance providing feedback• Liaison between mental health providers and

facility staff and managers• Mental health and psychiatrist participate in

quality assurance



Long Term Goal: Establishing A Performance Improvement

Committee

Long Term Goal: Establishing A Performance Improvement

Committee• Medical Director and QM Director Lead• Identify Staff to Be at Quarterly Meetings• Define Expected Practice Standards• Identify Process for Morbidity/Mortality

Reviews• Develop Standardized Forms• Utilize Available Resources: Involve

Everyone in PI Process



Long Term Goals Goals to Comply with 501 Through the Performance

Improvement Committee

Long Term Goals Goals to Comply with 501 Through the Performance

Improvement Committee

• Develop criteria/policies relating to care• Set standards for appropriate physician and

mental health professional services• Review credentials of all professionals & CME• Review performance providing feedback• Liaison between mental health providers and

facility staff and managers• Participate in quality assurance



Implications of 501 GuidelinesImplications of 501 Guidelines

According to the CMS Guidelines on coordination of medical care, the Medical Director should:– provide information

– identify educational needs

– assist in obtaining services

– evaluate services

– get feedback from physicians.




• Medical Director is connected to the staff and should share mutual respect, communication, cooperation, accountability, feedback, and care.

• Collective leadership implies coordinating care with attending physicians.




• Change needed in medical director/staff interfacing.– Medical Director should be included in:

quality assurance, staff education, and facility organizational issues.

• Include Medical Director as integral part of leadership team.




Surveyors are not our enemies.

We must work towards a collaborative, positive relationship in which the Medical Director can provide information on:

Physician issuesPracticesResident issues



Change in the Role of Medical DirectorProcess Rather Than Context

Change in the Role of Medical DirectorProcess Rather Than Context

• Medical directors must embrace dual mental models (values)

• Medical model focuses on clinical expertise, medical care, individualized thinking.

• Organizational leadership model focuses on physicians as leaders working in collaboration to achieve quality care goals in 3 areas: individual, team/group, and organization



Medical DirectorF-Tag 501 Implications for Mental Health

Medical DirectorF-Tag 501 Implications for Mental Health

New Responsibilities:1. Collaboration rather than only compliance.2. Involvement of psychiatrist and mental

health in the quality assurance process identifying staff educational meetings.

3. Asking and clarifying expectations regarding mental health services.

4. Coordination of service with nursing staff, families, and primary care physician.Reference: Collaboration is Key to Success with F-Tag 501, Caring for the Ages, Dee Dixon, February, 2006, 8-9



F-Tag 501 Has Major Implications for Mental Health

F-Tag 501 Has Major Implications for Mental Health

• The CME Interpretive Guidelines emphasizes:

1. Coordinating of medical care

2. Providing information and medical director identifying educational needs of staff

3. Obtaining adequate services with qualified professionals

4. Evaluating the quality of mental health services delivered

5. Obtaining feedback from mental health providers and patients and family



Reasons to Avoid Quality Standards for Psychiatrists and Mental Health

Practitioners

Reasons to Avoid Quality Standards for Psychiatrists and Mental Health

Practitioners

• Don’t Know Enough About Patient Care to Dictate Clinical Practice

• Mental Health Practitioners Have A Right to Practice As They See Fit



The Different Type of Quality Psychiatric and Psychotherapy Care Model

The Different Type of Quality Psychiatric and Psychotherapy Care Model

1. Consultation Acceptable

2. Individual Provider Good

3. Team Approach Better

4. Integrated Comprehensive Best

and Mental Health Care

Recommended by the

President’s Commission on

Aging



Quality and Best Practices in Geriatric Psychiatric Services

(President’s Commission on Aging)

Quality and Best Practices in Geriatric Psychiatric Services

(President’s Commission on Aging)

1. A multidisciplinary team approach2. Specific geriatric expertise and competence3. Individualized assessment and treatment planning with routine follow-up, ideally using standardized outcome measures4. Collaborative treatment planning between the consultant and the nursing home staff5. A strong educational component

Quality Required Quantity Future Visits Determined By

Complexity of Decision

Quality Required Quantity Future Visits Determined By

Complexity of DecisionFUTURE VISITS DETERMINED BY COMPLEXITY OF DECISION

Low Moderate High

Medical Problem Severity (+3 - more than 3 Dx)

1 2 3

Number of Psychiatric & Medical Dx and Management Options (+2/3 Suicidal Thought)

1 2 3

Amount & Complexity of Data Including Previous Medical Record Family Issues

1 2 3

Risk of Complications (+3 12-20 Meds) 1 2 3

Total Score 1-4 4-8 8-12

Visits 1xMo 1xWk 2xWk



Quality Care From A Physician’s Perspective

Quality Care From A Physician’s Perspective

Complex Decisions That Appear Simple:

Interaction of BioPsychosocial

Complex Decisions That Appear Simple:

Interaction of BioPsychosocial

Psychological Social Factors

Bio-Medical Factors

Valued but not

effective

Effective but not valued

ComplianceEffectiveValued

Non-Compliance

1 2 3 4 5 6 7 8

90

80

70

60

50

40

30

20

10

0

PROGRESSION OF SYMPTOMS BY YEARS

Jost BC, et al. Journal of American Geriatric Soc. 1996;44:1078-1081.

Depression

Diurnal Rhythm

Social Withdrawal

Anxiety

Paranoia

Suicidal Ideation

Agitation

Wandering Aggression

Hallucinations

Socially Unacceptable

Peak of Occurrence (% Patients)

Frequent Fluctuation of Symptoms of Alzheimer Disease Progression Requires

Weekly Monitoring and Medication Adjustment



80% of Nursing Home Residents Have Psychiatric Symptoms That Progress Unless

Properly Treated

80% of Nursing Home Residents Have Psychiatric Symptoms That Progress Unless

Properly Treated

•Hallucinations (5-15%) •Withdrawal (30-40%)

•Aggression (10-20%) •Anxiety (30-50%)

•Delusions (20-40%) •Blunted Affect (40%)

•Dysphoria (20-40%) •Mood Liability (40%)

•Hostility (30%) •Agitation (40-60%)

•Suspiciousness (30%) •Apathy (50-70%)

•Disinhibition (30-40%)

Medical Direction Pearls March 17, 2006 3:30-5:00 AMDA 29th Annual Symposium

Causes of Psychiatric Symptoms and Behavior Can Overlap

Causes of Psychiatric Symptoms and Behavior Can Overlap

Frontal LobeImpairment

MajorDepression

Psychotic Disorder

ImpulsivityHyperactivity

Agitation

AnxietyDysphoria

RestlessnessIrritability

VerbalAggression

WithdrawalPhysical Aggression

DelusionsHallucinations



AD Quality Care Requires: Diagnosing AD

AD Quality Care Requires: Diagnosing AD

Advantages of early diagnosis– Doctors rule out conditions that may cause

dementia– Coordinate care and families involved in plan

for future and care and support they need

Clinical Assessment Tools– Folstein Mini Mental Status Exam– Clock Drawing Test– Executive Function Measures



Reducing Psychotropic Drug Use

Evidence Based Medicine

Reducing Psychotropic Drug Use

Evidence Based Medicine



Quality Care of Depression and Dementia

Quality Care of Depression and Dementia

• Only 25% of those receiving medication alone from a PCP improved

• 51% receiving medication plus psychotherapy improved

• 58% with depression alone receiving comprehensive intervention recovered within 6 months

• Post stroke depression can last from 6 months-2 years



Quality Care of Depression and Dementia-Conclusions

Quality Care of Depression and Dementia-Conclusions

Patients using psychotherapy did 100% better than those on medication alone.

Without treatment:–20% exhibited behavioral symptoms one

or more times in two weeks–34% had one or more behavioral

symptoms at least once a week.



Patients with Depression and Dementia without Treatment had

behavioral symptoms :

• 13% exhibited aggressive symptoms• 20% had physically non-aggressive

symptoms• 22% showed verbal behavior symptoms• 13% resisted medication and care• 36% with behavioral symptoms

evidenced depression or psychosis.



Management of Dementia Symptoms: Agitation, Aggression, and Resistance to Care

Management of Dementia Symptoms: Agitation, Aggression, and Resistance to Care

• Differentiate between spontaneous or provoked disturbing behavior.

• Evaluate sensory impairment: vision, hearing, and ambulation.

• Transition from a care-giving model to a care-partner model.

• Appropriate diagnosis of type of dementia: frontal lobe, temporal lobe, Lewy-Body disease, vascular and psychiatric illness, i.e. depression or psychosis.

• Reference: Looking Beyond Aggressiveness and Dementia, Ladislav, Volicer, MD, Caring for the Ages, Feb. 2006, 6



A Simple Way To Improve QualityA Simple Way To Improve Quality

Inform Patients

– Respect their autonomy– Explains symptoms– Allows participation in decisions while able– Eases acceptance of assistance– Provides opening to discuss patient concerns– A professional has an obligation to find ways

to explain condition in terms they understand



A Simple Way To Improve Quality From A Patient’s Perspective

A Simple Way To Improve Quality From A Patient’s Perspective

• Inform Family Members

– Explain symptoms– Encourage family to use time that is left wisely– Enhance family collaboration in planning for

future– Encourage practical and emotional support– Provide opportunity for genetic counseling



• Motivations Not to Inform Individuals

– Consistent with therapeutic privilege– Avoids burdening patient with bad news– Diagnostic uncertainty– Lack of effective treatments for condition– Avoids uncomfortable conversations

A Simple Way To Not Improve Quality

Don’t Inform Patients and Family


Don’t Inform Patients and Family





Reasons Not to Inform Families

– Breaks patient confidentiality– Individuals may want to inform family– Family may treat patient differently– Potential abuse or abandonment– Burden of seeing decline– Overreaction



A Study of Disclosure of Dementia by Professionals

A Study of Disclosure of Dementia by Professionals

• Only 44% of psychiatrists inform patients• 56% professionals in memory clinics disclose

diagnosis• 75% geriatricians and geriatric psychiatrists

disclose AD or dementia• Stage of dementia predicting variable• 39% general practitioners disclose dx

50% PRACTITIONERS DO NOT DISCLOSE DEMENTIA DIAGNOSIS



Reality of Disclosure andIndividuals with DementiaReality of Disclosure andIndividuals with Dementia

• Only 47% knew correct diagnosis

• 66% said no one ever spoke with them about their illness

• 92% wanted to know to plan for the future and enjoy present while they could

• 65% were told after family was told

• 51% “reacted poorly” per family



What Can Be Accomplished in LTC in Diagnosis and Management of Dementia

What Can Be Accomplished in LTC in Diagnosis and Management of Dementia

Pre-intervention

N=23

Post-intervention

N=22

P Value

Etiology of dementia identified 12 (52%) 20 (91%) .007

Evidence of dementia management plan by MD

8 (35%) 19 (90%) <.001

Evidence of dementia management plan by other providers

5 (22%) 13 (62%) .013

Evidence of pharmacological treatment

2 (8%)



Quality in the FutureSpecial Care Unit Background

Quality in the FutureSpecial Care Unit Background

• SCU development in 1980s

• (1987) 7.6% of NH beds

• (1991) 9.6%

• (1995) 22%

• Includes dementia, rehabilitation, other

• Dementia SCU is 7% of NH beds and represents most SCU beds

Special Care Units (SCU)



Resident Outcomes:SCU vs. Non-SCU

Resident Outcomes:SCU vs. Non-SCU

• Functional decline rate same• ADLs same• Cognitive decline same• SCU

– Decreased use of physical restraints, increased use of chemical restraints.

– Slight increase in sociability and activity– Fewer behavior problems– Benefit to residents with no cognitive impairment.



SCU - Other OutcomesSCU - Other OutcomesFamily Outcomes• Higher satisfaction• More involvementStaff Outcomes• Greater satisfaction• More training in dementia• More stable staff assignments• Consistent staff, lower turnover• More frequent support group attendance



Diagnosing Quality Care

A Management Perspective

Diagnosing Quality Care

A Management Perspective



Quality :Requirements for Changing for The Better

Quality :Requirements for Changing for The Better

Pressure for

Change+ + +

SharedDriven Vision

Capacity for

Focused Change

ActionableFirstSteps

= Successful Change



Dx 1: Why Quality Initiatives FailsDx 1: Why Quality Initiatives Fails

+ + +SharedDriven Vision

Capacity for

Focused Change


= Bottom of the “in box” Low Priority



Dx 2: Why Quality Initiatives FailsDx 2: Why Quality Initiatives Fails

Pressure for

Change+ + +

Capacity for

Focused Change


= A Fast Start That Fizzles Directionless



Dx 3: Why Quality Initiatives Fails Dx 3: Why Quality Initiatives Fails

Pressure for

Change+ + +

SharedDriven Vision


= Anxiety, Frustration, Loss of Competitive Edge



Dx 4: Why Quality Initiatives Fails Dx 4: Why Quality Initiatives Fails

Pressure for

Change+ + +

SharedDriven Vision

Capacity for

Focused Change

= Haphazard Efforts, False Starts, Uncoordinated



Overcoming Challenges To ChangeOvercoming Challenges To Change

• Establish planning team• Include care staff representative• Do you homework• Establish goals for facility, staff, family and

resident and measure and give feedback• Allow sufficient time for change and

monitor changes• Practice what you preach



Twelve Innovations That Shaped Modern Management

Twelve Innovations That Shaped Modern Management

1. Scientific management (time and motion)2. Cost accounting and variance analysis3. Commercial research lab (industrialization of science)4. ROI analysis and capital budgeting5. Brand management6. Large-scale project management7. Divisionalization8. Leadership development9. Industry consortia (multicompany collaborative

structures)10. Radical decentralization (self-organization)11. Formalized strategic analysis12. Employee-driven problem solving



The Five Phases of GrowthThe Five Phases of GrowthPhase 1 Phase 2 Phase 3 Phase 4 Phase 5

Evolution stages

Revolution surges

Size of organization

Large

Small 1. Growth through CREATIVITY

1. Crisis of LEADERSHIP

2. Growth through DIRECTION

2. Crisis of AUTONOMY

3. Crisis of CONTROL

4. Crisis of RED TAPE

3. Growth through DELEGATION

4. Growth through COORDINATION

5. Growth through COLLABORATION

5. Crisis of ?



Change and Self Perceived CompetenceChange and Self Perceived Competence

Self

Perceived

Competence

Start of Change Time

4. Acceptance of “new reality” Letting go of past Relief Tentative movement

5. Testing New behaviors New approaches Stereotyped “shoulds”

6. Internalize Quiet and reflective Seek meaning and understanding

7. Integration Incorporate new ways into values, beliefs to become automatic through practice

1. ImmobilizationShock, disbelief, guiltMismatch of Expectation and “new reality”

2. Denial of changeTemporary retreatEmphasize old competencies 3. “Incompetence”

Awareness that change is necessaryNot sure how to deal with itFrustrationDepression

Motivations and Emotions in ChangePhases of Emotions - Awareness

Motivations and Emotions in ChangePhases of Emotions - Awareness

0 6 Months

12

DenialRealization

Motivations and Emotions in ChangePhases of Emotions - Dependence

Motivations and Emotions in ChangePhases of Emotions - Dependence

0 6 Months

12

Dependent

Independent

The Course of Success in ChangeThe Course of Success in Change

Self

Perceived

Motivation

Start of Change Time

AcceptanceOf “new reality”

Letting go of pastRelief

Tentative movement TestingNew behaviors

New approachesStereotyped

“shoulds”

InternalizeQuiet and reflectiveSeek meaning and

understanding

IntegrationIncorporate new ways into values, beliefs to

become automatic through practice

Motivations and Emotions in ChangePhases of Emotions - Feelings

Motivations and Emotions in ChangePhases of Emotions - Feelings

0 6 Months

12

NumbBusy Angry

Sad

Acceptance and Well Being



Selecting A Quality Medical DirectorSeeing the Trees and Not the ForestSelecting A Quality Medical DirectorSeeing the Trees and Not the Forest

The greatest problem is using the wrong criteria to select the medical director. They select a terrific independent investigator who can get government grants, a good researcher, a good teacher, a good clinician, or the biggest admitter.



The Ten Deadly Flaws of Medical Directors in Implementing Quality Initiatives

The Ten Deadly Flaws of Medical Directors in Implementing Quality Initiatives

1. Insensitivity and arrogance2. Inability to deal with medical staff3. Overmanaging (inability to delegate and collaborate)4. Inability to adapt to a boss5. Fighting the wrong battles6. Being seen as untrustworthy (having questionable

motives7. Failing to develop a strategic vision8. Being overwhelmed by the job9. Lacking specific skills or knowledge10. Lacking commitment to the job

Optimizing Outcomes and Ensuring Quality Care Clinical and Management Issues

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Transcript of Optimizing Outcomes and Ensuring Quality Care Clinical and Management Issues