Hcad 301 exam 2

Move away from

"do" and move towards PDCA (Plan, Do, Check, Act)

Human factors

Competence, correct tools for the job, tolerable work environment Strong and effective systems Avoid: -Creating additional work for fewer people ("do more with less") -Moving people out of roles that they were comfortable in -Placing people in unfamiliar, new roles (people ≠ interchangeable parts in a machine) -Making decisions without consulting those affected (no "I know what's good for you" approach) Cognitive overload

IMPROVING RESIDENT SAFETY

Failure mode and effects analysis (FMEA 1.) Organize information about the process. 2.) Conduct a hazard analysis. 3.) Develop the process changes required 4.) Implement and pilot test the process changes. 5.)Evaluate whether the process changes achieved the desired result. 6.)Make the process changes permanent or revise and retest the process changes. Proactive risk assessments Criticality (page 207) -Frequency -Severity -Detection *Each item is rated from 1-5 (1 being least likely to occur) and formula is:Frequency x Severity x Detection

Improvement initiatives are successful when it is expected that people will perfectly execute their job responsibilities.

False

The likelihood of human errors causing patient harm can be greatly reduced by disciplining staff for making mistakes.

False

There is no reason to investigate what happened to cause a near miss event because no patient was harmed.

False

Root Cause Analysis (RCA)

If we don't get to the "root cause" of the the problem, our solutions may: •Not work at all •Only work for a short period of time •Only fix part of the problem •Create additional problems Any time we find ourselves fixing the same problem over and over again, we haven't figured out the "root cause" or what is at the bottom of the issue. Steps: 1.) Understand what happened. 2.) Identify root causes. 3.) Develop risk reduction strategies to prevent recurrence. 4.) Implement and pilot test risk reduction strategies. 5.) Evaluate whether risk reduction strategies achieved the desired result(s) 6.) Make risk reduction strategies permanent or revise and retest strategies.

Both from one of the guest speakers, and this slide, answer: if you wanted to analyze workflow patterns and where movement/motion occurs, to eliminate or minimize that waste, you might use a spaghetti diagram to show common travel patterns.

True

For noncatastrophic processes, good outcomes depend on having at least 95 percent process reliability.

True

Process standardization improves patient safety

True

State Of WisconsinBoard On Aging & Long Term Care Ombudsmen ProgramPresented By: Joan M. Schmitz

WI BOARD ON AGING & LONG TERM CARE: • Ombudsman Program 1-800-815-0015 - Advocacy, formal and informal - Education - Monitoring Regulators •Medigap SHIP Counselors 1- 800-242-2060 - Education on all insurance benefits - Plan finders - Part D Counseling • Volunteer Ombudsman 1-800-815-0015 -Assigned to a specific facility, weekly visits Ombudsman: • The word, "Ombudsman" (om-budz-man), is Scandinavian. It means "voice of the people". • In this country the word has come to mean an advocate or helper. A long term care ombudsman protects and promotes the rights of long term care consumers, working with the consumers and their families to achieve their expected quality of care and quality of life. • Person Centered and Directed Care. Obudman history of program: • 1950: Government loans for not-for-profit NH - licensing required • 1965: Growth - for-profit NH with Medicare/Medicaid Funding • 1967: Licensing of NH Administrators • 1968: Start of regulation • 1972: NH Ombudsman Demonstration projects (Wisconsin) • 1975: Title XX - start of home and community-based waivers • 1978: OAA requires every state to have Ombudsman Program • 1987: OBRA Nursing Home Reform Act/OAA amendments strengthen ombudsman program • 1990s: Olmstead decision - broader HCBS - community integration • 1995-1996: Implementation of NORS - data reported to congress • 2006: Law now includes principles of consumer information for long term planning • 2010: Affordable Healthcare Act - Person Centered Care • 2016: Ombudsman Program Final Rule Ombudsman Not always good care: • 1970s public exposes': Congressional hearings on inhumane treatment by Ralph Nader, others, led to 1972 demo projects .- Lack of resident activities - Untrained, inadequate staff- Unsanitary conditions - Over-, under-medication - Discrimination against minorities - Reimbursement fraud - In appropriate physical restraints Roles and Responsibilities of Ombudsmen: • Focus is on the rights of long term care consumers, to assure quality of life and quality of care • Investigate complaints of rights violations and inadequate care and services • Primary goal is problem resolution to the satisfaction of the client(s) • Techniques include, Education, Consultation, Information and Referral, Mediation, negotiation, persuasion, Trouble-shooting/problem solving, Empowerment Who are your clients: 1. Residents of: - Nursing Homes - Community Based Residential Facilities (CBRF) - Residential Care Apartment Complexes (RCAC) - Adult Family Homes (AFH) 2. Members who receive Home and Community Based Services (HCBS). Those that participate in the following programs:- Family Care- IRIS- PACE- Partnership Resident Rights: • Universal Declaration of Human Rights by The United Nations • Constitutional Rights• Federal Regulation: - Nursing Home Reform Act of 1987 - The final Home and Community -Based Services (HCBS) regulations• State Regulation - Statutes and Administrative Codes:oDHS CH 50, 132, 89, 88, 93 When to Call an Ombudsman: • Resident rights are violated• Inadequate care/services • Roommate or resident conflicts • Residents with behavior symptoms • Family conflicts/dysfunction• Involuntary discharges • Inadequate supplies or equipment• Sexuality and Intimacy issues • Restraint issues• Guardianship and HCPOA issues • Aging network/systems problems• Closings, relocations • Regulatory process falls short• Discrimination • Benefits problems • Access to information *Long Term Care in America is The Perfect Storm=Increasing Need,Decreasing Resources Aging American Numbers: • U.S. Census projection: 65+ years will double and by 2060 to 98.2 million • "Oldest Old," 85 years + grows to 8.7 million by 2030 • "Oldest Old," 85 years + reaches 19 million by 2050 Concurrent Decreasing Resources: • Geriatricians/Gero-psychologists • Nurses • Nurses Aids • Kitchen staff • Personal Care Workers • Home Health Aids • Long Term Care Providers • Informal Supports Current Trends in Long Term Care: • Facilities feeling over Regulated • Family conflicts/dysfunction• Guardianship and HCPOA issues • Involuntary discharges/LOC & non-payment • Inadequate services, supplies or equipment (FC) • Staffing/ inadequate staff training (dementia) • Artificial Intelligence Applications • Abuse/Neglect allegations• Closings, relocations• Reimbursement Rates/Private Rooms • Intimacy & Sexuality, hello Baby Boomers • Mental Health /AODO issues/correction Future of Long-Term Care" • Increased diversification and specialization to meet wide range of needs, e.g., dementia, other chronic disease management of aging population • Staffing will continue to be an issue. Corps of Volunteers • ACA provisions support increased community -based care; PCMHs and ACOs integrate long-term care into service continuum - Potentially more rational, less costly, more coordinated long -term care system - Could be a return to institutional care for lack of providers, available funding High-Technology Home Care: Hospitals Without Walls • Advanced technology for intravenous infusions, ventilation, dialysis, parenteral nutrition, chemotherapy - Improvements in portability, mobility, reliability and cost of medical devices - Specialist home care personnel (nurses, pharmacists, respiratory therapists, etc.) - Cost effective; patient-preferred- Tele-medicine helps supply physician services to underserved areas Naturally-Occurring Retirement Communities (NORCs) • Coined by Dr. Michael Hunt (University of Wisconsin Prof. of urban planning), 1980s • Apartment building residents, neighborhoods, community sections harboring aging residents • Administration on Aging makes demonstration grants to not-for-profit organizations: evaluate case management, nursing, social, recreation, nutrition support services for aging-in-place What it Means For You • You can't start saving too soon • Take advantage of student loan repayment programs • Follow politics and VOTE: As painful as that may be - Future of Social Security - Future of Medicaid/Medicare• Invest in a HOME - Home improvements to make it a forever home - You can control who your caregivers are - Look at congregate housing• Complete your Advanced Directives

Strength of Actions

Weak: -double-cheks -warning and labels -new procedire and labels -memos -training -additional study/analysis Intermediate: -checklist/cogntive aid -increases in staffing/decrease in workload -redundancy -enhanced communication (read back) -software enhancements/modifications -elimination of looks-alikes and sounds-alikes -elimination/reduction of distractions (sterile medical environment) Strong: -architectural/physical plant changes -tangible involvement and action by leadership in support of patient safety -simplified process, with unnecessary steps removed -standardized equipment, process, or care map -new-device usuability testing before purchasing -engineering control or interlock (forcing functions)

The number of actions that achieve intended results divided by the total number of actions is measuring what aspect of performance?

Reliability

importance of reliability

Reliability science Scientific research/facts/information applied to processes, procedures, or health services to ensure performance under commonly occurring conditions Reliability measured with process outputs/outcomes (think back to the Donabedian SPO model; what affects the "O" in SPO) Formula: Number of actions achieving desired results/ Total number of actions taken Reliability in terms of "failure" Noncatastrophic processes (e.g., hand hygiene, low-risk meds) -Good outcomes = 95% process reliability Catastrophic processes (e.g., correct surgery site, blood transfusion) - Good outcomes = 99.5% process reliability "Improvement teams frequently favor weak interventions over higher-level actions because weak actions are lower risk and easier to create and implement."

Improving resident and patient safety

Resident and patient safety -Actions undertaken by individuals and organizations to protect residents/patients from being harmed by effects of health-care services; freedom from accidents or preventable injuries produced by medical care Organizational culture -Prevalent patterns of shared beliefs and values that provide behavioral guidelines or establish norms for conducting business

What technique can be used to minimize cognitive overload for hospital caregivers?

Add patient care decision aids

Measurement

Adverse events: Event resulting in unintended harm to resident/patient and related to care/services provided to resident/patient; not from condition Incident reports: Paper/electronic reports to document occurrences that could have led/did lead to undesirable reports Reportable events: Incidents/situations/processes that contribute to resident/patient injury;degrade provider's ability to provide safe care/treatment Failures: Compromised function/intended action Patient safety organizations from the 2005 PSQIA Risk management organizations

What is an improvement action considered to be strong—meaning it is more likely to achieve patient safety improvement goals than weak or intermediate actions?

Tangible involvement by leadership

The purpose of an A3 form

The A3 form supports efforts to organize the thinking of workers about new ways to improve.

Which of the following is the structured form of multi-voting, usually with five steps and a rank voting process to prioritize quality improvement initiatives? a. affinity process b. nominal group technique c. structured brainstorming d. unstructured brainstorming

b. nominal group technique

What type of form is used by hospital caregivers to document potential or actual patient safety concerns? a. Risk summary b. Environmental assessment c. Incident report d. Check sheet

c. incident report

During what type of improvement project does the team brainstorm what could go wrong in each step of a process. a. Root cause analysis b. Rapid cycle improvement c. Lean Six Sigma project d. Failure mode and effects analysis

d. Failure mode and effects analysis

What is the first step of a root cause analysis? a. Develop risk-reduction strategies b. Report event to the governing board c. Understand what happened d. Identify the contributing factors

d. Identify the contributing factors

What federally recognized group maintains a database of adverse patient events? a. Quality Improvement Organization b. National Patient Safety Foundation c. Agency for Healthcare Research and Quality d. Patient Safety Organization

d. Patient Safety Orgization

What is the primary purpose of root cause analysis and failure mode and effect analysis? a. Evaluate staff performance b. Meet Medicare requirements c. Reduce wasteful process steps d. Improve patient safety

d. improving patient safety

In a decision matrix, a. the lower the weight, the more important the criterion b. all weights are assumed to be equally important c. the weights can be positive or negative and sum to 0 (zero) d. the weights represent the relative importance of criteria

d. the weights represent the relative importance of criteria

If an individual wanted to visually represent a process/procedure to show problem areas, redundancy, and unnecessary steps, he/she might use which of the following tools?

flowchart/swimmlane diagram

Which of the following improvement actions can help achieve 95% process reliability?

standardizet the process steps

In a decision matrix (quantitative component):

the weights represent the relative importance of criteria

Discuss 6 sigma and its relation to the normal distribution in statistics

to the normal distribution in statistics Lean Six Sigma solves problems where the number of defects is too high. A high number of defects statistically equals high variation in the process. Helps Figure out how significant certain events are

In a survey questionnaire, if a question has a dichotomous response, how many potential answers are there to that question?

two

Lean presentation

• "Lean is a way of thinking about creating needed value with fewer resources and less waste. Lean is a practice consisting of continuous experimentation to achieve perfect value with zero waste" - Lean Enterprise Institute • Lean process improvement is a mindset, not an event • Goal is to enable teams to systematically find ways to deliver more value faster• Practicing continuous improvement as part of daily work. Lean environment: • Lean doesn't only apply to process improvement. • Since Covid, Organizations are operating extremely lean. -Positions deemed non-essential where either eliminated or consolidated. -Not all positions have returned. -Employment in healthcare sector slowly returning to pre-pandemic level. However, new financial struggles are causing cuts again. • Healthcare is in constant flux, and we must be adaptable Need for Lean for healthcare: • Reduce silo mentality • Improve efficiencies • Customer centered care • Reimbursements tied to effectiveness of care • Continuously changing environment • Decrease waste• Improve process flows• Decrease variation • Increase standardization • Financial incentives Qualities are a lean leader: • Trust and Integrity • Customer Advocacy • Passion• Change Leadership • Communication • Business Acumen • Project Management • Technical Aptitude • Team Player and Leader • Result Oriented • Fun 8 wastes of hosptial lean: -Defects. This includes all time spent doing something incorrectly and inspecting or fixing errors. -Over-production. This includes doing more than what is needed by the patient or doing it sooner than needed. -Transportation. Unnecessarily moving patients, specimens or materials throughout a system is wasteful. -Waiting. Waiting for the next event to occur or the next work activity can eat up time and resources. -Inventory. Hospitals create waste when they incur excess inventory costs, storage and movement costs, spoilage and waste. -Motion. Do employees move from room to room, floor to floor and building to building more than necessary? -Over-processing. This describes work performed that is not valued by the patient or caused by definitions of quality that aren't aligned with patient needs. -Human potential. This waste is caused when employees are not engaged, heard or supported. Employees may feel burnt out and cease sharing ideas for improvement Lean Project: • Start with where you actually are and not where you think you are. • Speak with those directly involved to determine current state. • Don't assume that current policy or procedures is being followed. Project Management JPACE: 12Project Management - JPACE • Justify Plan Activate Control End • Full life cycle project management tool • Creates executive buy in and a solid business case • Assists with securing recourses, budgeting, and risk mitigation • Motivates team members and keeps project on track • Captures success and lessons learned Ensuring project sucess: • Involve staff who are directly involved - varying perspectives• Foster clear and effective communication • Set clear goals for your project, reduce scope creep • Use the right tools to monitor progress• Continue to reinforce culture of continuous improvement • Establish appropriate owners of the process Data Utilization and Improvement: • Data monitoring is an important tool for identifying areas of opportunity as well as in maintaining performance. Statistical Process Control • "Use of statistical techniques to control a process or production method. SPC tools and procedures can help you monitor process behavior, discover issues in internal systems, and find solutions for production issues." - ASQ Method helps move towards prevention-based quality control instead of detection-based quality control. Benefits • Increase productivity • Improve overall quality • Continuous monitoring to maintaining control • Provide data to support decision making • Identify opportunities for company-wide improvements Control Charts: • Popular statistical process control tool. • Helps record data and identify outliers. • When to use: When controlling ongoing processes by finding and correcting problems as they occur When predicting the expected range of outcomes from a process• When determining whether a process is stable • When analyzing patterns of process variation and special causes • Attempts to distinguish between:• Common cause variation, which are inherent to process and will always be present. Variance is to be expected .• Special cause variation, which are unexpected variations and indicates the process is no longer in control. Bridges transition model: stage 1: ending, losing, and letting go Stage 2: neutral zone Stage 3: new beginnings

Affinity diagram

•Charts used to group common themes; organize ideas and issues; gain a better understanding of the issue(s), brainstorm solutions

Challenges in Utilization Management

•Costs can fall on patients if post-treatment reviews result in a denial of benefits. •Patients may have to bear costs if they don't follow the treatment guidelines of the insurer. •Patients may sue when coverage is denied, or if an experimental treatment is not permitted. •Physicians don't always have the insurer's medical necessity guidelines as their first consideration when delivering care. •Concurrent and prospective reviews may overturn wishes of primary care physicians. •The number of reviews are rising, as are denials of coverage. •The process steps required by insurers can be perceived as red tape or unnecessary by healthcare workers. •Physicians may not well-receive the results of retrospective reviews. •Even with UM in place, the cost of care is still high, so it may be seen as ineffective.

Planning Matrix

•Diagram to show tasks needed to complete an activity, people/groups responsible for tasks, schedule of deadlines •Graphic planning matrix: Gantt chart (Exhibit 6.17 on page 168)

The five ways: Washington Monument

•Dig deeper into the causes of a problem •Ask what and why until all aspects of the situation are reviewed example washington monument -why? Use of harsh chemicals -why? To clean pigeon poop -why so many pigeons? They eat spiders, lots of spiders at the monument -Why so many spiders? They eat gnats and there are lots of gnats at monument -Why so many gnats? They are attracted to the light at dusk. -Now what do you think we should do? Solution: Turn on the lights at a later time

DMAIC

-Define -Measure -Analyze -Improve -Control -If DMAICV, the V stands for verify.

Rapid Cycle Improvement (RCI)

-Accelerated timeframe *Several small process changes to achieve a set goal *Less comprehensive process analysis than in PDCA -Many, many PDCA cycles building off one another *Cycles can also work in an overlapping fashion (think about a Venn diagram) -See Exhibit 5.4 (page 127) *Is PDCA but faster, breaking down a larger project into smaller accelerated project. Like 6 weeks, facility staffing. -When an improvement needs to be made and the company has an efficient system in place to make the improvement and put it into practice. They also have a system in place to see if the improvement made is doing what it is intended and no further changes need to be made. PDSA within 6 weeks

Lean Thinking

-All work either adds value or it doesn't... -Value is the worth placed upon goods or services, as defined by the customer. -Overall, trying to reduce waste, not just stuff, could do with time as well

Direct supply guest speaker

-Amanda Jessup:Senior Sourcing Associate, Direct Supply Manufacturing -Eric WiechmanSourcing Manager -America's Population 85 and Older Will Dramatically Increase Over the Next 40 Years: 2000= 3.49 million 2050=19.0 million -Our mission is to enhance the lives of the millions of residents in the Senior Living profession: build, equipt, run -Supply Chain (SC): The global network of organizations and activities/processes involved in designing, transforming, consuming and disposing of goods and services. -goods/products:Everything you wear, eat, sit on or in, use, read, or give care with comes to you courtesy of supply chain. Goods Services • Tangible • Can be inventoried • Little customer contact • Long lead-time • Often capital-intensive • Quality easily assured • Material is transformed -services:Every book you borrow from the library, every medical treatment you receive, hotel stay, oil change, every service you receive comes to you courtesy of supply chain. • Intangible • Cannot be inventoried • Extensive customer contact • Short lead time • Often labor-intensive • Quality harder to assess • Information or customer is transformed Why is SCM important? : Team learns that a bariatric patient is being released from the hospital and will be arriving in three days and you do not have a bed or mattress for the resident. • Head Chef shares that egg prices are volatile and are expected to double in 2023. • Team needs to install a new access control system that works with current nurse call system .• A snowstorm delays all shipments for 3 days. • Surveyor is preparing a citation for your community if you do not resolve an issue they found. -holidays, covid-19, hurricane katrina Supply Chain managers: • Supplier management ▪ Vetting ▪ Contracting ▪ Escalations ▪ Lifecycle mgmt .▪ Contingency planning • Take cost out • Improve performance ▪ Quality ▪ Metrics ▪ Innovation Key SCM decisions: -what product or service -how, design,made, delivered, direct or distribution -When, timing of production, deliveries -Where and who, outsourcing and insourcing dilemnas *All goods and services delivered require the involvement of and decisions made by direct supply chain management Supply Chain common challenges: • Lowering costs • Improving quality • Meet customer needs and timelines • Enhancing product desirability • Evolving with the needs of customers, competition, and technologyConfidential FDA: • Food and Drug Administration • FDA classifies medical suppliers into three categories□ Drugs/Pharma - e.g. Bristol-Myers Squibb, Baxter, Roche, Pfizer, etc. □ Med-Surgical Suppliers - e.g. 3M, Abbott, Johnson and Johnson, etc. □ Medical Devices - e.g. Medtronic, GE, Zimmer, Siemens, etc .• Depending on classification, products are regulated for sale and manufacturers and distributors must meet certain minimum qualifications Advocacy :• Advocacy - Work collaboratively with all legislative and regulatory authorities to ensure fair and efficient procurement practices in an open and competitive market within the health industry. • Impact of Advocacy on: □ Medicare/Medicaid Funding □ Pandemic Relief □ Insurance/Private Pay GPOs: • A GROUP PURCHASING ORGANIZATION (GPO) is an entity that helps healthcare providers — such as hospitals, nursing homes and home health agencies — realize savings and efficiencies by aggregating purchasing volume and using that leverage to negotiate discounts with manufacturers, distributors and other vendors. • There are over 600 GPOs in the US today, roughly half of the GPOs in existence are focused on healthcare. • Examples: Premier, HealthTrust, Vizient Role of GPOs: Role of GPOs • GPOs enable hospitals and health care organizations to: □ Achieve savings goals for product and service costs □ Provide cost stability, typically GPOs have multi-year contracts □ Allows for access to information about your peers

Check

-Analyze the data you've collected *Were changes effective? If not, why not? *If so, do you need to do anything to "control" the results moving forward? -Compare results with expectations *Remember your Radar Chart/Diagram etc. -Summarize lessons learned and debrief with team

Many models, but all follow

-Define improvement goal -Analyze current practices. What we have done before and what you are doing. Move away from just "doing" towards PDCA. -For example: what did this student plan to do and what are they improving. What was done before. Do they use evidence based pratices, has this been done elsewhere. *What is working well? What needs to be modified? -Design and implement improvements. What did they change. -Measure success along the way. Do they align with goals and were they successful. Quatitative or Qualitative.

Systems of improvement: FOCUS PDCA

-Find a process to improve -Organize a team that knows the process -Clarify current knowledge of the process -Understand sources of variation -Select the Improvement -Plan the improvement and continue data collection -Do the improvement, data collection and analysis -Check (Study) the results -Act to gain hold

FADE

-Focus *Choose problem (what is your goal) *Write statement -Analyze *Gather data -Develop *Solution *Plan -Execute *Implement, monitor, and adjust where needed *most similar to PDCA

Act

-If your changes were not successful, then start the PDCA cycle over -If changes were successful, implement on a larger scale (i.e., whole facility) -Predict results -"Institutionalize" the changes *Keep the gains *Prevent any future slipping away from the desired result(s) -Celebrate, to an extent, too...

Do

-Implement your changes on a small scale (pilot project) -Document problems and unexpected events *Why did those happen? *Was there something you could have foreseen? -Gather data to assess impact *Quantitative? Qualitative? *Who are you trying to show the data to? What are you trying to measure?

6 sigma

-Increase quality, decrease waste, decrease cost in manufactoring -Toolset for business -Mindset and culture -Consulting and training industry

Focus on improvement

-Only so many resources... *Can't do performance improvement on every issue... -Initiation factors *Gaps, with results and performances *Priorities -Systematic (when you go about improvement, should be systemic methodology-set thought out improvement project) -Benefits include *Performance problems are solved. Want to prevent from things being a problem in the future forward *Work-life quality improves. To not get burntout *Communication improves, which improves collaboration.

Qualitative data vs Quantitative data

-Qualitative Data: non-numerical, Generate ideas, set priorities, maintain direction, determine causes of problems, clarify processes, -Quantitative Data: numerical, Measure performance, collect/display data, monitor performance

Plan

-State objectives -Determine needed improvements *Voice of the customer *Use data to drive decision-making -Design process changes -Develop a plan for implementation -Identify goals, outcomes, or indicators of your success -Identify data that need to be collected to measure success *A goal without a plan is just a wish

Dave guest speaker

-Talked about emergency preparedness and federal surveys. -What are the top three resources in order to sucessful respond and recover from an emergency. 1. Staff 2. Communication 3. Stuff (Meds, power, gas, water, and shelter) Federal surveys comes every 9-15 months. Before they come in for a tour, they do a entrace conferance, doc review, and then the building tour. Here are the top 10 things people get cited for 1. Sprinkler sys: Field modification and testing 2.Fire drills: staff participation shifts and use equipt 3.Fire alarm sys: testing and modifications 4.Hazard Areas: new rooms and resident rights 5.Egress: falls, lock, and obstruction 6.Elictrical outlits: Type of outlet and testing it the right way 7.Corridor doors: out of alignment and latching 8.Smoke components: wall continuity and fire stopping 9.Cooking: fires, staffing, and inspection 10.Power: Essential power

Omnibus Budget Reconciliation Act (OBRA)

-To mark the 20th anniversary of the passage of landmark federal legislation to improve the quality of nursing home care -1987 (known as OBRA 87)

What is a kaizen event?

-a focused, short term project aimed at improving a particular process

How are fishbone diagrams a helpful way to determine root cause?

-creates a snapchat of collective knowledge and consensus of a team -displays various theories as to the causes of a problem -helps you dig deeper by looking at it visually and notice some components - also know as ISHIKAWA DIAGRAM -an example with this is long clinical waitimes *environment *People *Equipment *Long waiting times *Methods

Discharge planning: 1). What should be considered 2). What are the 3 "levels"

1). -Patient/family interview -Medical record documentation -Demographic information -Patient diagnosis/history -Nursing Rounds -Daily interdisciplinary team meetings 2). The three levels Basic discharge plan: Routine for patient with no additional needs outside of -Routine presciptions -Routine follow up -Written discharge instructions Moderate discharge planning: Indicated for patient with adequate independent and or social support: to be discharge home with minimal intervention or that may require -Home Health -Simple durable medical equipment -Community resource information or refferal -Outpatient rehab 3). Complex discharge planning:Indicated for indigent patient; with long-term chronic needs including -Inpatient rehab -Skilled nursing services -Hopsice -Dialysis -High-costs drugs or biologicals -Adult home -Medically complex home care -Nursing home placement -Consumer directed programs -Substance abuse -Behavioral Health

Utilization review includes 3 components- what are they?

1).Prospective review: review ahead of time *Preadmission: certification or approval (e.g., inpatient admission at hospital or nursing home before care/services are provided) 2).Concurrent review: review during delivery of services •Nurse role •Physician role •Physician advisor role 3).Retrospective review: after the services are delivered •All are designed to ensure appropriate care/services for the resident/patient in the least costly setting

1. Resident/patient safety/safety 2. Hazards 3. Incident 4.Accidents 5.Risk

1. Freedom from danger, injury, or damage 2. Events, actions, or things that can cause harm 3. Events/occurrences that could have led/did lead to undesirable results 4. Unplanned, unexpected event; usually has an adverse consequence 5.Possibility of loss/injury

1. Overuse 2. Underuse 3. Misuse

1. Overuse •Provision of health care/services that do not benefit the patient/resident and are not clearly indicated •May be provided in excessive amounts/unnecessary setting 2. Underuse •Failure to provide appropriate/necessary services •Provision of inadequate quantity or lower level of service than required 3. Misuse •Negligent or intentional use of care/services in such a way that the patient/resident is harmed or does not benefit from the care/services

1.What is utilization? 2.What is utilization management?

1. Utilization •Use of medical services/supplies •Traditionally looking at patterns/rates of service use (e.g., hospital, physician) 2. Utilization management (UM) •Planning, organizing, directing, and controlling health care products in a cost-effective manner •Maintain quality of care standards and still meet organizational goals •Involves measurement, assessment, and improvement (Spath model) •Ensure patients/residents necessary medical services at the least cost •Medically necessary care/services •Attempting to eliminate underuse and/or overuse *to keep costs down

Symbols and what they represent

1. full oval: The start and end of a process 2. square: A task, action, or step in the process 3. square with two arrows (yes or no): A decision point in process 4. Rectangle with wave at bottom: A document used in process 5. Half U shaped: A delay in process 6. An arrow: The direction or flow of process

Provide an example and the purpose of these: 1.5S methodology 2.Mistake-proofing 3.Visual control 4.Kanban 5.Value Stream Map

1."The 5Ss are Sort, Simplify, Sweep, Standardize, and Sustain. They are tactical ways of organizing any process and can guide your Kaizan events, helping you find and eliminate the eight wastes. "Example: When delivering food trays, waste less time. 2.Improving processes to prevent mistakes or to make mistakes obvious at a glance; also called error-proofing. EX: set up instructions on how to check certain residents 3.making current performance and potential problems immediately visually apparent warning lables EX: Set up safety bed heights to help make sure residents don't fall at a dangerous hight 4.a manual system that signals the need for parts or materials, ways to show your process. Ex: When new medications need to be ordered, have a system in place to order them on time 5.A complex flowchart documenting processes and flows to help a manager determine which processes add value and which do not. EX: emergency evacuation

1.What is OSHA? 2.Why is it important? 3.Who is covered by OSHA? 4.What are OSHA inspection priorities?

1.Occupational safety and health administration -Formed in 1971 by congress -established health and safety standards -enforced standards 2.Worker safety -inspections -reduce workers fatalities -enforce work rights 3.-Private sector workers, covers most private sector employers and worker in all states -Federal gov workers, applies to all federal agencies 4.-imminent danger situations -catastrophes/fatalities -workers complaints and referrals -industries with high illness and injury rates, severe violations -follow up inspection

1.When are improvement teams helpful? 2.What are the two factors that influence the decision to start a project? 3.What are the 4 common steps of performance improvement 4.What is the most widely recognized improvement process today?

1.acquire new skills and gain a gain deeper understanding of problem-solving techniques. Impovement projects shouldn't be done alone. When the improvement process is more involved and in depth. 2. Has only so much time and resources and gaps with results performances 3. of performance improvement? Step 1: define the improvement goal Step 2: Analyze current practices Step 3: Design and implement improvements Step 4: Measure success 4. Plan do check act (PDCA)

Achieving Reliability

80-90%: -Standardization and staff education -Vigilance -Engagement from management and those directly involved with process/procedure 95% - Add decision aids (i.e., stronger interventions like checklists or computer reminders) - Advanced failure prevention and failure identification and mitigation strategies 99.5% or better Process failures closely monitored Targeted interventions designed and tested Performance regularly reviewed and feedback provided Reaching 95% or better process reliability (Dlugacz and Spath, 2011) -Agree on a measure(s) for assessing reliability -Measure how often accuracy is achieved according to the agreed-upon measure, thereby establishing a baseline against which to compare results -Establish reliability goals for the measure -Make stepwise improvements and measure success along the way

Brainstorming

Brainstorming: -Interactive decision-making to generate ideas; structured, unstructured, silent In silent brainstorming: -Have participants write ideas individually on sticky back notes or small slips of paper -Everybody's individual ideas are captured (adv) -Collects the papers and post them for all to see In Structural brainstorming: -Solicit one idea from each person in sequence -Participants who don't have an idea at the moment may say pass In Unstructured brainstorming: -Participants simply contribute ideas as they come to mind -The advantage of free form brainstorming is that the participants can build each other's ideas. The atmosphere is very relaxed

When to use?

Mess finding: check sheet and pareto diagram Fact finding: flowchart, histogram, and control chart Problem finding: cause-and-effect diagram and scatter diagram

Prevention

Mistake-proofing: Improving processes to prevent mistakes or making mistakes obvious at a glance (a.k.a. error-proofing) Safeguards: Controls incorporated into a process to identify and correct errors before harm occurs to a resident/patient

Which of the following is the structured form of multi-voting, usually with five steps and a rank voting process to prioritize quality improvement initiatives?

Nominal group technique

Nominal group technique

Nominal group technique •Structured form of multi-voting with five steps • rank voting after discussion

Decision Matrix

Prioritization matrix •Large number of factors and assessing each factor's relative importance Weight the different factors based on selection criteria •Not every solution is equal; different criteria matter depending on various factors of interest Making meetings more valuable •Exhibit 6.5 (page 151) •Keep in mind that a decision matrix is not the only decision-making tool available. For example, sometimes, a simple pros-and-cons list works. However, a decision matrix can shed light on the best choice for a decision in which there are multiple options and diverse features to consider. Tip: Consider using a decision matrix when there are several factors vying for your attention. It can help you to establish priorities and rank your criteria to arrive at the best possible decision

Qualitative Data Quantitative Data

Qualitative Data: analytic improvement tools used foor generating ideas, setting priorities, maintaining direction, determining problem causes, and clarifying processes Quantitative Data: Analytic improvement tools used for measuing performance, collecting and displaying data, and monitoring performance. Decision matrix is quantitative. •Bar graphs/charts, line graphs, histograms, scatter diagrams, check sheets, control charts •These should all sound familiar... •What you're interested in measuring (and whether or not you're factoring in time) helps guide which tool to use •Surveys •Likert scale questions •Pre- and post-test knowledge/skills/abilities

If an individual wanted to visually represent a process/procedure to show problem areas, redundancy, and unnecessary steps, he/she might use which of the following tools? a. flowchart/swimlane diagram b. fishbone diagram c. control chart d. Pareto chart

a. flowchart/swimlane tools

Discharge planning

•Discharge planning - what is the value? •Evaluation of patients'/residents' medical/psychosocial needs for the purpose of determining the type of care they will need after discharge from a certain health care facility •Avoiding fragmented and haphazard care during transitions •Bad discharge planning = increased costs; poor quality of care •Role of case managers •Primarily nurses and/or social workers •Some do URs as well as discharge planning •See Exhibit 10.7 (page 267) •Re-hospitalizations

How Utilization Management Can Reduce Denials

•For example, after a primary care physician informs a patient that their diagnosis requires surgery (as well as referral to a surgeon), a patient contacts her employer's insurance provider. The insurance provider contacts the surgeon to discuss the following options: •In discussing inpatient versus outpatient surgery, they see that inpatient procedures have fewer complications, so they opt for that. •They determine that pre-surgical tests can be performed on an outpatient basis. •Based on those conclusions, they settle on the anticipated post-surgery recovery time and scheduled release date. •Having these conversations in advance

Forcefield analysis Stakeholder analysis

•Force field analysis (Lewin) -Driving and restraining forces (pros and cons) -A technique for identifying and visualizing the relationship between significant forces that influences a problem or goal. *example: the hospital hosts quarterly focus group discussions with parents of former pediatric patients to solicit ideas for improving satisfaction. •Stakeholder analysis -How do you deal with people/individuals resistant to change? -Allies, associates, enemies, opponents -A tool used to identify groups and individuals who will be affected by a process change and whose participation and support are curcial to realizing successful outcomes. The team considers the following issues: benefits to the stakeholders, benefits to the stakeholder's patients, changes the stakeholder will have to make and activities that might cause conflict for the stakeholder.

Multivoting

•Generate ideas, set priorities, maintain direction, determine causes of problems, clarify processes •Multi-voting -Spread out number of votes; pare down a broad list of ideas to prioritize a few

How Utilization Management Can Improve Care

•Here is another example of how utilization management improves care: •A hospital admits a heart attack patient after they have been stabilized in the ER. The hospital contacts the patient's insurance provider and they discuss the options for treatment and the optimal length of stay. The insurance provider checks in for progress reports regularly. The doctor says that the original treatment plan is not getting the expected results, so they change to a different treatment that has shown promise in similar patients.

Medically necessarry services

•Highmark Blue Cross/Blue Shield (BCBS) •Coverage decisions based on definition of medical necessity of services that providers agree to in the payer-provider contract •Services must: •Be appropriate for symptoms, diagnosis, and treatment of condition/illness/injury; •Be provided for diagnosis, direct care, or treatment; •Be provided in accordance with standards of good medical practice; •Not be delivered primarily for the convenience of the patient/resident or the provider of the patient/resident; and •Constitute most appropriate supply or level of treatment safely provided to the patient/resident

Workflow Diagrams

•Illustration of movement of employees or information during a process •Floor plan diagrams are common

How Utilization Management Can Help Contain Costs

•In addition, the following actions by insurance providers can also contribute to the goal of reducing costs: •Incentives for doctors to prescribe less-costly treatments •Education and feedback for doctors about effective care standards and practices •Gatekeeping to manage patient referrals away from expensive services and specialists •Patient education •Design benefits to reward patients and healthcare providers that opt for less expensive treatments •Contracts with providers that have proven records of cost containment

Surveys

•Objectives: purpose/intent of survey (gather data/information) •People and sample •Population vs. sample •Survey construction •Questionnaires vs. interviews •Response scales •Dichotomous, interval/Likert, frequency •Test (pre-test with volunteers) •Administer •Response rates (%) *Mail: 50%= adequate, 60-70%=good to very good *Phone: 80%=good *Email: 40%=average, 50-60=good to very good *Online: 30%=average *Face-to-face: 80-85%=good

Benefits of Utilization Management

•Patients: Get lower costs, more effective treatments, and fewer claim denials. •Healthcare Providers: Get fewer claim denials, lower costs, more effective treatments, better data, and better resource deployment. •Insurers: Get lower costs, better data, and the evaluation of the effectiveness of new treatments and protocols.

Success or failure

•Process or system •Underpinning of operation •Think through what you are trying to achieve and the tool(s) to best accomplish that •Management or communication •Are we using systems and tools effectively? •Too many? •Too complicated? •Right people/right time or not?

Utilizatioin improvement

•Reduce cost of care, but also for other purposes •Quality improvement parallels •Job aids •Reminders •Short forms, stickers; remind providers to do a certain task •Clinical paths •Descriptions of best practices for managing care delivered to patients/residents •Remind caregivers of intervention and milestones expected during an episode (routine episode) of care •Standards of care •Protocols (formal outlines of care; treatment plans)

Flowcharts

•Shows problem areas, redundancy, and unnecessary loops •Compares actual versus ideal process flow •Allows a team to reach agreement on process steps •Identify components and order of systems example: patient admit flowchart *Patient enters *Admit patient *Patient care