Closing the Gap: Linking MDS 3.0, Organizational Person Centered Practices and QAPI to Accelerate Quality Outcomes Barbara Frank, B&F Consulting Nedra Adelizzi, ACTS Retirement-Life Communities Peggy Brenner, ACTS Retirement-Life Communities

Requires each nursing home to provide care and services to: attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident OBRA 87 ©B&F Consulting

Highest Practicable = No “avoidable” decline Unavoidable = natural progression of a resident’s disease or condition ©B&F Consulting

Highest Practicable = No “avoidable” decline Avoidable = Iatrogenic = We caused it “Genic” – Beginning/Cause “Iatro” – We ©B&F Consulting

Mr. McNally: What was he like when he first came in? His decline was not a natural progression of his disease, so what was the progression of actions that caused his decline? Mr. McNally: What was he like when he first came in? His decline was not a natural progression of his disease, so what was the progression of actions that caused his decline? ©B&F Consulting

Mr. McNally: What could have prevented his declines? Mr. McNally: What could have prevented his declines? © B&F Consulting What were the root causes of his declines? Cascading effect

Risk Prevention Health Promotion Individualized Care Institutional Care Avoidable Adverse Events Highest PracticableW ell-being FROM IATROGENESIS TO WELL-BEING ©B&F Consulting

Risk Prevention Health Promotion Individualized Care Institutional Care Iatrogenesis Highest PracticableW ell-being FROM IATROGENESIS TO WELL-BEING ©B&F Consulting

Risk Prevention Health Promotion Individualized Care Institutional Care From Iatrogenesis to Well-being Physical Environment, Care Delivery Systems, and Work Routines Waking and Morning Routine Eating – what and when Bathing – when, how, how often Going to bed at night Sleeping & night-time routines Daily activities and pursuits Medication Pass Highest PracticableW ell-being ©B&F Consulting

Risk Prevention Health Promotion From Iatrogenesis to Well-being Physical Environment, Care Delivery Systems, and Work Routines Waking and Morning Routine Eating – what and when Bathing – when, how, how often Going to bed at night Sleeping & night-time routines Daily activities and pursuits Medication Pass Highest PracticableW ell-being Iatrogenesis ©B&F Consulting Individualized Care Institutional Care

How important is it to you to: A. Choose what clothes to wear B. Take care of your personal belongings C. Choose between a tub bath, shower, or other D. Have snacks between meals E. Choose your own bedtime F. Do your favorite activities G. Go outside to get fresh air MDS Section F Customary Routines ©B&F Consulting

Surveyor Resident and Staff Interviews Choices over schedules to include: waking, eating, bathing, and going to bed at night, as well as health care schedules ©B&F Consulting

Facility must: Actively seek information Be “pro-active” in assisting residents to fulfill their choices Make residents’ choices known to caregivers ©B&F Consulting

CNAs ask five simple questions within an hour of a new person’s arrival: 1.How would you like to be addressed? 2.What time do you want to shower? 3.What time do you want to go to bed? 4.What time would you like to wake up? 5.What would make you comfortable? ©B&F Consulting

As a result: 1.Fewer family complaints 2.Fewer rehospitalizations 3.Fewer missed therapy sessions 4.Better resident satisfaction from Day One 30% of rehospitalizations of nursing home residents occur for residents who have been in the nursing home for less than 7 days! ©B&F Consulting

Customary Routines: What’s your cycle time for getting this information to the people who need it on Day One? ©B&F Consulting QI Exercise: Map your current process

Relationships Closest to the Resident Matter Most Interdisciplinary and Interdepartmental Collaboration within and across units and shifts CNAsResidents Nurses Quality of workQuality of care Eaton, Bishop, Gittell Housekeeping, Food Services, Activities, Social Work ©B&F Consulting

Engineering High Quality Care An Infrastructure for Communication and Problem-solving Among and With Staff Closest to the Resident Consistent Assignment Huddles CNA Involvement in Care Planning QI Closest to the Resident ©B&F Consulting

Individualized QI Closest to the Resident Prevents Iatrogenesis (Avoidable Decline) Background Daily Preferences and Routine Clinical Mr. McNally’s Solution © 2015 Communication Map developed by Amy Elliot and Sonya Barsness to illustrate B&F Consulting’s method for Engaging Staff in Individualizing Care used for Pioneer Network's National Learning Collaborative on Using the MDS 3.0 as the Engine for High Quality Individualized Care funded by the Retirement Research Foundation

Drink up The Why of Consistent Assignments B&F Consulting

What was it like to be helped to drink? The Why of Consistent Assignments B&F Consulting

Receiving Intimate Care is Emotionally Difficult How Care is Provided Really Matters B&F Consulting

How consistent are you? You have it in theory…do you have it in reality Measure your current practice: How many different CNAs is a resident receiving care from? How many times are “consistent” CNAs moved to another assignment to cover an absence? B&F Consulting

How-to Basics for Dedicated Assignment A Good Process – Fair distribution of work – Matches work for residents and staff B&F Consulting

Process for Weighting and Balancing Assignments Rate each resident on scale of 1 – 3 in each dimension – physical and non-physical factors B&F Consulting

Making the math work Consistent Assignment: Implementation Issues B&F Consulting

An Option for Scheduling 4 on 2 off schedule With an Even # of CNA assignments, 3 CNAs serve 2 resident assignments MTWThFSSMTW FSS Maria 1111OO1111OO11 Jen 22OO2222OO2222 Ellie OO2211OO2211OO David Farrell B&F Consulting

We’re doing pretty well with our consistent assignment except when we have to ask people to move. Then we have a hard time because they don’t want to move. They give us a lot of pushback. So what do we do? Consistent Assignment: Implementation Issues B&F Consulting

Time for critical thinking… Identify and challenge our assumptions Explore and imagine options and act on them When we stopped using restraints, because they are iatrogenic, many homes physically removed them from the building so they were no longer an option… Stability at the point of care is the most important relationship for good outcomes. Instability is iatrogenic and contributes to avoidable declines. Engineer practices so that disrupting stability is no longer an option. Consistent Assignment: Implementation Issues B&F Consulting DON’T MOVE THEM

FREE TOOLKIT: Tipsheets, Video clips and Starter exercises at Look under Provider resources at Engaging Staff in Individualizing Care

AN INFRASTRUCTURE FOR QUALITY Pioneer Network is pleased to announce that the Implementation Handbook for Engaging Staff in Individualizing Care, developed by B&F Consulting through our National Learning Collaborative funded by The Retirement Research Foundation will be available soon at pioneernetwork.net. This Handbook will support implementation of a communication infrastructure essential for effective care delivery to ensure positive resident and staff experiences, and good organizational performance. Forty-nine nursing homes, five state culture change coalitions and four corporations worked together with the Pioneer Network and B&F Consulting to share how-to’s from their successful pilot of these foundational organizational practices. At

LET’S HUDDLE Definition A brief stand up “gathering” of a team’s players to share and discuss important information.

LET’S HUDDLE Huddles aren’t just for athletes!

LET’S HUDDLE A huddle is a process used by caregivers and neighborhood staff in long term care.

LET’S HUDDLE WHY???  Provide a new culture to the organization  Foster person-centered living  Improve engagement by all care givers and staff  Enhance communication

LET’S HUDDLE Help staff develop critical thinking and problem solving skills Enable all players to hear exactly the same information Focus on risks and opportunities

LET’S HUDDLE With huddles in place, identifying the root cause becomes more evident

Let’s Huddle Who participates?  Nurses and CNAs working together by neighborhood or household  Housekeeping, social service, recreation and therapy

LET’S HUDDLE Discussion Topics  New Residents  Complaints/Complements  Clinical Areas  Resident Issues

Let’s Huddle Follow up on any issue previously discussed Exceptions

Let’s Huddle TYPES 1.Shift Huddles 2.New Resident Huddles 3.QI Huddles 4.Fall Huddles 5.Resident Exception

Let’s Huddle Huddle assistance:  Use of the “Stop and Watch”

Why Bother? Huddles reinforce teamwork Provides opportunities for improving quality of care and quality of life Reduces avoidable re-hospitalizations Everyone hears EXACTLY the same information and can share

Why Bother? True Quality Improvement Staff Engagement and Empowerment Creates prevention versus repair for residents and caregivers

Learning Circles A method of problem solving that helps teams make decisions and create solutions. An effective method of high involvement that has existed for centuries

Learning Circles Goal: Develop common ground and mutual respect among the diversity of nursing home residents, care givers, families, management, different departments and professions.

Learning Circles When to use?  Problem Solving and Staff Meetings  In-service Training

Learning Circles Resident Council Family Nights Culture Change Meetings

Learning Circles Rules: Sit in a circle with no obstructions participants One person as the facilitator A question or issue is posed No cross talk

Learning Circles Rules One may choose to pass Open general discussion

Learning Circles Learning circles support values, aspirations and behaviors for all participants which brings about profound change in an organization (Senge et al.)

Involvement of the CNA in Care Planning “Relationships closest to the resident matter.” Frank, Brady and Farrell

Involvement of the CNA in Care Planning

Let the CNAs know what to share: ADLs Mood/Behavior Activities

Involvement of the CNA in Care Planning CNA must know: Date, Location and Time ARD Period Documentation needs

Involvement of the CNA in Care Planning Staff Engagement and Empowerment Individualized Care Better Outcomes

COMMUNITY ASSESSMENT A tool to determine your community’s progress along its culture change journey.

Artifacts of Culture Change Another means of determining your community’s progress towards its goals.

VISION Serves as the foundation for the purpose, work and success of an organization Basis for drive and motivation Its what the organization wants to create The ultimate destination

VISION  A guided set of fundamental principles and values  Provides a source of inspiration  Determines the direction of change within the community

VISION What is your VISION???

QUESTIONS/COMMENTS