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Quality Close-Up: Stories From Three Administrators

May 1, 2005
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QIOs are getting results-three Ohio skilled nursing facilities show how based on interviews by Richard L. Peck, Editor-in-Chief; Jason Stahl, Associate Editor; and Todd Hutlock, Assistant Editor
Quality close-up

BASED ON INTERVIEWS BY RICHARD L. PECK, EDITOR-IN-CHIEF, JASON STAHL, ASSOCIATE EDITOR; AND TODD HUTLOCK, ASSISTANT EDITOR Former Health and Human Services (HHS) Secretary Tommy Thompson had a surprisingly quiet tenure in that position, some would say, considering his record of achievement as governor of Wisconsin. Other Bush administration first-term cabinet members received more media coverage, and more credit for initiative, than he did. Some would argue, though, that very subtly he pulled off a major coup: a transformation of quality improvement in nursing homes. The Nursing Home Quality Initiative used Quality Improvement Organizations (QIOs), which had been serving as government monitors of medical care quality for some 30 years, to teach nursing homes how to use some newly developed Quality Measures. While the early progress of this initiative escaped major media attention, Thompson's virtual "swan song" as HHS secretary was to pay tribute to the work of the 50-plus QIOs in achieving dramatically measurable results in nursing home restraint reduction and pain relief.

Although the process is viewed by some as quality improvement taken at a snail's pace-only some 10 to 15% of nursing homes have been directly involved, with best practices expected to move by a sort of osmosis from "good" to "poor" performers-double-digit percentage improvements occurred in participating facilities within only a couple of years. (The fact that improvements of such magnitude remain achievable after 15 years of the state survey system tells a story in itself.) Recently, Nursing Homes/Long Term Care Management turned to its local QIO, Ohio KePro, to get the stories of some of its "star performers." We asked administrators to discuss the experiences, motivations, and explanations behind their quality improvement success stories. Their comments follow.

Mark Beggs, Executive Director, Eliza Jennings Community, Cleveland

At Eliza Jennings, a 150-bed facility, we've been able to reduce the number of residents with pain by 78% and pressure ulcer incidence by 84% since 2002. And we are completely restraint-free.

We began our process of attacking these clinical areas even before KePro was created. When KePro began, we found that they were aligned with the areas that we already thought were important, and it was good to have an additional resource to work with through our process development.

Several factors ultimately contributed to our success:

    1.Total commitment of the organization and of the staff-whatever resources needed to improve areas critical to resident care have always been a priority for the Eliza Jennings Senior Care Network.

    2.Developing systems that work for our approach. For example, we have permanent care teams consisting of representatives of therapy, housekeeping, dietary, and nursing assistants for each of our households-in short, everyone who comes in contact with a resident's care. By bonding each team together over critical areas, we find they can develop standards that they want to achieve and, as a result, the goals become important to every member.

    3.Real-time information and opportunities to educate and train staff, such as weekly rounds for wounds and falls. With wounds, we have a weekly review of every resident at risk conducted by our full-time nurse practitioner (NP), as well as a contract NP, and attended by the relevant hands-on staff. By the way, we also try to keep residents as active as possible, with some doing daily workout routines; about one-third of our residents have a personal trainer through our on-site wellness program. With falls, our approach does not focus only on preventing falls, but on ways to increase resident independence safely, with staff focusing on each resident's situation.

    4.Ongoing education of staff about the importance and impact of different areas of care (not only pain, pressure ulcers, and restraints, but medication levels, behaviors, dementia care, nutrition, and end-of-life issues, to name a few). Our education is done as a team, with everyone feeling that he/she is learning from each other and contributing. It's important that staff realize and acknowledge each member's expertise and contribution because it creates an environment where everyone feels valued.

    5. Frequent praise of staff and sharing of outcome information, so that staff can see and appreciate the results of their hard work.

More specifically on training, it is provided to our staff in many forms. Around dementia care we developed a two-day training program called Magnolia, which encompasses all aspects of care delivery within our organization. Every employee, from the receptionist to the beautician to the CEO, is required to go through this training to better understand our residents and how to deliver care and provide them with an exceptional quality of life. As mentioned, our NP is available on-site and provides education through the daily process of giving clinical care and guidance to the nurses and nursing assistants, and our medical director provides staff with regular education on a wide variety of topics, using helpful data he has put together. We also take advantage of external educational resources; KePro, in particular, is invaluable with teleconferences that allow our staff to receive low-cost, high-quality training without leaving our community. All of this is presented in a "blame-free" format, with an interest not in pointing fingers, but in educating staff.