Performance Improvement Fundamentals: Post-Acute Settings

Transcription

1 The Joint Commission Continuous Customer Engagement Targeted Topics Performance Improvement Fundamentals: Post-Acute Settings July 27, 2022

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7 The learning objectives for this session are: 1. Describe performance improvement based on Joint Commission's Performance Improvement (PI) Chapter 2. Describe concepts learned about fundamental performance improvement principals and methodologies within post-acute settings and 3. Identify at least one new practice applicable to performance improvement within post-acute settings 7

8 Disclosure Statement These staff and speakers have disclosed that they do not have any conflicts of interest. For example, financial arrangements, affiliations with, or ownership of organizations that provide grants, consultancies, honoraria, travel, or other benefits that would impact the presentation of today s webinar content. Susan Funk, MPH, LSSGB, Associate Project Director, Measurement Coordination and Outreach Brandi Wamhoff, MPH, Associate Project Director, Measurement Coordination Outreach Lisa DiBlasi Moorehead, EdD, MSN, RN, CENP, CPPS, JCPC - Hospital and Psychiatric Hospital Field Director Caroline Christensen, BS. Project Director, Department of Standards and Survey Methods 8

9 Presenter Introductions 9

10 Presenters Lisa DiBlasi Moorehead, EdD, MSN, RN, CENP, CPPS, CJCP Associate Nurse Executive/Field Director Accreditation and Certification Operations Brandi L. Wamhoff, MPH Associate Project Director, Quality Measurement Division of Healthcare Quality Evaluation

11 Agenda i. Performance Improvement (PI) Framework ii. Applying PI Principles iii. Setting Specific Example iv. Tips and Resources

12 Performance Improvement Framework 4

13 Performance Improvement (PI) Definition The systematic process of detecting and analyzing performance problems, designing and developing interventions to address the problems, implementing the interventions, evaluating the results, and sustaining improvement. 5

14 Performance Improvement (PI) Principles Improving quality & safety of care, treatment & services Steps to Achieve Improvement 1. Data Collection; based on setting, scope, and services 2. Developing Plan 3. Analyzing Data 4. Taking Action 6

15 PI Resources - Data Collection The Joint Commission Connect Site: Joint Commission Survey Reports National Patient Safety Goals DASH Accelerate PI Dashboard DASH SAFER Dashboard Heads Up Report 7

16 PI Resources - Planning PI methodologies: Plan Do Check Act (PDCA) also known as Plan Do Study Act (PDSA) Lean Six Sigma Define Measure Analyze Improve Control (DMAIC) Robust Process Improvement (RPI ) IHI Model for Improvement Quality Assurance and Performance Improvement (QAPI) 8

17 PI Resources - Analyzing Data Joint Commission Targeted Solutions Tool Joint Commission (DASH Accelerate PI ) Quality Measurement Trends and Benchmarks Report Centers for Medicare & Medicaid Services (CMS Compare websites) Clinical Data Registries Organizational tools, such as Excel, to create control charts and run charts 9

18 PI Resources - Taking Action and Improving Check for evidence-based literature for successful improvement practices and strategies Use available resources, such as R3 Documents: Link to R3 documents The Joint Commission Continuous Customer Engagement (CCE) Webinars: link to CCE Webinars DASH Accelerate PI QI Resources are embedded in the dashboard for each quality measure: link to DASH resources 10

19 Applying PI Principles Source: The Joint Commission (2018). Fundamentals of Healthcare Improvement, 3 rd Edition.

20 Applying PI Principles Model for Improvement 1. What are we trying to accomplish 2. How will we know that we ve improved 3. What change/s can we make Brainstorm ideas Use PDSA cycle for small test of change 12

21 Applying PI Principles - P D S A 13

22 Applying PI Principles - P D S A 14

23 Applying PI Principles - P D S A 15

24 Applying PI Principles Using Accelerate PI as an example. 16

25 Accelerate PI

26 Accelerate PI

27 Another reason to choose falls.

28 Accelerate PI example

29 Applying PI Principles Brainstorm ideas likely to result in improvement Evidence/research-based practices Use AHRQ resources part of Accelerate PI 21

30 Applying PI Principles Plan Zero harm patient falls Incremental goal: Fall rate 3.4/national average within 12 months Implement AHRQ Falls Cue Sheet evaluating medications, at risk behaviors for 60 days on the 3B unit 22

31 Applying PI Principles Do Implementation of small test of change Set up process for frequent touchpoints during the test to evaluate any course corrections needed during test 23

32 Applying PI Principles Study Collect data on what worked well and what did not Nursing completing the assessment but found at risk behavior assessment often incomplete and missing key details Evaluate impact on falls rate compared to others not included in the small test of change 24

33 Applying PI Principles Act PT/OT to evaluate at risk behaviors Objective to continue to decrease falls rate Test Get Up and go Test: Transfer Test: Wheelchair Screen: Description Ask the resident to sit in a standard armchair, rise, walk 10 feet, turn, walk back to the chair and sit down. The resident should wear his/her normal footwear and use his/her customary walking aid. Look for unsteadiness, difficulty rising or lowering, and any gait problems. Determine level of staff assistance required for safety. Ask the resident to transfer in and out of the bed, on and off the toilet, and in and out of the lounge chair. Determine if the resident is safe: if the height of the bed, toilet, or lounge chair needs adjustment; if existing handrails need adjustment; and if the resident's assistive device needs further evaluation. For all residents who use a wheelchair or sit in a wheelchair for reasons other than transport only, collect the following measurements and assess the resident's position while seated. Based on your evaluation, determine if the resident is unsafe while seated in the wheelchair. 25

34 Applying PI Principles Plan PT/OT to evaluate at risk behaviors that will be more sensitive to determine falls risk behaviors Will re-evaluate in 30 days Do Study Act 26

35 Applying PI Principles PDSA Not always straightforward Plan for barriers 27

36 Setting Specific Examples

37 Setting Specific Example Hospice agency (Y) regularly reviews EHR data collected around HIS scores (comprehensive pain assessment) To make it easier to review the data and identify trends, they create a simple bar chart

38 Setting Specific Example Data informs them that their scores for comprehensive pain assessment began declining in 2016 compared with the national average They document a plan to make improvements using PDSA cycles

39 Setting Specific Example To better understand WHY the scores were declining, they gather the team to determine possible causes. A review of the clinical documentation reveals it frequently lacked duration, frequency, and/or aggravating factors Although pain screening was completed % of the time, it was missing key elements

40 Setting Specific Example The team has conversations with the nurses about barrier to full pain assessment and complete charting Leadership buy-in is gained and a plan is developed to modify the EHR to promote easier documentation of a comprehensive pain assessment

41 Setting Specific Example After implementing changes to the EHR, they review the data again Scores increase from 65.4% to 72.0% but they haven t met their goal

42 Setting Specific Examples They investigate WHY the EHR modifications are not as effective as they hoped and find RN workarounds to avoid the EHR changes Resistance to change Alarm fatigue with new changes RNs not sold on the need for change They implement additional solutions Increase RN engagement and understanding of the why Mandatory RN pain management education Promoted the Hospice Compare website Updated the EHR to decrease visual-only prompts

43 Setting Specific Examples A final review of the data reveals the results that they were targeting Scores increase from 72.0% to 77.9% to 89.6%

44 Key Takeaways Regular review of the data to monitor performance Data was presented in an easy-to-read format Improvement plan was developed and documented using Plan Do Study Act method Key team members were involved (nurses and leadership) The plan had to be modified and multiple solutions were implemented It s not always a quick fix- don t get discouraged!

45 Tips and Resources

46 Tips for Staff Engagement Ensure the right people are on the team Create a shared goal Clarify the impact of the change for staff based on their role Give real responsibility so that team members are invested in the project Actively listen to all team members and encourage participation Manage skepticism and passivity

47 Engaging Staff and Leadership Resources Agency for Healthcare Research and Quality The Role of Leadership in Improvement Efforts podcast and transcript What are 7 ways to engage clinicians in QI? WIHI: Making the work of QI Less Draining and More Sustaining

48 Joint Commission PI Chapter Revisions Link to the Joint Commission Performance Improvement Chapter Revisions Webinar (Jan 2022) 40

49 Why Use Performance Improvement? Successful efforts have demonstrated that planning is essential to achieving and sustaining improved performance. Plans that include desired goals and identify which data to collect along with timelines for measurement and improvement activities tend to both achieve and sustain change (Chen et.al 2019; McLees et. al., 2015; Nakhleh et al, 2015). 41

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57 Joint Commission Continuous Customer Engagement Targeted Topics Webinar Performance Improvement Fundamentals: Post-Acute Settings July 27, :00:06,810 --> 00:00:07,730 Welcome everyone, and thank you for joining us today for our Joint Commission Continuous Customer Engagement Webinar, Performance Improvement Fundamentals for Post-Acute Care Settings. 00:00:20,490 --> 00:00:23,910 Before we start, just a few comments about today's webinar platform. Audio is by Voice Over Internet Protocol Only. Use your computer speakers or your headphones to listen. There are no dial-in lines. If you hear background music, you have more than one window open close the "test" window, and the music will stop. If you currently cannot hear audio, click the "play" triangle icon in the upper left pane to launch audio. Feedback or dropped audio are common for live streaming events. Refresh your screen or rejoin the event if this occurs. 00:00:56,010 --> 00:01:00,900 The slides are available now in the Event Resources Pane. Select the link to download or print the PDF of the slides. 00:01:08,800 --> 00:01:12,430 The "Ask a Question" Pane permits participants to ask questions. If possible, please reference the slide number or presenter to whom your question should be addressed. Please visit links or resources noted in the slides. Please also share the session recording and slides with your interested colleagues. The recording and slides will be available via the same link used to join the live session two hours after the session concludes. 00:01:35,980 --> 00:01:36,900 CE credits are offered for this webinar. This webinar is approved for one Continuing Education credit for the entities listed on this slide. The Accreditation Council for Continuing Medical Education, American Nurses Credentialing Center and International Association for Continuing Education and Training. 00:01:57,470 --> 00:02:00,010 Credit is available for the live webinar only. Credits will not be available for webinar replays. To claim credit you must have individually registered for the webinar, participate for the entire live webinar, complete a post program evaluation and attestation. An automated sent to participants tomorrow will provide information on how to access the survey. If you are listening with colleagues and did not use your own link to join, you can still obtain CE credit if you meet these three criteria. If you did not preregister, do so now so you can be eligible when the session concludes. When you complete the online evaluation survey, after you click submit, you will be redirected to a URL from which you can print or download and save a PDF CE certificate. An automated will be sent from the survey platform after you complete the survey, that includes the link to access the PDF certificate. For more

58 information on The Joint Commission, Continuing Education policies, visit the link found at the bottom of this slide. 00:03:08,800 --> 00:03:12,310 The learning objectives for this session are: Describe performance improvement based on Joint Commission's Performance Improvement (PI) Chapter. Describe concepts learned about fundamental performance improvement principles and methodologies within the postacute setting and Identify at least one new practice applicable to performance improvement within post-acute settings. 00:03:36,170 --> 00:03:39,160 These staff and speakers have disclosed that they do not have any conflicts of interest. For example, financial arrangements, affiliations with, or ownership of organizations that provide grants, consultancies, honoraria, travel or other benefits that would impact the presentation of today's webinar content. Susan Funk, Brandi Wamhoff, Lisa DiBlasi Moorehead and Caroline Christensen. I will now turn it over to Brandi, and Lisa to begin your presentations. Brandi, please take it away. 00:04:12,380 --> 00:04:13,080 Thanks Susan. Hi everyone. Thanks for joining us today, for this Continuous Customer Engagement Performance Improvement Fundamentals webinar for Post-Acute settings. Today, we're going to be talking about Performance Improvement as a systematic approach to detecting and analyzing performance problems, and also implementing solutions. Today's presentation will be delivered by Lisa DiBlasi Moorehead and myself Brandi Wamhoff. Lisa's a Field Director in the Division of Accreditation and Certification Operations at The Joint Commission, and I'm an Associate Project Director in the Division of Healthcare Quality Evaluation. 00:04:53,290 --> 00:04:56,940 During today's call, Lisa and I will provide an overview of the Performance Improvement framework, discuss applying Performance Improvement Principles, share Setting Specific Examples, and Provide Tips and Resources to assist your organization with taking the next step forward in your continuous journey of Quality Improvement to provide consistent high quality care for patients. 00:05:15,300 --> 00:05:19,330 Let's begin with the Performance Improvement framework. The following slides are in alignment with The Joint Commission Standard Performance Improvement chapter. A more detailed webinar is available on our website and we've provided the link to this later in the presentation. 00:05:32,740 --> 00:05:37,330 The Joint Commission definition contained within our manual glossary, defines Performance Improvement as a systematic process of detecting and analyzing performance problems, designing and developing interventions to address the problems, implementing the interventions, evaluating the results and sustaining improvement. 2

59 00:05:56,730 --> 00:06:00,570 Using that definition as the framework for the PI process, we further delineate the actions required to successfully implement the Performance Improvement process within our accreditation requirements. Data Collection. This really starts with determining what data needs to be collected, and you want to take into account setting, scope, and services that are provided when choosing the best available data for your improvement. Based upon the results of that data, you will determine the Performance Improvement activities that your organization will focus on, which then becomes your Performance Improvement plan. In order to transform raw data into useful information, the organization should analyze data over time using statistical tools and techniques. And finally, an organization will act upon the Analyzed Data using tools or methodologies to improve or sustain performance. 00:06:54,860 --> 00:06:58,560 An organization may collect data from many areas, including internal and external sources. The Joint Commission has identified important areas that should be measured regularly. Resources available within an organization's secure Joint Commission Connect Site include Survey Reports, National Patient Safety Goals, DASH which stands for Data Analytics for Safe Healthcare, Accelerate PI Dashboards and DASH SAFER Dashboards as well as, Heads Up Reports. I want to take a moment to also note how utilizing these resources can also help organizations demonstrate compliance with standards and Elements of Performance. So for example, Standard PI , the organization collects data to monitor its performance. If we use Nursing Care Centers as an example, Element of Performance 33, specifies the organization collects data on psychotropic medication use, including the use of antipsychotics. The quality measures within the Accelerate PI Dashboard for Nursing Care Centers include long stay and short stay measure data for residents that receive antipsychotic medication. This data is already presented to the organization in an easy to read format that allows the organization to compare its performance: the national rate, state rate, as well as the accredited cohort. Therefore, an organization could regularly examine the data in their Accelerate PI report to potentially demonstrate that they are meeting this Element of Performance. 00:08:34,660 --> 00:08:37,740 Planning is also essential to achieving and sustaining improved Performance. Tested improvement tools and methods can be the difference between a lasting change versus a quick fix, that's just as easily forgotten. It should also be noted that although The Joint Commission does not require a specific method, the healthcare organization does need to use one. Examples of common Performance Improvement methodologies include: Plan Do Check Act, Plan Do Study Act, Lean Six Sigma, DMAIC, Robust Process Improvement, and The Institute for Healthcare Improvement Model for Improvement. Once again, I want to point out that the use of any of these methodologies is a potential way to help organizations demonstrate compliance. With PI , that specific standard, Element of Performance three, the organization uses Improvement tools or methodologies to improve its performance. 3

60 00:09:34,960 --> 00:09:39,570 Once the data are collected, they should be analyzed using statistical tools and techniques. Analysis of data allows the organization to identify patterns and trends and monitor its performance. The organization may also have access to external data that allow it to compare its performance with other organizations on a specific topic. Before I share some of the tools listed, I'd like to highlight that compiling and analyzing data is a potential way to help meet the intent of several Elements of Performance that fall under standard PI Including the Element of Performance four, the organization analyzes and compares internal data over time to identify levels of performance, patterns, trends, and variations. So onto the tools, The Joint Commission Targeted Solutions Tool, or TST, is an online application that guides healthcare organizations through a step-by-step process to accurately measure their organization's true performance level, identify the causes of performance failures and direct them to proven solutions that are customized to address their particular causes. DASH Accelerate PI Dashboards, which I've mentioned, and Quality Measurement Trends and Benchmarks Reports are located within an organization's secure Joint Commission Connect site. The reports show the organization's performance on a select subset of quality measures when compared to national, state, and Joint Commissionaccredited averages. There is also CMS Compare and there are many clinical data registries available. Organizations can even use Excel to create control and run charts. 00:11:17,400 --> 00:11:20,460 Taking action is the next step to implement improvements. The organization should check the evidence base for literature that will help identify successful improvement practices and strategies. Examples of resources are listed on the slide and note that each has embedded links to access more information. The resources listed include the R3 documents, which provide a brief summary of the rationale and references for new Joint Commission requirements. The Continuous Customer Engagement webinar recordings, as well as QI Resources that are embedded in the Dashboards for each measure. 00:11:56,090 --> 00:11:59,910 At this time, I'd like to turn things over to my colleague, Lisa, to provide more details on applying Performance Improvement principles. Lisa, go ahead. 00:12:06,080 --> 00:12:07,030 Thank you, Brandi. And thank you everyone for joining us today. As Brandi mentioned, I will be going over some information around applying PI Principles and we are using a source document that we've listed here on the slide. It is a document that we publish at The Joint Commission, but there are many, many other resources available to you books for sure about Applying PI Principles, Principles of Performance Improvement, but we did want to provide you with one, in case you wanted to, do some additional research and study on your own. 00:12:48,590 --> 00:12:56,370 The one model that we have chosen to, to use as our example today is a model that includes three questions followed by the Implementation of Change for Improvement using the Plan 4

61 Do Study Act approach. So these first three questions are: One, what are we trying to accomplish? What do we want to improve? What is the problem at hand that we're trying to solve? The second question then would be, how will we know that we've improved? So here would be the comparison of data that Brandi mentioned, where you can compare your performance in a particular indicator with others within the state, national, or accredited organizations to determine what you need to improve, but also benchmarks for, stretch goals. The third question would be: What changes can be made? And this is where you have the key stakeholders involved to brainstorm ideas about what could lead you in the direction that, that you want to go in making the improvement. And so brainstorming ideas could be based on leading practices. Also based on research and other literature that you may have available to you. Included in those brainstorming sessions would need to be those end users of the process, as well as stakeholders and other leaders who would be involved in the process. And then, once you have the ideas together, you decide on where you want to start with those improvement ideas. You begin the PDSA cycle for Small Test of Change. So we selected this particular model because it is used and set up for those small tests so that you can implement one particular intervention that is supported in the literature. You can evaluate that intervention to see if it's going to get you the outcome that you desire and then make course corrections based on the outcome of this one small test or implementation. And this particular model builds on each small step that's taken to lead you to a greater change in the end. 00:15:23,750 --> 00:15:28,170 We thought it would be helpful to go over the PDSA model in a little more detail. The first thing that stands out to me in this model that you'll notice is the arrows on the outside. And these arrows are indicative of this being a continuous process. So the Act, that last or the fourth step, really informs the next Plan phase in this model. So the Plan phase is generally thought of as a define phase. So you have your objectives for the test, you make predictions or your hypothesis of what you think the result is going to be, and then you have the Who, What, When, Where of the implementation. The Do phase is, the do or the carrying out or the implementation of the test. So you start the change, you start implementing the change, and you document what occurs and what observations you have. You begin an initial analysis of the data because in my experience, and then probably in yours, I never think of everything. And as you begin your implementation for change, you may realize that 'darn it, you know, we, we forgot about this,' or, you know, 'we needed to include this in the education' or 'the form is missing this.' So in my experience, I've always forgotten something. And within that Do phase, you begin your analysis of what's working well, what's not, and any course corrections that you might need to take. The Study step is, when you have concluded your testing phase, you begin to analyze the data and you compare those outcomes to the prediction. Did you get the outcome that you expected? What was learned, what worked well, what didn't work well and what changes or 5

62 modifications need to be made before that fourth stage, the Act stage where you actually put your change in place. And then that Act stage informs your next stage in the process. What will the objective be for the next cycle? What will you implement next within this small test of change and the cycle begins again. 00:17:50,900 --> 00:17:57,670 The next slide that we have for you illustrates this building upon Small Test of Change, to the next Small Test of Change, to the next Small Test of Change. So that over time, the complexity of the change, increases because you're adding to each step you're adding intervention upon intervention. And you might notice also that, as those circles begin to roll uphill there, the, the stages may alter a little bit too, you know, as we mentioned with the Act phase, informing the Plan phase, and, and so forth. 00:18:38,820 --> 00:18:44,920 The next slide, is probably a more realistic depiction of what happens during the PDSA cycles. And whenever we are making change within our organizations. This slide is very neat and organized. And if only that was what we would experience when making change. This is a little more realistic, I think, in what to expect. A couple of points that I wanted to make about this slide. You see that there's a dark line snaking through the diagram there. A little different than the Improvement line and that dark line going just straight up, you know, in this particular slide, but in this slide, it's a little, you know, it's, well, it's not straight. It s still depicting Improvement over time and an increase in complexity of the change as you add one Small Test of improvement upon the other. But I think what is important about this particular slide, it illustrates how there could be stops and starts within the process. There could be barriers that you might not have anticipated. You may need to, start the Planning phase all over again because the implementation was not working as you had expected it to. So I-we thought this particular slide might be a little more realistic in what you can expect as you begin an improvement process. 00:20:27,920 --> 00:20:32,260 Now, we wanted to actually go through an example using some of the resources that Brandi highlighted for you. In particular, we'd like to use an example from the DASH Accelerated PI Dashboard. We'll still use this model that we mentioned with the three questions. What is it that you're trying to accomplish? How will you know that a change, is an improvement? And then what change can we make to result in improvement? So we'll keep those three questions in mind, followed by the PDSA cycle. 00:21:06,500 --> 00:21:11,640 So at your extranet site, your Joint Commission Connect site, you have access to the Accelerated PI Dashboards, and I've just captured a screenshot for you here for where you can find the Accelerated PI Dashboards. 6

63 00:21:23,590 --> 00:21:27,930 And then, for this particular example, we'll use the Nursing Care Center Dashboard. And in this particular organization example, when we look to see the Rate of Falls with Injury for this particular reporting period, the organization had a fall rate of 6.0 compared to a fall rate of 2.9 for the other accredited organizations in the database. And 3.4 to 3.4 state and national rate. So answering the question of what is it that we want to improve by looking at the data, this organization would determine that we want to improve our falls rate, and then looking at how will we know we improve that second question. We could use the benchmarking data and information to tell us where we need to get to. Of course we would want zero harm from patient falls, but you can use this benchmarking data to say, well, maybe a, a realistic goal for us would be to have a fall rate according to the state rate or the national rate. Just as an example, and using those first two questions of our model. 00:22:35,630 --> 00:22:43,110 I did want to mention, our Sentinel Event rate for Falls for Certainly another reason for choosing falls. This is not part of the Accelerate PI Dashboard, but I did want to share it here in looking at the increase in sentinel events related to falls from 2020 to So certainly a noble project for your Improvement efforts, for many reasons. 00:23:05,490 --> 00:23:11,190 So back to the Accelerate PI Dashboard, you will also see some comparison data in graph form. And Brandi mentioned the use of graphs, and other statistical components as part of your work in improving performance. So as part of the Accelerated PI Dashboard, you can see the, the line graph at the bottom left that shows the national rate in yellow, and this organization's performance over time. There's been improvement you can see from the graph, but still above national data. The bar chart to the right will show you how many organizations by the number and height of bars to the left of the dotted line are performing better than this particular organization. But I also wanted to mention here, in the red circle, the Accelerated PI Dashboards also provide links to resources that have been supported in the literature as making improvements in these areas. And so we're going to use the example of an AHRQ tool as a tool for implementation using our PDSA model. 00:24:26,870 --> 00:24:30,290 So we've already answered the first two questions about what are we trying to accomplish and how will we know that a change is an improvement. Now we need to brainstorm about what change can we make to result in that improvement. So here is where you have your team together and you brainstorm ideas about what is in the literature. What evidence is present that have indicated do this, and you will have an improvement in your fall rate. So your team could come up with other ideas, such as gate belts, motion sensors, bed alarms, slippers that have the grips on the bottom, falling stars outside of the room, they can brainstorm a whole host of ideas. And part of the work of the team then would be to prioritize where you want to start. And in this particular example, we'll use the AHRQ resource that is a behavioral cue resource to help staff identify those individuals that are at high risk for falls. 7

64 00:25:38,030 --> 00:25:42,570 So in the Plan stage, which is the Define phase of our improvement, we establish the goal, of course, that we want zero harm related to patient falls. An incremental goal however, it could be that the fall rate is 3.4, which is the national rate and the state rate. And we want to get there within 12 months. And the action that we are going to, or the strategy that we're going to implement is that falls cue sheet from AHRQ that will evaluate medications and at risk behaviors. And we're going to evaluate that for 60 days on the 3B unit beginning, August 15th. So we're very specific with the details for the planning of this strategy implementation the next step, or the next phase would be 00:26:28,310 --> 00:26:30,970 The Do phase where we actually implement that Small Test of Change on the 3B unit, where we provide staff with the education and tools to begin the use of the AHRQ behavior cue assessment. It would be important to set up a process for frequent touchpoints during the test to evaluate the progress and make any course corrections that are needed during the test. So these could be daily huddles, it could be weekly meetings. It could be rounding on the unit because you want to hear from staff, how's it going. What challenges are they facing? What's working, what's not working so you can make course corrections. Maybe there's not enough of the tool available. If a staff or several staff, people are asking the same question. Maybe there needs to be some just in time education to answer the question that staff might have. 00:27:26,270 --> 00:27:29,850 The next phase would be the Study phase, where you collect your data, that, and you realize, or you understand what was working well, what didn't work well. And in this particular example, we found that, you know, nurses were doing a really good job of collecting the information around the medication that might put a patient at risk for use, but we're having some difficulty in the evaluation of the risk behavior. And that often the assessment was incomplete or missing key details. So that would be an area for improvement for our next action, and maybe even the next plan for a, another incremental improvement or layer added to the improvement cycle. Also part of the Study phase would be to evaluate the impact of the falls rate compared to others that were not included in the Small Test of Change. So, other nursing units, other than, the 3B unit that we selected, in an example, could be that there, there were no falls on this particular unit. Maybe there were falls on other units. It was the halo effect that was preventing falls on this particular unit, but we don't have enough data information yet to say absolutely that the AHRQ tool is making an impact on the falls rate in a in a one to one type of relationship. 00:28:55,760 --> 00:29:02,470 The next step within this model is the Act or what will actually be implemented. And in this case, a change to the process that could be implemented would be to ask our colleagues from physical therapy and occupational therapy to evaluate those at risk behaviors. That would be one option. Another option could be to have physical therapy, occupational therapy work with the nursing staff in how to really, evaluate and test an individual's response to these behaviors that I've included in this slide, The Get Up and Go Test the Transfer Test, the 8

65 Wheelchair Screen Test, certainly this falls within the area of PT, OT. They're much more comfortable in this area. And in this particular example, having OT, PT do this component of the evaluation, could lead to a more accurate evaluation of high risk behaviors. So this would be the Act that we would implement. And if we wanted to continue that arrow around for the planning and the Do and the Study and the Act we would-we would continue to evaluate the impact that PT, OT performing this component of evaluation would have on the accuracy of risk identification and the continued identification and monitoring of the falls risk rate. It could be that at this particular time, we want to add another strategy. Maybe we want to add the use of a gate belt and have those individuals that were at high risk for falls, have a gate belt readily available in the room to assist with their mobility needs. 00:30:51,990 --> 00:30:57,730 The Plan phase we mentioned with PT, OT evaluating, or-or assisting with the evaluation of those at risk behaviors. We determine in the plan stage that we'll re-evaluate in 30 days in this example. And then, then we have our, our nice straight line iterative process of one PDSA cycle building on the next PDSA cycle. 00:31:18,030 --> 00:31:25,410 And then the next, and then one more slide, to review with you is remember this chart, this diagram. We'd like to think that our improvement efforts follow this pattern, but more than likely, you know, we're going to have some barriers. Our line is not going to be straight, we'll have some, some curves or bumps in the road. And we'd be remiss if we didn't mention the need to plan for barriers in your improvement process. There are going to be folks that don't think it's a good idea. You'll run into barriers, maybe resources, maybe staffing, certainly barriers that you can plan for at the beginning of your Performance Improvement cycle. Ways to consider these barriers would be to identify key stakeholders and leaders and end users that need to be involved in the process, maybe even patients and families, to be involved in your Performance Improvement process. Being able to identify a particular area or unit that would be amenable to testing a change. I know I have been to organizations that have innovation units. Units where new things are tested before they are, taken to other units or implemented broadly within an organization. Many teams and I would certainly recommend this, that part of your improvement efforts would include a communication plan so that you can share with your organizations what is going to be the, the topic of an improvement project, what the measures are, what you hope to achieve. So that folks know what you're working on. That part of the communication plan includes clarity of the project, creating a level of excitement about the improvement project, and also to share and show appreciation for the work that's being done. Another component to help with the implementation in addition to a communication plan would be a Measurement or Evaluation plan. So that, you know, those markers that will let you know that improvements are being made. And once the project concludes to continue to have measurement, to make sure that the improvement is sustainable and we've all heard, the adage of what's measured is improved. And just one comment more about sustainability. When you're thinking of your improvement interventions and your strategies. We know that to have the, to improve or increase the likelihood for sustainment, your 9

66 improvement strategies need to be hardwired, that there needs to be a process change. In this case, with a change in falls risk assessment, certainly having it integrated into any electronic health records that you have, or certainly having the forms available if your assessments are still on paper. Hardwiring changing a process, certainly improves the sustainability of the improvements more so than, read and sign education or training, which is important and needed, but certainly not the, the only strategy to be put in place to make sure that your improvement sticks. 00:35:08,210 --> 00:35:13,510 So Brandi, I am happy to turn, the presentation back over to you to finish this up. 00:35:16,610 --> 00:35:18,390 Sounds great. Thank you so much, Lisa. At this time, let's walk through another example of Performance Improvement in action to further demonstrate the concepts that we've covered. Sorry, everyone. 00:35:44,370 --> 00:35:49,120 So let's go ahead and start with a sample hospice agency. Hospice agency Y regularly reviews data collected around Hospice Item Set Scores, specifically Comprehensive Pain Assessment. The organization presents the data in an easy to read format, using a simple bar chart with an indicator of the National Average. Looking over that data, they're able to identify that their pain assessment scores began declining in 2016 compared with the National Average. And so they document a plan to make improvements using the PDSA method. 00:36:32,560 --> 00:36:35,890 They first need to get a better understanding of why the score is declined. So they gather the team to determine possible causes while conducting some case reviews. They discover that the clinical documentation frequently lacked duration, frequency, and/or aggravating factors. And although pain screening was being completed about 99% of the time, it was missing these key elements. 00:37:02,370 --> 00:37:04,580 In order to fully understand the problem, the team talks with nurses about barriers to full pain assessment and complete charting. Before moving forward, leadership buy-in is gained and they develop a plan to modify the EHR to promote easier documentation of a comprehensive pain assessment. 00:37:26,940 --> 00:37:31,630 They then implement the changes to the EHR and allow time before reviewing the data. Again, the data suggests that the changes to the EHR help them to increase their score about 7%, but they haven't met their goal of meeting or exceeding the National Average. 00:37:51,680 --> 00:37:55,020 So going back to the drawing table, they investigate why the EHR modifications haven't yielded the results that they hoped for. They find that staff are not sold on the new change, and there is resistance. And therefore the nurses have found workarounds to avoid the changes. The staff note alarm fatigue with all of the new changes that they have to keep up 10

67 with. And I'm sure some of our folks on this call can identify with that. Given this feedback, they implement additional solutions starting with increasing staff Engagement and understanding of the WHY behind these changes. They promote the Hospice Compare website during staff meetings and assign mandatory pain management education to staff and modify the EHR to decrease visual only prompts. After implementing the additional solutions They checked to make sure that those changes did yield an improvement, and a final review of the data tells them that they have achieved the results that they were targeting. Scores have gradually increased to above the National Average. 00:39:02,330 --> 00:39:06,030 So what are some of the key takeaways from this example? Staff regularly looked at their scores to monitor their performance and the data was presented in a way that everyone was able to understand the team, documented their plan and set a target using the Plan Do Study Act method so that they would know if a change actually led to an improvement. Leadership was brought in to support the project. And key staff were involved to elicit feedback. Last, but not least, there were multiple solutions that were implemented and they conducted two PDSA cycles before achieving the results that they set out for. So kind of going back to Lisa's portion of the presentation, where you saw those little circles, you know, kind of in and out in a, not necessarily a linear method, that's somewhat of, of what she was referencing that you may need to go back to, to your starting point, or have multiple cycles of the PDSA or your methodology before you achieve the results that you set out for. And that's actually okay and is expected. 00:40:10,680 --> 00:40:13,120 For the final part of today's presentation. We wanted to share some additional tips and resources with you all. 00:40:19,150 --> 00:40:22,090 One of the questions that we often receive around Performance Improvement is, "How do we engage staff and leadership?" As you know, change isn't always easy. And so you want to do your best to make sure change is as easy as possible for all involved. You can do that by making sure that you involve the right people on the team, create a shared goal and individualize the impact of the change based on the role of staff. Another tip is to assign each team member some responsibility so that they have a voice and are equally invested in the success of the project. Lastly, actively listen to what the team is saying and manage skepticism and passivity so that it doesn't have a negative impact on the attitude of the additional team members. And I know that's much easier said than done but we do have some actual resources for you available here. 11

68 00:41:15,710 --> 00:41:19,450 So on this slide, we've included links to some resources offering tips on staff and leadership engagement. Specifically the AHRQ podcast speaks to suggestions to enhance leadership involvement. And I won't dive into these in more detail today, but I encourage everyone to download the slides and then review these resources when time permits. 00:41:42,040 --> 00:41:45,380 And finally above we made reference to The Joint Commission Performance Improvement Chapter Revision Webinar. So we've also provided the link to the recording, and materials here. 00:41:57,160 --> 00:42:01,140 So in closing, it's important to create a shared goal and understanding of why behind change. And so I like to close with this message that highlights that exact point. Planning that includes specific goals, data elements, to be collected and timelines for measurement and improvement activities contribute not only to achieving change, but also sustaining that change. 00:42:23,570 --> 00:42:24,190 And that's it. Thank you so much, everyone. 00:42:27,990 --> 00:42:28,340 Great. Thank you so much, Brandi, and, Lisa for those great presentations and also for the really specific, Post-Acute setting specific examples. Those were, those were great. I think they, they bring a lot to understanding how the methodology comes to life so to speak. 00:42:45,480 --> 00:42:49,660 Just as a quick reminder, we're going to go into our question and answer segment now. To ask a question, please type your question in the "Ask a Question" pane and include the slide reference number. And if you know which individual you would like to ask a question to, you can also add that. We will answer as many questions as possible in the remaining time, and all questions submitted will be addressed in a follow up Q&A document. And Brandi, Susan, and, Lisa, I will turn it over to the, the three of you and Caroline, I know you'll, also pipe in as needed, to moderate and, and get through the questions and answers that we've received so far. 00:43:29,540 --> 00:43:30,290 Thank you, Susan. This is Susan Yendro and I'm going to be monitor, moderating, the Q&A. 00:43:36,630 --> 00:43:44,480 So our first question is, Is DMAIC a form of the Lean Six Sigma?" And, Lisa or, Caroline, would you like to answer that one? Well, well, this is Lisa. You know, we, we use DMAIC, quite a bit at The Joint Commission. And we've included that in our Robust Process Improvement. It's what we, what we identified as when generally when folks think about, Lean Six Sigma it's, eliminating waste within a 12

69 system, and certainly DMAIC can be part of that process, to identify and eliminate waste. That would be how I would answer that particular question, but others feel free to, to add. This is Susan Funk, just, just on a more basic level, for those that aren't familiar with, what DMAIC stands for, DMAIC stands and it's just another improvement methodology it's Defined, Measure, Analyze, Improve and Control. So it's, rather than Plan Do Study Act it just takes improvement through a different kind of an improvement cycle. 00:44:59,480 --> 00:45:01,430 Great, thank you both for those answers. 00:45:02,850 --> 00:45:08,190 And another question that we received is, and I'll direct this to Lisa. In your, experience in working with organizations, this particular organization says they have a challenge, in that they face in using a method like PDSA, but also using a DHA A3 display, which is an eight step problem solving process that they've been directed at their organization to use. So, just any, tips for the-for them as the PI coordinator and how they can, provide guidance to cover both of these without confusing staff? Well, that's a good question. Because sometimes I think these models can be a little daunting, when folks just want to improve a process, I think anything that you could do, and before I, before I go on you just organizations can choose a variety of models, to work with in order to have that as their approach to improving Performance. So I think anything that you could do to simplify the definitions for those steps, to provide examples, of, of what those steps could mean in a very simple improvement process as an educational point for how this model can be used, those might be strategies that, that would be beneficial. 00:46:38,120 --> 00:46:38,470 Great. Thank you, Lisa. 00:46:40,500 --> 00:46:41,100 I hope that helps. 00:46:41,280 --> 00:46:43,530 I'm sorry. 00:46:44,780 --> 00:46:46,160 Oh, I just said, I hope that helps. 00:46:47,220 --> 00:46:52,400 Oh, it sounds like it would, please feel free to, to answer follow up questions if you, if you have any, from the audience. 00:46:56,260 --> 00:46:57,120 Okay. 13

70 00:46:57,180 --> 00:47:01,560 We have another question that, speaks to slide 22. It's so neat of a slide. That was the one I think that was showing the, the circles in a linear fashion. "I wonder if strengths and weaknesses can be incorporated considering there is that complexity that covers both challenges and opportunities over time." Thoughts from our experts on the use of strengths and weaknesses being incorporated into the model. Well, you know, I, I don't know about expert, but I can jump in, you know, with this question, in a response there, because I think absolutely strengths and weaknesses should be included. As you start any particular project, and even as the project's ongoing. So when you're getting your team together and you're identifying the task at hand, looking at barriers and certainly weaknesses, within systems within individuals should be included in that risk mitigation plan, that risk for failure. Conversely the strengths that you have can also assist you in determining what, what particular unit to test, what particular staff or leaders that you want involved in a test. So absolutely strengths and weaknesses should be incorporated into your Performance Improvement. So that's a, you know, a great comment and a comment that would be helpful for all of us to remember is considering organization and individual strengths and weaknesses as part of the process. Absolutely. And then Lisa, this is Brandi. Oh, sorry. I was just going to add to what Lisa said, and that, the SWOT analysis or the, uh, Strengths, Weaknesses, Opportunities and Threats, Quality Improvement tool, can be a great tool to help you, evaluate, those areas as well. And it can be done, before you start a project during the project and also after the project. So, yeah. 00:49:09,920 --> 00:49:10,360 Thank you. Great. Great point, in that there certainly are many tools, that are available to organizations as they move through whichever model it is. There are many tools to help you move through either answering those questions or moving through your Plan Do Study Act, pulling in a variety of tools across models is, certainly a good use of your, time and efforts. So thank you for those responses. 00:49:41,690 --> 00:49:47,630 Brandi, this question is for you, to clarify, "Is Accelerate PI resource something a system has to pay extra for?" That's a great question. And one that we have gotten often. So, there are a couple of, of different, tools available under the data analytics for safe healthcare suite, Accelerate PI Dashboards does not impart in additional cost to organizations. It is available, as a benefit, to those organizations that have received accreditation. And it's available within your Joint Commission Connect site. Now the caveat to that is that, we are talking about our Post-Acute settings today. So I'll specify that. That data does come directly from the centers for Medicaid and Medicare and 14

71 as publicly available data, which is why it allows us to provide that feedback to organizations without imparting an additional cost. 00:50:51,230 --> 00:50:51,580 Great. Thank you, Brandi. 00:50:54,040 --> 00:50:58,420 Here's a question, Lisa, I'm thinking you, you might have some thoughts on this one, with your work in particular the nursing workforce, but this question says, "How would you create a shared goal among a high turnover area, such as, maybe a unit that uses a lot of travel nurses? Any thoughts on that?" Well, you know, I always have thoughts and what, came to mind as you were reading that question. I thought of having the display boards or bulletin boards that would, would depict your, the goal, your progress to goal data. I've seen, you know, some folks have the, how many days since the last fall, and you can change that number and add to that number every day. In any communication that you have to staff, including travelers or agency staff, you know, including progress report on improvements for your unit is one also including it in any orientation or onboarding information, what the, the targeted improvements are for a particular unit or department or division you can incorporate, you know, those as well. So those would be some strategies that, that I have tried before. I know it's challenging with the current workforce and the temporary, agency staff that we have, but those are ideas that come to mind, you know, having it posted, included in regular rounding and information in your communication strategies that you use, for your staff. This is Caroline. I would add to that Lisa, in saying that, you know, travelers, frequently are, they're coming from other organizations and any encouragement that can, you can give to them to share strategies they've learned in other settings. And other organizations they've worked in, that is also another way to engage them in the activities of, of that, of your organization. 00:53:10,700 --> 00:53:14,310 Caroline, that's a great addition to involve them. That's perfect. Great. Thank you for that. 00:53:19,790 --> 00:53:21,850 Here's another question, "Is a Root Cause Analysis required yearly?" I can take that one. This is Caroline again, Root Cause, our standards don't have a requirement that says that there's a specific timing for when root cause analysis should be used or should be conducted. It should be based on data, what you're seeing in your data and what kind of problems or concerns your organization is having. It's just knowing, conducting one when it's 15

72 required and when it's necessary to understand a problem and to better look for better solutions. 00:54:10,940 --> 00:54:11,290 Great. Thank you, Caroline. 00:54:13,390 --> 00:54:18,530 Here's another question, on some challenges that, are being faced. So this one says, "Sustaining or controlling a good process is difficult. Staff like to think an initiative is over because we achieved the goal. What are some ideas to sustain or control gains you've made in Performance Improvement?" Well, I can start with that one. This is Lisa. I think, you know when you start your process improvement plan to think about how you will communicate, the progress of the plan, and the improvements going forward, the measurement plan should consider the, the periodic evaluation of the plan once it's considered implemented. You know, using things such as, you know, including in-unit meetings or other communications with staff, good catches or, great ways that this wasn't implemented or how the new change impacted care or staff safety in, in this way. So sharing the good news, of the, the change. But also continuing to monitor it so that staff know that it's still an issue it's still a priority, by what you measure and what you discuss with staff. Also, including it in, in those, those bulletin boards on Performance Improvement and the, the, the continued gains that you're able to realize. Those would be some initial thoughts that, that I would have Susan Yendro, this is Susan Funk. Some other, you know, kind of ways to make it concrete for the employees or to create the standard operating procedures. So make sure it's documented, get it in your policies and procedures. If you've got EHRs, you can hard code elements. So that it's hard to, to slip back to the old way of doing things. Those are just some other examples that are helpful in the control aspect. And then this is Brandi. I was, oh I'm Sorry. I was just going to add one more thing to that. Really great ideas from Lisa and Susan. But also, I have read, about some organizations kind of using their staff, maybe like a champion to help bring about change and sustain it. So kind of, you know, like I was saying giving some staff, a specific responsibility, around an implemented change, so that they can continue to be responsible sort of for keeping that, you know, as a, as a topic that's covered, like, as Lisa mentioned within meetings and, making sure that they're invested in it, and also maybe training new staff on the policy or procedural change. 00:57:16,910 --> 00:57:17,260 Great. Thank you for those thoughts. 16

73 00:57:18,800 --> 00:57:22,220 So, and thank you to the audience for those great questions. We are almost out of time. So your additional questions we will take offline and post those with the slide deck and the recording to our website within a couple of weeks, I will turn it now back over to Susan Funk to close us out for today. Thank you. 00:57:44,250 --> 00:57:44,810 Great. Thanks so much. This was really, really excellent. You know, dialogue that we've all just had. So I, I really, think that there's a lot of value in that. 00:57:52,350 --> 00:57:55,050 Just a few, reminders as we close out. The slides are available in the Event Resources Pane. So don't forget to download those before you close out. 00:58:01,840 --> 00:58:06,150 To access the recording, we've included the link on the slide. If you've downloaded the slides you can find them there. The recording and slides are accessible by the same link you used to join today. So if you would like to share with your colleagues, about two hours after the session concludes the recording will be available. 00:58:24,650 --> 00:58:27,610 To access all of the previous Continuous Customer Engagement webinars. You can visit this section on The Joint Commission website. We've provided the link on this slide. The follow up Q&A document that's been referenced a transcript from this, session and the slides and a link out to the webinar recording will all be available on The Joint Commission website within a couple weeks after this webinar. 00:58:47,450 --> 00:58:51,590 Just a couple thoughts on the CE evaluation and certificate. A survey link will be ed to participants tomorrow. If you qualify for CE credits, you need to complete the survey and provide the that you use to register. At the end of the online evaluation survey, when you click submit, you will be redirected to a URL from which you can print or download and save a PDF CE certificate. You will also receive an automated that includes the link to that CE certificate. 00:59:19,760 --> 00:59:23,280 And finally, thanks to our presenters and thank you to everyone that attended today and have a great day. 17

74 Q&A - Webinar: Joint Commission Continuous Customer Engagement Webinar - Performance Improvement Fundamentals: Post-Acute Settings Live webinar broadcast 7/27/2022 Note: Please refer to the transcript for questions that were answered verbally during the live session. Question I am having a hard time finding fall rates for hospice agencies. Do you have any data on this? Is there a certain way Joint Commision likes the PIP's to be documented in our QAPI programs? Answer Unfortunately, there is not a lot of published data on fall rates for hospice agencies which presents a challenge for benchmarking data. A general suggestion would be to establish a fall rate and benchmark with your own organization quarter over quarter or with peer hospices if the data is available. Organizations with multiple sites have the advantage to benchmark with other programs within the system. Performance Improvement Project (PIP) documentation can be in any form the organization prefers to use. The Joint Commission identifies some specific components that could be included in a PIP per standard PI , EP 1, as follows: The process needing improvement, any stakeholder requirements, project goals and planned improvement activities; Method(s) for measuring performance of the process(es) identified for improvement; Analaysis method(s) for identifying causes of variation and poor performance in the process(es); Methods impemented to address process deficiencies and improve performance; and Methods for monitoring and sustaining the improved process(es). In our organization in home health, our population we served are managed care. Our biggest challenge is timely access to authorized visits and DME. We are trying to improve our fall rate but certain interventions Ave been challenging. What do you suggests for organization like us to improve? THe R3 report on June 18, 2021 on performance improvement new standards seems to indicate that PSDA is not a sufficient model, is that true? Leverage your data. Consider analyzing your fall data more closely and in deeper ways. For example, is it possible to display your patient falls data by payers so you can make comparisons and look for trends? Once you have this data, look deeper into these cases to determine the reasons that could have contributed to the patient experiencing a fall. Does the data support your hypotheses that delays in authorizations for visits and DME are resulting in increased patient falls in your organization s patient population? Sharing such patient outcome trends with the managed care company, along with any data that supports what your experience has determined is the optimal timing for assessment visits and supplying DME to avoid patient falls, can be a powerful influencer on their performance. The R3 encourages selecting process improvement techniques from evidence-based methodologies that will best satisfy the scope and scale of the improvement project. The R3 is not providing an evaluation of the existing methodologies or improvement techniques/tools.

75 When facilitating improvement teams as a member of the Quality/Performance Improvement department, what do you recommend to get improved staff and leader involvement during current times where staffing is so strained. Is there a presentation like this specific to home health? When resources are limited, it can be helpful for leadership to identify priorities based on the payoff/benefit and the effort needed to achieve the goal. Goals with a high payoff/benefit and low amount of effort/resources are desirable at this time. When involving staff, include only the team members that are critical to the success of the project and help them understand how it applies to their specific role. Have each team member contribute to the project to create a shared investment. This presentation was intended to span across a variety of post-acute care settings. The concepts and methodologies discussed are broadly applicable to home health organizations as well as other settings. We will continue to evaluate the need for additional education on this topic based on feedback received from the evaluation survey.