Developing Quality Systems and Personnel Putting the Pieces Together

Developing Quality Systems Objectives o Identify components of quality validation review process o Identify how to schedule and make assignments o Identify how to review findings with team o Identify how to monitor progress Objectives o Identify components of quality validation review process o Identify how to schedule and make assignments o Identify how to review findings with team o Identify how to monitor progress

Impetus for change Average number of deficiencies per standard survey increased Number of immediate jeopardy citations increased QIS survey process Average number of deficiencies per standard survey increased Number of immediate jeopardy citations increased QIS survey process

Quality Validation Review Proactive Process oriented Collaborative Initiated 6 months prior to anticipated standard survey Follows 7 survey tasks Uses Critical Elements from QIS survey Proactive Process oriented Collaborative Initiated 6 months prior to anticipated standard survey Follows 7 survey tasks Uses Critical Elements from QIS survey

Annual Timeline

Quality Validation Review Scheduling and Attendance Scheduling Six (6) months prior to anticipated standard survey Twice a year for higher risk centers Scheduling Six (6) months prior to anticipated standard survey Twice a year for higher risk centers

Quality Validation Review Scheduling and Attendance

Quality Validation Review Assignments

Quality Validation Review Process Entrance conference Assignment review and completion target Follows 7 survey tasks Uses Critical Elements, QM/QI validation tools Preliminary exit with administrator, DON Conference with facility and regional or divisional management team Quality Milestone Action Plan development Entrance conference Assignment review and completion target Follows 7 survey tasks Uses Critical Elements, QM/QI validation tools Preliminary exit with administrator, DON Conference with facility and regional or divisional management team Quality Milestone Action Plan development

Critical Element

QM/QI Validation Tool

Summary of findings Grouping of like findings by F tag Team conference Agreement on: Citation or concern F tag Scope and severity Responsibility for POC & QMAP Calculation of SFF points Grouping of like findings by F tag Team conference Agreement on: Citation or concern F tag Scope and severity Responsibility for POC & QMAP Calculation of SFF points

Plan of Correction Development

Quality Milestone Action Plan

Monitoring Responsibility of facility to assure completion of plan of correction Regional consultant follow-up and assistance with education and audits Re-validation 90 days later (STAT) Responsibility of facility to assure completion of plan of correction Regional consultant follow-up and assistance with education and audits Re-validation 90 days later (STAT)

Survey Training and Tools Re-validation of plan of correction from Quality Validation Review “Clear” previous citations Identify new citations Preparation of survey expandable file Education of staff regarding survey process Re-validation of plan of correction from Quality Validation Review “Clear” previous citations Identify new citations Preparation of survey expandable file Education of staff regarding survey process

QVR to STAT to Survey QVR STAT SURVEY 2007 Average SFF points Range SFF points28 – – Average SFF points Range SFF points19 – –

Facility Perspectives Views from a facility team: Administrator – Matthew Baad Director of Nursing – Fran Brown Views from a facility team: Administrator – Matthew Baad Director of Nursing – Fran Brown

Developing Quality Personnel Objectives o Identify components of the licensed nurse orientation program o Identify the process steps needed for implementation o Identify components of the preceptor training program Objectives o Identify components of the licensed nurse orientation program o Identify the process steps needed for implementation o Identify components of the preceptor training program

Before… Turnover Rates 2007 o Licensed Nurses = 51%!!! Turnover Rates 2007 o Licensed Nurses = 51%!!! YIKES

Getting Ready for Change Infrastructure o Human Resources o Regional Nurse Educators o Preceptors Infrastructure o Human Resources o Regional Nurse Educators o Preceptors

Human Resources Considerations: o Role definition o Education calendar o General orientation schedule o Mastering Caring Leadership o Turnover and retention tracking system Considerations: o Role definition o Education calendar o General orientation schedule o Mastering Caring Leadership o Turnover and retention tracking system

Regional Nurse Educators Considerations: o Site selection o Clinical skills labs o Classroom settings o Equipment and Supplies o Skills validation process Considerations: o Site selection o Clinical skills labs o Classroom settings o Equipment and Supplies o Skills validation process

Preceptors Considerations: o Compensation model o Training sites o Selection process o Training o Follow-up Considerations: o Compensation model o Training sites o Selection process o Training o Follow-up

Putting it all Together DayTaskLocation 1General OrientationFacility of hire 2Mastering Caring LeadershipRegional training center 3Disease Management & Physical Exam Series Regional training center 4-5Clinical Skills ValidationRegional training center 6Preceptorship – ClassroomFacility of hire 7-10Preceptorship – On-the-unitFacility of hire

…After Turnover Rates o Licensed Nurses = 15%!!! yippee

Facility Perspectives Views from a facility team: Director of Nursing – Henrietta Makowski Regional Nurse Educator – Rose Zlotecki Views from a facility team: Director of Nursing – Henrietta Makowski Regional Nurse Educator – Rose Zlotecki

Thank You! Questions