1. Stop Managing for Survey; Start Managing for Quality! Kathy Owens, MSN, RN, NP Donna Kelsey, MS, NHA

2. Objectives By the end of this session, participants will be able to:  Overview of Quality Improvement  Discuss Root Cause Analysis (RCA)  State the elements of the Four Step Plan of Correction  Integrate RCA and Four Step Plans of Correction into the PDSA Model  Discuss how to use the Four Step Plan of Correction as a response to a serious event  Complete a sample Four Step Plan of Correction for a clinical concern  Discuss Change Management principles to guide the implementation of the Four Step Plan of Correction into the center’s daily PI process.

3. Quality Improvement  Definitions  Challenges  “Survey Ready Every Day”  Strong Systems  Routine Monitoring

4. Root Cause Analysis  Definition  Refinement

5. Plan of Correction  Traditional Use  Pro-Active Model for achieving sustained results

6. The “Four Steps”  Corrective Actions  Identification of Others At Risk  Systemic Changes  Monitoring

7. Integrating the Four Steps of the POC into daily Quality Improvement  Response to a Survey Result (2567)  Making the Four Step part of the PDSA Model  What centers do well  Opportunities for more effective application

8. Response to a Survey Result  Familiar  Reviewed in center Performance Improvement process  Requires ongoing monitoring for sustained results

9. PDSA Model  Based upon an accurate Root Cause Analysis  Plan  Do  Study  Act

10. Integration of Four Step POC into Routine PI Process Event/ Trend Occurrence Investigate & Corrective Actions Working Root Cause(s) Identify Others At Risk Refine Root Cause Systemic Changes Monitor PLAN DO STUDY Expand to Entire Center ACT Continue to MONITOR

11. When to Use the Four Step POC  Identification of a Trend  Increase in Nosocomial Pressure Ulcers  Increase in Falls  Response to a Serious Event  Resident develops Stage III Pressure Ulcer  Resident Falls and Fractures

12. Four Step Plans of Corrections: Comfort Zones for Centers  Corrective Actions  Correcting the problem for the resident involved  Systemic Changes  Education of Staff

13. Opportunities  Emphasis on Identifying Others At Risk for same issue  Requires a systematic, documented baseline audit  Results can be used to refine the Root Cause  Correction of newly identified issues  Monitoring  Requires disciplined, documented monitoring  Results of monitoring need to be reviewed  May lead to further refinement of systems changes

14. Embracing Serious Events as Opportunities  The Silver Lining of a Serious Event  Can be a “red flag” of a broken part or whole system  Examples  Using the “Four Step POC” as a routine response to a serious event  Examples

15. Documenting the Process  Part of Performance Improvement  Create a “paper trail” as evidence of completion of each step of the plan of correction  Place evidence of completion in a file or binder  Easily accessed if needed to produce the documents

16. Topic / Opportunity / Problem Current Measurement/ Target Action / InterventionsTarget Dates Responsible Party Follow-Up Corrective Actions : Identification of Others At Risk Systemic Changes Monitoring Performance Improvement Action Plan Result of Root Cause Analysis: Privileged and Confidential - Prepared for use by Quality Assurance Committee, Insurer and Corporate Counsel 42 C.F.R. 483.75(o) PI – FRM 05 Performance Improvement Action Plan Form

17. Response “Template”  First Step: Always protect resident; corrective actions for resident(s) involved  Begin Root Cause Analysis  Based upon “working” RCA, begin a baseline audit to identify others at risk from same practice  Refine RCA, based upon trends revealed through the baseline audit

18. Root Cause Analysis (RCA)  Initially based upon information gathered as part of Event Investigation  May have several “working” RCAs

19. Determining Others At Risk  Requires a thorough baseline audit of others who could be at risk for same deficient practice (s)  Repeating assessments  Review of current orders and documentation trail  Review of Care Plans  Review of communication of interventions  Window into the functioning of the System/Process  May lead to a refinement of the RCA

20. Systemic Changes  Actual Systems Changes  Dependent on Root Cause (s)  May require revisiting current Policies and Procedures with no new changes needed  May requires the use of a Workgroup or Subcommittee  Education of Pertinent Individuals  Staff, Residents, Families  Clarify Content and Approach of Educational Sessions  Document completion of educational opportunities

21. Monitoring  More frequent at first, then reduce in frequency  Review of results critical  Correct any newly identified concerns  Trends reviewed in center PI Committee  ONGOING!

22. Protecting the Process  Maintain records under the Umbrella of Performance Improvement Process  Example: Privileged and Confidential - Prepared for use by Quality Assurance Committee, Insurer and Corporate Counsel 42 C.F.R. 483.75(o) PI – FRM 05 Performance Improvement Action Plan Form

23. Success Stories  Abuse  Skin  Falls  Advance Directives

24. Responding to Substantiated Abuse Allegation  Scenario:  Root Cause Analysis  Four Step Response

25. Responding to development of Nosocomial Pressure Ulcers  Scenario  Root Cause Analysis  Four Step Response  Integration into Center PI Process

26. Extra Bonus: Surveyor Response  “Acting as if already cited”  Success Stories

27. Organizing for Sustained Results  Documentation Trail  Keeping Team Focused

29. Integration of Four Step POC into Routine PI Process Event/ Trend Occurrence Investigate & Corrective Actions Working Root Cause(s) Identify Others At Risk Refine Root Cause Systemic Changes Monitor PLAN DO STUDY Expand to Entire Center ACT Continue to MONITOR

30. Application Exercise  Break into Groups  Each Group Given a Summary of a Serious Event  Group Charge  Identify Recorder  Create an Four Step Action Plan for Event Management  Identify Presenter

31. Group Presentations

32. Managing Multiple Plans of Correction  Prioritize  Track completion of plans, and results of ongoing monitoring  Team reviews trends and directs continued monitoring

33. Now What?  For things to change, somebody, somewhere has to start acting differently  Knowledge does not change behavior

34. We Need to Change  In the business we tend to think in two stages  plan and execute  there is no learning stage or practice stage. “We don’t care how you do it, just get it done.”

35. Integration of Four Step POC into Routine PI Process Event/ Trend Occurrence Investigate & Corrective Actions Working Root Cause(s) Identify Others At Risk Refine Root Cause Systemic Changes Monitor PLAN DO STUDY Expand to Entire Center ACT Continue to MONITOR

36. Plan What does the center do now? What change do you want? What is holding you back? How do you make the change?

37. Do Select a leader, a champion in each center Give clear direction, train, give examples Demonstrate the value and what will happen if you don’t change Start small, “what are you going to do differently by Tuesday” Grow your people

38. Study Review Outcomes at PI Lower fall rate Lower incident of acquired pressure ulcers Celebrate Success Review the process Provide templates Review the Four Step action plans for completeness

39. Act When change works, it tends to follow a pattern: the people who change have clear direction, ample motivation, and a supportive environment.

40. Questions?