The National CMS Pilot Study: Improving Nursing Home Culture (INHC) This material was designed by Quality Partners, the Medicare Quality Improvement Organization.

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-082006-2

Improving Nursing Home CultureWhat 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 CultureWho was involved . . .

• We worked with 21 QIOs /168 nursing homes

• 7 MPQs (corporations or QIOs serving with trade associations /86 nursing homes

IMPROVING NURSING HOME CULTURE Special Study

Person Directed Care 23 QIOs recruit

5-10 Nursing Homes from their state

Workforce Retention 8 Corporations

& 2 State Triads (QIO, State AASHA & AHCA)

recruit 10-12 nursing homes

Training

QIO 4 Sessions

Nursing Home Sessions

Training

Corps 4 Sessions

N H Sessions

1 year September 2004– August 2005

1 year August 2004-October 2005

5 21

Outcomes Congress

168 NH Participants86 NH Participants

Improving Nursing Home CultureThe design . . . .

Five Key Pieces:

1.The Framework

2.The Way of Inquiry

3.The Tools

4.Adult Learning Design

5.Measurement

1. The FrameworkHolistic Approach to Transf ormational Change

HATCh

Leadership

Government & Regulations

Community

Family

2. The Way Of InquiryPerson Directed Care Way of Inquiry

Phase 1 Irritant -Live with it -Can’t quite put my finger on it Internalize the “no” (rationalize the reasons it can’t change) Accept the “no” Impose the “no”

Phase 2 Catalyst -outside influence -internal influence -tipping point Prompts us to begin to ask questions

Phase 3 Awakening -become aware that there is the necessity or possibility of something different (dawn of hope) Can’t any longer ignore it

Phase 4 Action Step -now ready to ask the questions that have been suppressed

Immobilization Absence of Growth or action -continue the current process

Hope vs. Despair

Choosing hope: -Gives rise to growth

and our greatest humanity

Choosing despair: -Produces resignation

and surrender

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 7 - 11 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 WantWhat 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): 32-7.– 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

Act Plan

Study Do

What are we trying toaccomplish?

How will we know that achange is an improvement?

What changes can we make thatwill 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 Q1 2004 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 Q3 2004.

• So comparing Q3 2004 to Q3 2005 we find even better results…

INHC - WFR Collaborative• Results from 95 SNFs -

Impact on Quality Measures• Comparing Q3 2004 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