Mary Jane Koren, MD, MPH Assistant VP, The Commonwealth Fund Chair, AE Steering Committee Stefan Gravenstein, MD, MPH Professor of Medicine, Brown University Clinical Director, Quality Partners of Rhode Island Carol Benner, Sc.M. Field Director, AE 1

Campaign Mission To help nursing homes achieve excellence in the quality of care and quality of life for the more than 1.5 million residents of America’s nursing homes by: – Establishing and supporting an infrastructure of local QI networks – Strengthening the workforce – Improving clinical and organizational outcomes 2

What the Campaign Does Advancing Excellence is helping nursing homes make a difference in the lives of residents and staff. Advancing Excellence provides free, practical and evidence-based resources to support quality improvement efforts in America’s nursing homes. Advancing Excellence is committed to providing support to those on the frontlines of nursing home care. Advancing Excellence promotes open communication and transparency among families, residents, and nursing home staff. 3

Campaign History – Stakeholders come together to plan Campaign – Campaign launch – Website developed – Steering Committee and Work Groups formed 2007 – Process frameworks developed – Commonwealth Fund grant awarded – Field Director hired (October) – First national LANE Conference (December) – First data suggesting success 4

Campaign History (continued) 2008 – National Webinars (Pain, Pressure Ulcers, Consistent Assignment, Staff Stability) – Monthly newsletter – Consumer fact sheets – AHRQ Grant for Interchange 2008 awarded – Top Ten Guides for Front Line Workers – Second National LANE Conference: Dallas,TX 12/1/08 5

Campaign History (continued) 2009 – More Webinars  Resident Satisfaction, Restraints, Adult Learning (May 12) – Hired second person – Videos on Website – New CMS contract (coming) – Focusing on more communication - brochure about resources – Phase II of Campaign  Nursing Homes can update profiles  New Goals (Staff Satisfaction and Advance Care Planning)  Website Revisions (Best Practices, Easier TA Tools) 6

Founding Organizations Alliance for Quality Nursing Home Care American Association of Homes and Services for the Aging (AAHSA) American Association of Nurse Assessment Coordinators (AANAC) American College of Health Care Administrators (ACHCA) American Health Care Association (AHCA) American Medical Directors Association (AMDA) Centers for Medicare & Medicaid Services (CMS) and its contractors, the Quality Improvement Organizations (QIOs) and State Survey Agencies National Association of Health Care Assistants (NAHCA) NCCNHR: National Consumer Voice for Long Term Care The Commonwealth Fund The Evangelical Lutheran Good Samaritan Society 7

Steering Committee (continued) Agency for Healthcare Research and Quality (AHRQ) Alzheimer’s Association American Academy of Nursing -- Expert Panel on Aging American Association for Long Term Care Nursing (AALTC) American Health Quality Association (AHQA) Association of Health Facility Survey Agencies (AHFSA) Centers for Disease Control and Prevention (CDC) Foundation of the National Association of Boards of Examiners of Long Term Care Administrators Hartford Institute for Geriatric Nursing Institute for Healthcare Improvement (IHI) National Association of Directors of Nursing Administration in Long Term Care (NADONA/LTC) National Association of State Long- Term Care Ombudsman Programs (NASOP) National Conference of Gerontological Nurse Practitioners (NCGNP) National Gerontological Nursing Association (NGNA) PHI Pioneer Network Service Employees International Union (SEIU) 8 8

National Learning Network Engages Leaders Shared aims or goals Welcomes everyone and harnesses energy Self-conscious – participants are a part of the whole Non-linear Devolves control/bottom-up learning Manages knowledge with agility Seeks critical mass – not total coverage Values asking, not merely sharing 9 McCannon and Perla, JQPS, May, 2009

Campaign Steering Committee Nursing HomesConsumers Recruitment Workgroup Technical Assistance Workgroup Communications Workgroup Local Area Networks for Excellence (LANEs) Consumer Workgroup LTC Professionals and Frontline Staff Results Workgroup Staffing Workgroup Goals Taskforce Organizational Chart Advancing Excellence Campaign

Who Does What Steering Committee ( meets bi-weekly) Work Groups – Governance, Policy, National meetings – the “Interchange”, Communications, Technical Assistance CMS Support through its Nursing Home QIO Special Study – Website. data analysis, STAR target setting web site, limited administrative support Commonwealth Grant – Supports Local Area Networks of Excellence (LANEs), Webinars, Technical Assistance, Outreach 11

The Eight Goal Areas Clinical Quality Goals 1) To reduce high risk pressure ulcers; 2) To reduce the use of daily physical restraints; 3) To improve pain management for longer term nursing home residents; and 4)To improve pain management for short stay, post-acute nursing home residents. Organizational Goals 5) To establish individual targets for improving quality (STAR); 6) To assess resident and family “satisfaction” for quality of care; 7) To increase staff retention; and 8) To improve consistent assignment of nursing home staff, so that residents regularly receive care from the same caregivers. 12

Using the Goals for Success 1. Lay the organizational groundwork for improvement Stabilize your workforce: Increase staff retention (Goal 7); Improve efficiency by letting your staff get to know their residents: use consistent assignment so that residents regularly receive care from the same caregivers (Goal 8); and Know where you’re headed: use STAR (on the CMS web-site) to set QI targets (Goal 5). 13

Using the Goals for Success 2. Work on the really important problems Reduce the use of daily physical restraints (Goal 1); Reduce high risk pressure ulcers (Goal 2); Be sure people in your home aren’t “hurting”: Improve pain management for short and long stay residents (Goals 3 & 4). 14

Using the Goals for Success 3. Find out what your “customers” think Ask residents and families to tell you how you’re doing: measure experience with care (“satisfaction”) (Goal 6). 15

Major Accomplishments More than 7,200 (45%) nursing homes and 2100 consumers National coalition of government, providers, workers, professionals and consumers LANEs in 49 states Robust web site Evidenced – based technical assistance/ Webinars Consumer Fact Sheets for each goal Guide to engage nursing home front-line staff 16

Benefits of a National Campaign Increased staff retention and focus Cost savings because of improved quality and staff retention Improved customer satisfaction Preparation for Pay-for-Performance Advances standards development Fosters Quality Improvement and Data Culture Stakeholders at the table – now and in the future

0% – 25% 26% – 50% 51% – 75% 76% – 100% RI DC Percent Participation NH Participation in Advancing Excellence (December 2008)

LANE Roles and Responsibilities Provide statewide leadership Raise awareness about the campaign Recruit nursing homes Pull stakeholders together Provide technical assistance Communicate key campaign messages Respond to critical issues

Core LANE Members Nursing home associations (AHCA and AAHSA affiliates) Quality Improvement Organizations (QIOs) State Survey Agencies Ombudsmen Consumer Advocacy Groups Others – DONs, Medical Directors, Administrators, CNAs 20

Attributes of Successful LANEs Regular meetings Inclusion of statewide leaders Good attendance Shared goals Regular agenda that includes reviews progress and plans next steps Celebration and recognition 21

Characteristics of Coalitions Trust Buy-in Inclusion Creativity Communication Sharing of Resources Synergy Win – Win Success Satisfaction 22

“If men of good will wish to come together for the purpose of upholding reason and establishing a rational society, they should begin by following the example of the cowboys in Western movies when the sheriff tells them at the door to a conference room: 'Gentlemen, leave your guns outside.‘” Ayn Rand,

Coming together is a beginning; keeping together is progress; working together is success. …Henry Ford 24

Alone we do so little; together we do so much. Helen Keller 25

Characteristics of Coalitions Trust Buy-in Inclusion Creativity Communication Sharing of Resources Synergy Win – Win Success Satisfaction 26

Five Coalition Myths The only agenda is the coalition’s Agenda… Coalitions don’t get stuck... Coalitions are about love, joy, peace, brotherhood….. Coalitions don’t accomplish anything… Coalitions are easy… 27

LANEs 49 States have LANEs Different as night and day January 2008 – 80% QIO conveners – NY – four provider associations – WA, CA – ombudsman – MD, FL, IN, OK – provider associations Core members include SSA, ombudsman, provider association representatives, QIO representatives – May also include AMDA, NADONA, CAG, hospital reps, culture change coalition, nursing groups 28

29 The Relative and Absolute Number of Residents at High Risk for Developing Pressure Ulcers is Increasing

30 Presure Ulcers

31 Restraints

32 Chronic Pain

33 Pain -Acute

Source: This material was prepared by Quality Partners of Rhode Island, the Medicare Quality Improvement Organization for Rhode Island, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the US Department of Health & Human Services. The contents presented do not necessarily reflect CMS policy. Data through one year (four quarters). Goal Progress Toward Goals Progress Toward National Goal, By Participation and Target-Setting (Campaign results after year 1)

Accelerated Improvement since Campaign Start 2005 Q Q3 (year before) vs Q Q4 (year after ) 35 RESTRAINTS

Campaign Progress Campaign participants have improved faster than non-participants in all things measured. Campaign participants improved faster in the goals they selected to work on in every case. Those homes for which targets were set for improvement improved fastest 36

Summary - Oklahoma NationalOklahoma (Rank)List of 4000 Recruitment46.6%29.6% (44) Pressure Ulcers 11.7%14.5% (48)91 of 327 (27.8%) have pressure ulcer rates >20% Restraints 4.1%5.7% (44)127 of 327 (38.8%) have restraint use rates >11.0%) Chronic Pain 4.1% 5.9% (47) Acute Pain20.4%21.9% (33) Target Setting32.7%22.8% (45) Data is from the AE Campaign website ( and the CMS list of 4000 nursing homes used by QIOs in the 9 th SOW. Clinical measures are QMs from Q The pressure ulcer QM is for residents at high risk for developing pressure ulcers. Recruitment is from the real-time clickable map and was extracted in March For the clinical measures, lower numbers are better; for recruitment and target setting, higher numbers are better. A rank score of “1” for each of the categories is the best.

Summary – South Dakota NationalSouth Dakota (Rank)List of 4000 Recruitment46.6%90.9% (5) Pressure Ulcers 11.7% 11.3% (25)8 of 110 (7.2%) have pressure ulcer rates >20% Restraints 4.1% 2.2% (19)11 of 110 (10%) have restraint use rates >11.0%) Chronic Pain 4.1% 4.7% (38) Acute Pain20.4%25.6% (43) Target Setting32.7%36.9% (23) Data is from the AE Campaign website ( and the CMS list of 4000 nursing homes used by QIOs in the 9 th SOW. Clinical measures are QMs from Q The pressure ulcer QM is for residents at high risk for developing pressure ulcers. Recruitment is from the real-time clickable map and was extracted in March For the clinical measures, lower numbers are better; for recruitment and target setting, higher numbers are better. A rank score of “1” for each of the categories is the best.

Summary – Arkansas NationalArkansas(Rank)List of 4000 Recruitment46.6%103.9% (1) Pressure Ulcers 11.7%10.5% (19)28 of 236 (11.9%) have pressure ulcer rates >20% Restraints 4.1% 5.9% (45)114 of 236 (48.3%) restraint use rates >11.0% Chronic Pain 4.1% 3.1% (13) Acute Pain20.4%13.0% (1) Target Setting32.7%44.7% (16) Data is from the AE Campaign website ( and the CMS list of 4000 nursing homes used by QIOs in the 9 th SOW. Clinical measures are QMs from Q The pressure ulcer QM is for residents at high risk for developing pressure ulcers. Recruitment is from the real-time clickable map and was extracted in March For the clinical measures, lower numbers are better; for recruitment and target setting, higher numbers are better. A rank score of “1” for each of the categories is the best.

Arkansas Restraint Rate Q through Q

How did they do it? A strong LANE 100% Recruitment in Campaign 2 rounds of regional educational programs (12 total) Used AE resources from the web: – Process frameworks – Clinical practice information 41

Describing Your Results Gather your data Decide on presentation messages Organize data for that message – For example: is message how well we are doing, or how much better we must do, or something of both

Finding Your Results Click on Campaign Progress Select national or state progress – National gives graphs like the ones just shown (presently updated to 2008 Q1) – State data is linked to a live update engine, and should give most current data (presently updated to 2008 Q3)

AE Resources Care Guides – Flow diagrams, best practices, evidenced-based Audio Recordings from Webinars – National speakers, success stories, based on Care Guides Consumer Fact Sheets – Easy to understand language Downloadable Web-based Videos – National speakers, best practices 44

AE Resources Ten Ideas for Staff Involvement in Advancing Excellence – Ideas, worksheets, and templates to involve CNAs in QI – Planning a campaign kickoff – Suggested articles for newsletters – Templates for showing staff how their efforts are paying off Consumer Guide – Educational materials about nursing home care – Suggestions for consumers to actively participate in the care planning and QI 45

46 AE Resources Care Guide Audio Recording Consumer Fact Sheet Video Pressure Ulcers Restraints Pain Target Setting Resident Satisfaction Staff Retention Consistent Assignment X X X X X X X X X X XXXX X X XX XX XX XX

How to Use AE Resources 1.Choose an AE Goal 2.Look at your Data 3.Set a Target 4.Involve staff to develop a plan 5.Review AE resources 6.Finalize Plan 7. Use Audio Recording with all staff 8. Reinforce with Care Guide 9. Distribute Consumer Fact Sheets 10. Reinforce with Video 11. Monitor success 47

To Join the Campaign Go to Upper right hand corner under Action Links select Join the Campaign Need your Medicare/Medicaid Provider No. Choose three goals: – 1 clinical – 1 organizational – One other goal, either clinical or organizational

Reasons to Join the Campaign Campaign provides resources to succeed – Campaign identifies areas that need improvement – Campaigns provides technical assistance tools – Campaign provides guidance to meet goals Good care costs less – Reduction/elimination of pressure ulcers saves money – Reducing staff turnover and consistent assignment is efficient – “Value based purchasing” will be rewarding high performance Consumers are more knowledgeable, expect good care Successes (Arkansas!) It’s the right thing to do

Moving Ahead: the Campaign Continues Eliminate target setting as a separate goal and require target setting for all goals. Add statewide (LANE) target “No state will have a pressure ulcer rate higher than 15%”. Lower national target for physical restraints to 3%. Combine 2 pain goals into one. Clarify definition and measurement of consistent assignment, resident satisfaction and staff turnover. Add goal that focuses on staff satisfaction. Add a new goal that focuses on “advance care planning”.

Thank you! 51