1. Using the Quality Award Criteria as Your Roadmap to Excellence
Using the Quality Award Criteria as Your Roadmap to Excellence!: Getting the Silver!
Kathleen Martin, RN, MSN, MPA, LNHA, CPHQ, WCC, HACP

2. Three Levels of Distinction
Organizations must achieve the award at each level to continue to the next level
Bronze – Commitment to Quality
Silver – Achievement in Quality
Gold – Excellence in Quality

3. AHCA Quality Awards:
Bronze-Commitment to Quality Award; first step; examines organization’s approach to performance improvement; assess mission, vision and key factors for success.

4. Bronze Application: Organizational Profile:
P.1 Organizational Description-What are your key organizational characteristics?
Service offerings
Vision and mission
Key measures: perf measures: cust satis, financial, census, clinical
Workforce profile
Assets: technologies
Regulatory requirements
Core competencies

5. Con’t Organizational Relationships P.2 Organizational Situation
Competitive environment
Strategic Context
Performance Improvement system
THAT’S IT! Not bad!

6. Silver-Second step Achievement in Quality Award;
Based upon the Baldrige Criteria;
must respond to 7 Baldrige categories and 15 overall item requirements.
Very quality outcome focused.
This is our focus……

7. Gold-Is the Silver Award on Steroids!
Achievement in Excellence and Quality
Must get into over 85% in all categories;
Quality outcome focused with a systems and process focus.
Is the third step.

8. Program Criteria: SILVER
Organizational Profile
1.0-Leadership-120 Pts
2.0-Strategic Planning-85 pts
3.0-Customer Focus-85 pts
4.0-Measurement, Analysis, and Knowledge Mgt-90 pts
5.0- Workforce Focus-85 pts
6.0-Operations Focus-85 pts
7.0-Results-450 pts

9. Integrated Management System
Guided by Organization’s Mission, Vision and Values
Workforce
Skilled, engaged & empowered
Customers/ Stakeholders
Residents, families, payors
Results
Optimum performance
Leadership & Strategy
Operations
Effective, consistent, reliable work processes
Measurement, Analysis & Knowledge Management
Data to drive decisions and dashboard to monitor progress
Adapted from Quantum Performance Group

10. Systems Based Performance Improvement
Foundation of the Quality Initiative
Model based on Baldrige and QAPI philosophy
Baldrige and QAPI principles are grounded in systematic performance improvement model
Not task oriented
Organizations who practice this management model will drive success in quality & business outcomes

11. Baldrige Core Values Systems perspective Management by fact
Visionary leadership
Societal responsibility and community health
Patient-focused excellence
Ethics and transparency
Valuing people
Delivering value and results
Organizational and agility
Focus on success
Managing for innovation

12. So How to Start? Decide as a team, that this is a goal
Obtain the Silver application, criteria, etc from AHCA website. (should all be members of AHCA-Trend Tracker).
Leadership team read through, discuss
Think about how to plan for this-should be at least 1 year prior to a November date. November is the date a letter of intent is due. February of the next year, the application is due.
Think ahead about the clinical indicators might use to show improvements (and some non-clinical).
Read the sample applications provided on web site.

13. Con’t….. Set up steering committee Determine sub groups-
Administrator/CEO,
Corporate reps
Board member
DON
Determine sub groups-
Team A:
Sect 1.0 Leadership
Team B:
Sect 5.0 Workforce Focus
Team C:
Sect 2.0 Strategic Planning
4.0 Measurement, Analysis and Knowledge Mgt
Team D:
Sect 3.0 Customer and Market Focus
Sect 6.0 Operations Focus
Team E:
Sect 7.0 Results
Use GANNT type chart to plan over a year’s time.
Sample:
Jan
Feb
Mar
April
May
June
July
Steer *
Team A
Team B
Team C
Team D
Team E

14. Meet weekly-to actually write sections, then share.
Share sections after 5-6 weeks time.
Each member of teams read thoughtfully through using the set criteria to see if it is addressed.
Remember, the most important aspect is the improvement in areas that must be demonstrated via graphs over time: can be 6 mos, 1 yr, 2 yrs, 2+ yrs. SO KEEP THIS IN MIND EARLY ON.—Can’t do this at the end!

15. Before any of this…. Must look inward: What systems need improvement?
In groups, choose one improvement priority and discuss:
To improve performance on this goal, what are all the areas that you need to consider and address in your center?
Think broadly – go beyond the obvious
Identify a note taker to record your team’s thoughts – we will come back to this in a later exercise.
What systems need improvement?
Do you have data, trends on any?

16. Examples of Quality Indicators:
Non-Clinical:
5 Star Rating over time
Readmissions
Transfer to hospital
Customer Service Ratings
Staff Satisfaction Ratings (Can break out RN, Aide, etc)
Physician Satisfaction
Turnover
Training hours
% of Nurses with degrees (over time)
-Staffing
-Survey results
-Market Growth: addition of services
-Call light response
-Occupancy
-Financial (revenue, other)

17. Clinical: Pressure Ulcer-Acquired measure Hand Hygiene Falls
Foley catheter use
Prevalence of Pain
Short term
Long term
Med errors
Unplanned Wt. Loss
Antipsychotic use
ADL maintenance

18. DATA TRENDS Preferable to use accepted data systems: Trend tracker QI
ABAQUIS
QM Reports
EMR data systems
Press Ganey (Not is LTC business anymore)
My Innerview
NNDQI
Home-grown data systems not recommended as unable to compare facility to others: County, State, Nation

19. QAPI

20. QAPI and the Quality Award Program
QAPI Element
Design and Scope
Governance and Leadership
Feedback, Data Systems and Monitoring
Performance Improvement Projects
Systematic Analysis and Systemic Action
Baldrige Framework
Organizational Profile
Category 1 Leadership
Category 2 Strategy
Category 3 Customer Focus
Category 4 Measurement, Analysis & Knowledge Management
Category 5 Workforce Focus
Category 6 Operations Focus
Category 7 Results

21. Using an Integrated System Approach Falls Case Study
Issue:
Leaders note increased falls - affects multiple customers and stakeholders
Actions:
Leaders communicate focus , set goal, charter a team
Team uses PDSA to design and implement a set of changes
Root Cause Analysis to identify reasons
Analyze data, talk to workforce, review operations
Noise and chaos at shift change identified as key factors
Team designs solutions, pilots one 1 unit
Team analyzes and measures results, finding solutions effective
Team rolls out changes to entire workforce in variety of ways
Team continues to measure and monitor results until goal met
Team communicates results to all staff and celebrates success
Continue monitoring and set up an alert if rate goes above target

22. The AHCA/NCAL Quality Award Program Value Proposition
Silver and Gold Quality Award recipients demonstrate better results than peers:
Five Star Rating
Health Outcomes
Financial Performance

23. Overall Five Star Rating
Great inc in 5 star

24. Your Member Resource Survey History Resident Characteristics
Staffing Information
AHCA Post-Acute Measures
CMS Five Star Rating

26. Quality Boards & Quality Week
Display data on monthly basis, newsletters on Quality…

28. Quality….. ….is a constant… ….has always been a key variable…
…is dynamic….
…requires dedicated resources to sustained success….
…is done every day, all day long…

29. Be not afraid of growing slowly. Be afraid only of standing still
Be not afraid of growing slowly. Be afraid only of standing still. -Chinese Proverb

30. Call me…..
To consult on your QAPI process, or AHCA, Silver Award process
Office: