The National CMS Pilot Study: Improving Nursing Home Culture (INHC) This material was designed by Quality Partners, 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 and Human Services. Contents do not necessarily represent CMS policy. 8SOW-RI-NHQIOSC

Improving Nursing Home Culture What we did... Pilot tested a model and methodology to transform nursing homes into a better place to live and work Integrated quality improvement practices with person directed care and workforce retention practices-drawing on both the science and psychology of change

Improving Nursing Home Culture Who was involved... We worked with 21 QIOs /168 nursing homes 7 MPQs (corporations or QIOs serving with trade associations /86 nursing homes

168 NH Participants 86 NH Participants

Improving Nursing Home Culture The design.... Five Key Pieces: 1.The Framework 2.The Way of Inquiry 3.The Tools 4.Adult Learning Design 5.Measurement

1. The Framework

2. The Way Of Inquiry

3. The Tools: Domain of Workplace Practice Susan Eaton’s: What A Difference Management Makes –5 key practices between high & low turnover homes –The Grid Jim Collins -Good to Great –Small steady changes no fanfare or pronouncements Exercises The “Drill down”

3. The Tools: Domain of Workplace Practice (cont’d) Homework Assignments-Explored the Common Irritants Homework 1. What is your cycle of turnover? Homework 2. What is your cycle of understaffing? Homework 3. Where is your money going? Homework 4. What are your financial incentives? Homework 5. High-Turnover/Low-Turnover -- Looking At Your Facility’s Landscape

3. The Tools: Domain of Workplace Practice (cont’d) Homework Assignments-Explored the Common Irritants Homework 6.What Do Employees Want in Their Job? Homework 7.Management Practices That Support Retention Homework 8.Building on Intrinsic Motivation Homework: Mystery Shopper Homework: Exploring Our Worlds

Cost of Turnover Nationwide $2,500 per employee $2.5 billion nationwide Direct costs –Advertisement costs –Staff time to interview, check references, etc. –Drug screen, pre-employment physical –Classroom orientation –Unit orientation –Cost of coverage of the vacant position Indirect costs –Vacant shifts, lower quality, slower service, lost new admissions, workers compensation, lost revenue, stress leading to errors Seavey, D., “The Cost of Frontline Turnover in LTC.” 2004

Turnover Rates Drill Down In one Corporation: 37% of their turnover occurred in the first 90 days 53% in the first 6 months In another: 200% turnover rate of CNA class participants In one individual facility: 50% of new hires left within the first 7 days

Cycle of Understaffing What they found when they asked how it felt to work short: –“Unsafe.” –“Hectic-fingernails don’t get cut, people don’t get changed.” –“Stressful.” –“Can’t give residents emotional support.” –“Can’t do little things like give a hug.”

Cycle of Understaffing (cont’d) What does it feel like when you have enough staff? –“Relief – feel you accomplished something.” –“Can do little things for the residents like give them a hug.” –“Can give them a back rub, talk to them, you can take the time to be more human.”

Cycle of Understaffing (cont’d) What they found: Avg. call-outs per month was 45 Highest in September, October, November One unit of one facility was down one CNA every day for 30 consecutive days

Financial Incentives What they did: Find out what incentives exist (bonuses,shift differentials,two 12 hour shifts-paid for 36, extra per hour pay for working per diem) –Sign-on bonuses –Recruitment bonuses –Longevity bonuses –Completing a class Find out the outcomes of the bonuses

Financial Incentives (cont’d) What they found out: –$3 per hour extra to work an unscheduled shift - awarded the bonus 27 times per month –Offered a $4K sign-on bonus - 3 RN’s were eligible only one remained after 3 months When staff were asked what incentives they wanted: –Snow removal from their cars –Paid CEUs –Gift cards

Practices that Support Retention What they found: On-being a new staff member –“Terrified.” –“People did not seem happy to see me.” –“I did not receive instruction on proper transferring techniques until three weeks after I started.” What they observed in the break room: Needed paint, gloomy Bare windows, dirty refrigerators

Practices that Support Retention What they found regarding staff education: –Offered only those topics required by law –One person teaches all –“Repetitive and boring.” –“Needs a more open forum for dialogue and questions.” –“When training is scheduled during work, I get stressed out and I fall behind in my work.”

Attendance Issues What happens that leads your co-workers to call-off? –“Just tired mentally. Overwhelmed and can’t overcome it.” –“Burn out if you worked am.” –“Stress – someone is always asking you to stay late.” Top reasons for call-offs: –Sickness of self –Sick family member –Baby sitter problem –Car problem –Domestic crises

The “Stop Doing” List Incentives to waive benefits Bonuses for working short Scheduling overtime and double-time Rotating staff Sick pay – use it or lose it No sick pay until second day of absence No incentives or disincentives

What Employees Want What they did: Asked – “What brought you into care giving?” Asked - “What keeps you here?’ What they found out: “I like to care for people.” “I enjoy older people.” Why they stay: “RESIDENTS!” “Administration is fair.” “It is like family here.” “I make a difference in someone’s life.”

Results: Domain of Workplace Practice Consistent assignment Peer mentoring Self governed work teams Self scheduling Cross training Communities / neighborhoods Opportunities for leadership development On-going & Consistent recognition

3. The Tools: Domain of Environment Judith Carboni - Homelessness among the institutionalized elderly. J Gerontol Nurs 1990 Jul; 16 (7): –Home vs. Homelessness Exercise: What is home? INHC teams were asked-”How close is this facility to home”

Results: Domain of Environment De-institutionalize the common rooms (bathrooms, living areas) Design for accessibility Diminish barriers The creation of sanctuary, shelter and peace that provides a sense of community, safety and free of unwanted intrusions The creation of beauty and comfort

3. The Tools: Domain of Care Practices “Bathing Without A Battle” - Joanne Rader “Look at Me” - Veterans Administration Exercises –McNally Exercise –Change Ideas Sheet

Results: Domain of Care Practices Waking and Sleeping Meals-Service, Delivery, variety Food Preferences Daily routine Bathing-frequency, time, method ADL’s Activities Innovative, creative care solutions “I” format care plans Community mourning

3. The Tools: Domain of Leadership Kouzes and Posner -The Leadership Challenge –5 principles Connie McDonald, Administrator,Maine General Rehabilitation and Nursing Care at Glenridge Exercises –Stand Up and Tell Them (BJBC) –Power Island –Privilege Walk –People of Color/What hue are you?

Results: Domain of Leadership Support the full empowerment of workers allowing them to grow, direct, and affect the care of elders Create a climate in which compassion and common sense can flourish Became visible leaders-managing by walking around Recognize the value of all staff

3. The Tools: Domain of Family and Community Lori Todd and her staff from Loomis House Carolyn Blanks from the Mass Extended Care Federation provided powerful examples to support efforts in this domain

3. The Tools: Domain of Regulatory/ Government Karen Schoeneman, Senior Policy Analyst, Centers for Medicare & Medicaid Services Creating inclusion with surveyors- process for getting answers when attempting change Exercise: “Think like a surveyor”

Results: Regulatory & Government Opportunities to direct questions about changes to CMS Created a relationship with surveyors

4. Educational Design Experiential Learning Design Susan Aylward, PhD-Effectiveness of Continuing Education in Long Term Care. The Gerontologist 2003; Vol. 43, No 2, 2003

Measurement is Key Collecting data Baseline Evaluate impact of changes Balancing measures Correlation to other measures Creating new measures

© 2003 Institute for Healthcare Improvement ActPlan StudyDo What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Model for Improvement

Creative Measures – Quality of Life Individual facility’s measures and results: Room tray requests – reduced from 15 per day to 6 Plate waste – reduced by 75% Resident socialization - increased Staff stress levels - decreased Resident behaviors - declined Focus group responses – from negative to positive Staff time with residents - increased Peanut butter sandwiches – declined from 6 to 0

Other Key Measures Individual facility’s results: Falls – dropped 8.9% Antipsychotic medications – decreased by 50% Resident satisfaction – 100% said staff listen to me Staff satisfaction – from 60% to 80% Worker’s Compensation claims – dropped from 44 to 7 Weight loss – reduced to 0 Survey results – from 13 deficiencies to 3 Pressure ulcers – from 4.9% to.7% Suppositories – reduced from 9 to 0

INHC - WFR Collaborative Results from 95 SNFs Impact on Quality Measures Comparing Q to Q1 2005: Pain – chronic care population –Dropped from 6.32 to 5.44 Greatest impact – Physical Restraints –Dropped from 6.51 to 5.94 –66% of all SNFs had a decline –4 dropped to 0%

INHC Special Study Outcomes – WFR Results from 4 MPQ’s representing 55 SNFs Nursing Department (RN, LPN, CNA): Relative change = -10% Annualized = 196 fewer terminations Annualized direct-cost savings = $490,000

Outcomes – CMS Special Study (cont’d) Across all job categories Annualized latest re-measurement period in 2005 compared to baseline: MPQ #1 Apr/May/Jun = 15.2% turnover decline MPQ #2 Apr/May/Jun =.8% turnover decline MPQ #3 Apr/May/Jun = 1.2% turnover increase MPQ #4 Jun/Jul/Aug = 20.4% turnover decline MPQ#5 Jun/Jul/Aug = 6.8% turnover decline

Percentages to People As a result of the pilot study: 245 people were set free from physical restraints 143 people were relieved of moderate to severe pain

Hot Off The Press: New Results But the work really started late in Q So comparing Q to Q we find even better results…

INHC - WFR Collaborative Results from 95 SNFs - Impact on Quality Measures Comparing Q to Q3 2005: Pain – Chronic care population –Dropped from 5.81% to 5.41% Pressure ulcers – high risk population –Dropped from 12.87% to 11.69% ADL decline –Dropped from 18.53% to 17.00% Locomotion worsening –Dropped from 14.89% to 14.09% Greatest impact – Physical Restraints –Dropped from 6.61% to 5.12% –66% of all SNFs had a decline –4 dropped to 0%

Percentages to People As a result of the CMS special study: 345 people were set free from physical restraints 191 fewer people are depressed 128 fewer people experienced an ADL decline 78 fewer people have a pressure ulcer

Staff Stability and Empowerment Individualized Care Better Quality Better Retention Increased Census Better Bottom Line It Makes Good $ense