Process Improvement Handbook. A Commitment to Ongoing Improvement Using a QAPI Framework

Process Improvement Handbook A Commitment to Ongoing Improvement Using a QAPI Framework

This material was prepared by the New York State Offi ce of Mental Health, Offi ce of Quality Management, and adapted by The Carolinas Center for Medical Excellence (CCME), under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily refl ect CMS policy. 10SOW-BI-C7-13-36

Table of Contents SECTION 1: Introduction and Process Improvement Principles... 1 Quality... 1 Process Improvement Principles... 1 SECTION 2: Leadership and Organization... 3 Leadership Support.....3 SECTION 3: Goals and Objectives... 4 QAPI Steering Committee... 4 SECTION 4: Performance Measurement... 5 Purpose... 5 Measurement and Assessment... 5 SECTION 5: Performance Improvement Project (PIP)... 6 Plan... 6 Do... 6 Study... 6 Act... 6 SECTION 6: Evaluation... 7 SECTION 7: Process Improvement Steps... 8 APPENDICES: Quality Improvement Tools... 9 Appendix 1: Process Mapping... 10 Appendix 2: Brainstorming... 11 Appendix 3: Run Chart... 12 Appendix 4: Benchmarking... 13 Appendix 5: Root Cause Analysis and Fishbone Diagram... 14 Appendix 6: PDSA Cycle... 15 Appendix 7: Dashboard... 16

TOOLS AND EXAMPLES... 17 5 Whys Worksheet... 18 5 Whys Worksheet Example... 19 Root Cause Analysis Using the Fishbone Diagram... 20 Fishbone Diagram Example... 21 PDSA Worksheet for Testing Change... 22 PDSA Worksheet Example... 24 Goal Setting Using SMART Objectives... 26 Goal Setting Worksheet Example... 28 Dashboard Example... 30 REFERENCES... 31

Section 1 INTRODUCTION The Process Improvement Plan serves as the foundation of the nursing home s commitment to continuously improve the quality of the care it provides. Quality. Quality services are safe, effective, resident-centered, and timely. Committing to the ongoing improvement of care your residents receive, as evidenced by the outcomes of that care, the nursing home continuously strives to ensure that: Care provided incorporates evidence-based, effective practices Care is appropriate to each resident s needs and is available when needed Risk to residents, providers, and others is minimized, and errors in the delivery of care are prevented. All adverse events are tracked and analyzed. Individual needs and expectations of residents and families are respected. Residents or those whom they designate have the opportunity to participate in decisions regarding their treatment, and services are provided with sensitivity and caring. Care is provided in a timely and efficient manner, with appropriate coordination and continuity across all phases of care and departments Process Improvement Principles. Quality improvement (QI) is a systematic approach to assessing and improving care on a priority basis. The approach to QI is based on the following principles: Resident Focus. Services are based on meaningful resident and family dialogue to promote and preserve wellness and to expand personal choice. This approach promotes maximum flexibility and choice to meet individually defined goals and to permit person-centered services. Staff Empowerment. Effective programs are based on meaningful and respectful relationships among members of the staff and between staff and residents. QI depends upon staff who are trained and empowered to work as a team in real time to problem solve and use critical thinking skills to improve resident outcomes. Leadership Involvement. Strong leadership that provides direction and support of QI activities is key to performance improvement. Involvement of organizational leadership ensures that QI initiatives are consistent with the mission, values, and goals of the facility. www.ccmemedicare.org 1

Data Informed Practice. Successful QI processes create feedback loops, using data to inform the practice and measure results. Fact-based decisions are likely to be correct decisions. QI Tools. For continuous improvement of care, tools and methods are needed to foster knowledge and understanding. Continuous Quality Improvement (CQI) organizations use a defined set of analytic tools such as run charts, cause and effect diagrams, process maps, and dashboards to turn data into information that staff can use to improve care. They use QI methods, like root cause analysis and Plan-Do-Study-Act (PDSA) to support critical thinking and problem-solving. Prevention Over Correction. Quality Assurance Performance Improvement (QAPI) is proactive and drives good processes to achieve excellent outcomes rather than fix processes after the fact. Continuous Improvement. Processes must be continually reviewed and improved. Small incremental changes do make an impact, and providers can always find an opportunity to make things better. No matter what barriers exist in a nursing home environment, incremental change is possible. Team Based. Interdisciplinary teams that include frontline staff drive the work of improvement. A QAPI Steering Committee provides overall management of process improvement, and smaller teams drive individual performance improvement projects. Performance Improvement Projects (PIPs). Individual QI projects called PIPs are used by teams to address identified outcomes and processes that need improvement. Just Culture. CQI organizations respond to errors by examining their systems and processes, not by blaming individuals. Unintentional errors are differentiated from intentional errors or reckless behavior. Leadership maintains a balance between justice and accountability by focusing on systems and identifying opportunities for learning rather than on one individual who can be blamed for the error or unexpected outcome. 2 www.ccmemedicare.org

Section 2 LEADERSHIP AND ORGANIZATION Leadership Support. Key to the success of process improvement is leadership. The following describes how leaders provide support to QI activities. The QAPI Steering Committee provides ongoing operational leadership of CQI activities at the nursing home. Core membership should include the director of nursing (DON), administrator, and medical director. The Steering Committee s responsibilities include the following: 1. Establish a format and frequency for meetings. 2. Establish a method for communication between meetings. 3. Establish a way to document and track plans and discussions. 4. Develop and approve a facility-wide QI Plan. 5. Establish measurable objectives based upon priorities identified through the use of established criteria. 6. Develop indicators of performance on a priority basis. 7. Assess information periodically based on the indicators and take action as evidenced through QI initiatives to solve problems and pursue opportunities to improve. 8. Establish and support specific QI initiatives or PIPs. 9. Formally adopt a specific approach to QI, such as PDSA. Leaders support QI activities through the planned coordination and communication of measurement results related to QI initiatives. Leaders, through a planned and shared communication approach, ensure that staff, residents, and family members have knowledge of and input into ongoing QI initiatives. This planned communication may take place through a variety of methods including: Storyboards and/or posters of teamwork, PIPs, and data trends displayed in common areas Resident and family participation in QI through satisfaction surveys and family councils Committee reports to staff, residents, and families Distribution of newsletters and/or handouts about QI projects www.ccmemedicare.org 3

Section 3 GOALS AND OBJECTIVES QAPI Steering Committee. The committee identifies and defines goals and specific objectives to be accomplished each year. These goals include training of clinical and administrative staff regarding both CQI principles and specific QI initiatives. Progress in meeting these goals and objectives is an important part of the annual evaluation of QI activities. Short-term goals: Indicate a plan for facility-wide QAPI training. Describe the plan to provide staff time and equipment for training as needed. Long-term goals and the specific objectives for accomplishing these goals for the year: Implement quantitative measurement to assess key processes and outcomes. Identify sources of data that you will monitor. Describe the process for collecting and analyzing data. Develop a data tracking system (i.e., dashboard) to display and track monthly data of selected outcome measures and process measures. Bring together managers, clinicians, and frontline staff to review quantitative data and major clinical adverse events to identify and describe problems. Focus on process and not individual performance. Carefully prioritize identified problems. Select benchmarks whenever possible and set target goals. Provide education and training on best practices to managers, clinicians, and frontline staff. Develop or adopt necessary tools, such as practice guidelines and satisfaction surveys. Monitor implementation of strategies and new processes developed to achieve goals. Achieve measurable improvement in the highest priority areas. Meet internal and external reporting requirements. 4 www.ccmemedicare.org

Section 4 PERFORMANCE MEASUREMENT Performance Measurement is the process of regularly assessing the results produced by systems of care. It involves identifying processes, systems, and outcomes that are integral to the performance of the care delivery system; selecting indicators of these processes, systems, and outcomes; and analyzing information related to these indicators on a regular basis. CQI involves taking action as needed based on the results of the data analysis and the opportunities for improvement they identify. The purpose of performance measurement is to: Assess the stability of processes or outcomes to determine whether there is an undesirable degree of variation or a failure to perform at an expected level Identify problems and opportunities to improve the performance of processes Assess the outcome of the care provided Assess whether a new or improved process meets performance expectations Measurement and assessment involves: Selection of a process or outcome to be measured on a priority basis Identification and/or development of performance indicators for the selected process or outcome to be measured Aggregating data so that it is summarized and quantified to measure a process or outcome Assessment of performance with regard to these indicators at planned and regular intervals Taking action to address performance discrepancies when indicators show that a process is not stable, is not performing at an expected level, or represents an opportunity for QI Reporting within the organization on findings, conclusions, and actions taken as a result of performance assessment www.ccmemedicare.org 5

Section 5 PERFORMANCE IMPROVEMENT PROJECT (PIP) Once the performance of a selected process has been measured, assessed, and analyzed, the information gathered by the performance indicator(s) is used to identify a CQI initiative or PIP to be undertaken. The decision to undertake the initiative is based upon priorities. The purpose of an initiative is to improve the performance of existing services or to design new ones. The basic model staff can use to conduct a PIP is called Plan-Do-Study-Act (PDSA). Plan. The first step involves identifying opportunities for improvement. At this point, the focus is to analyze data to identify concerns and to determine new, potential outcomes. Ideas for improving processes are identified. This step requires the most time and effort. Affected staff and residents are identified, data compiled, and solutions proposed. Do. This step involves implementing the proposed solution usually on a trial basis on one unit. Conducting a small-scale pilot of the proposed change is always recommended. Study. At this stage, data are again collected to compare the results of the new process with those of the previous one. Did the changes make a difference in the area you were trying to improve? What did the team learn? Act. Does the change need to be adapted and re-studied? Can the change be adopted and extended to other areas? At this stage, the PIP team involves others who will be affected by the changes, those whose cooperation is needed to implement the changes on a larger scale, and those who may benefit from what has been learned. Finally, it means documenting and reporting findings and following up. 6 www.ccmemedicare.org

Section 6 EVALUATION An evaluation is completed at the end of each year. The annual evaluation is conducted by the QAPI Steering Committee and kept on file, along with the QI Plan. The evaluation summarizes: The goals and objectives of the facility-wide QI Plan The QI activities conducted during the past year, including the targeted process, systems, and outcomes The performance indicators utilized The findings of the measurement, data summaries, assessment, and analysis processes The QI initiatives taken in response to the findings Annual activities include: 1. Summarize the progress towards meeting the annual goals and objectives. 2. For each of the goals, include a brief summary of progress. 3. Provide a brief summary of the findings for each of the performance indicators you used during the year. These summaries should include both the outcomes of the measurement process and the conclusions and actions taken in response to these outcomes. For each PIP, provide a brief description of the activities that took place, including the results. What are the next steps? How will you hold the gains? 4. Based upon the evaluation, state the actions you see as necessary to improve the effectiveness of the QI Plan in the coming year. www.ccmemedicare.org 7

Section 7 LET S GET STARTED WITH THE PROCESS IMPROVEMENT PLAN! Step 1: Select the process to be improved and establish a well-defined process improvement goal. The goal may be established by the team. What do we want to improve? Use the SMART formula to help describe your goal: Specific, Measurable, Attainable, Realistic, Timeframe. Step 2: Organize a PIP team to improve the process. This involves selecting the right people to serve on the team and identifying the resources available for the improvement effort, such as people, time, money, and materials. Step 3: Define the current process using a flowchart or process map. This tool is used to generate a stepby-step map of the activities, actions, and decisions which occur between the starting and stopping points of the process. Step 4: Simplify the process by removing redundant or unnecessary activities. People may have seen the process on paper in its entirety for the first time in Step 3. This can be a real eye-opener which prepares them to take these first steps in improving the process. Step 5: Develop a plan for collecting data and collect baseline data. This data will be used as a yardstick for comparison later. Step 6: Assess data trends. The team creates a run chart or other graph from data collected in Step 5 to gain a better understanding of what is happening in the process. The follow-up actions of the team are dictated by whether cause variation is found in the process. Step 7: Identify the root causes that prevent the process from meeting the objective. The PDSA cycle starts here, using brainstorming and root cause analysis to generate possible reasons why the process fails to meet the desired objective. Step 8: Develop an action plan for implementing a change based on the possible reasons for the process s inability to meet the objective set for it. These root causes were identified in Step 7. The planned improvement involves revising the steps in the simplified process map created in Step 4. Step 9: Modify the data collection plan developed in Step 5, if necessary. Step 10: Test the changed process. Collect data and add to a run chart. Step 11: Assess where the change improved the process. Using the data collected in Step 10 and entered into a run chart, the team determines whether the process is closer to meeting the process improvement goal established in Step 1. If the goal is met, the team can determine if spread is feasible; if not, the team must decide whether to keep or discard the change. Congratulations! You have just completed your first PDSA cycle. 8 www.ccmemedicare.org

Appendices Quality Improvement Tools www.ccmemedicare.org 9

Appendix 1: Process Mapping Recognizing A Change in Condition Map out the steps to a process in a linear path and note any components to the right that are essential to that specific step in the process. Process Mapping as a QI exercise compares the policy and procedure to the actual way a process is occurring. It allows for identification of deviations. The use of process mapping with a team allows staff to pinpoint exact opportunities for improvement. EXAMPLE OF A PROCESS DESIGNED TO REDUCE AVOIDABLE HOSPITAL READMISSIONS Resident has a change in condition Observe the change, complete the Stop and Watch tool CNA notifies nurse immediately Nurse assesses resident and gathers relevant information Vital signs Cognitive level review S/S of reported concern Nurse reports change of condition to physician Complete SBAR prior to call. Gather chart. Notify supervisor Nurse records orders in chart Repeats to confirm Nurse initiates orders Notify family Explain plan of care to resident 10 www.ccmemedicare.org

Appendix 2: Brainstorming Brainstorming is a tool used by teams to bring out the ideas of each individual and present them in an orderly fashion to the rest of the team. Brainstorming provides an environment free of criticism. Team members generate issues and agree to defer judgment on the relative value of each idea. Brainstorming is used when one wants to develop a large number of ideas about issues to tackle, possible causes, approaches to use, or actions to take. Brainstorming is a good time to think outside the box. It fosters new ideas which can lead to creative solutions. The advantages of brainstorming are that it: 1. Rapidly produces a large number of ideas 2. Equalizes involvement by all team members 3. Fosters a sense of ownership in the final decision as all members actively participate 4. Provides input to other tools, such as a Fishbone Diagram or other RCA tool 5. Encourages creativity and critical thinking www.ccmemedicare.org 11

Appendix 3: Run Charts A run chart is the most basic tool to show how a process performs over time. Data points are plotted in order on a line graph. Run charts are most effectively used to assess process stability through a visual display of variation. A run chart can help to determine whether or not a process is stable, consistent, and predictable. Simple statistics such as median and range may also be displayed. The run chart is most helpful in: 1. Understanding variation in an outcome or process performance 2. Monitoring performance of a process or outcome over time to detect signals of change Number 30 RUN CHART Facility-Acquired Pressure Ulcers 25 20 15 10 5 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Months (2012) Note: The diagram can include a trend line to identify possible changes in performance. 12 www.ccmemedicare.org

Appendix 4: Benchmarking A benchmark is a point of reference by which something can be measured, compared, or judged. It can be an industry standard against which a performance indicator is monitored and found to be above, below, or comparable to the benchmark. National and state benchmarks are provided for all quality measures (QM). For example, the current national average for all reporting nursing homes in the United States for the percent of long-stay residents who received an antipsychotic medication is 23.4 percent. The current average in North Carolina is 20.8 percent. A new national benchmark is a 15 percent reduction. If your facility s average is 25 percent, how do you compare to the state and national averages? What would be your new benchmark with a 15 percent reduction? Currently your facility is 1.6 percent above the national average and 4.2 percent above the state average. With a 15 percent reduction, the new benchmark for your facility would be 21 percent. For some measures, internal benchmarking is more appropriate. In this case, for example the number of falls per month, a facility might trend their monthly rate for the previous year using a run chart. Based on the variation, the team would then set an internal benchmark for a new target number of monthly falls. The new benchmark for number of falls per month might be a reduction of 20 percent or it might be a specific number, e.g., less than 12 falls per month. www.ccmemedicare.org 13

Appendix 5: Root Cause Analysis Root cause analysis (RCA) is a systematic process for identifying the most basic factors/causes that underlie variation in performance. It helps teams determine what happened, why it happened, and how to reduce the likelihood of it happening again. First, the team must identify the underlying cause of a problem before members can identify effective interventions that can be implemented in order to make improvements. Focus on systems and processes, not individual performances. Individual blame never serves the QI process well. One RCA technique is the 5 Whys Tool that helps to promote deep thinking about a specific problem. First, accurately state the complete problem. Second, ask why this problem is taking place. Record all answers. For each of the broad answers given, ask a series of whys until there is no further new information provided or the information provided by the team becomes redundant. Encourage complete honesty, and be determined to get to the bottom of the problem and to resolve the issue. Another method to guide and document the RCA process is the Fishbone Diagram. It helps the team identify, sort, display, and analyze possible causes of a specific problem. The problem or adverse event is written in the box on the right. Boxes at the end of the larger bones are general categories used to guide the discussion. For most issues in nursing homes, the categories are staff factors, care methods, environmental factors, and equipment factors. These categories, however, can be adapted as needed. List causes for each category, filling in the smaller bones of the fish. Begin with the most obvious cause. Then keep asking why to determine all of the underlying causes and to produce the detail needed for future critical thinking about solutions. 14 www.ccmemedicare.org

Appendix 6: PDSA Cycle Each performance improvement project, or PIP, requires careful and organized planning by the assigned team. Using Plan-Do-Study-Act (PDSA) as a formal problem-solving model helps the team manage and complete the process in a systematic and logical manner. Suggested activities for each component of the PDSA cycle are: 1. Plan a. Develop or design a new process or improve an existing process you have identified. b. Decide how you will test the new process. c. Investigate and integrate evidence-based practices into your design. d. Identify measures that can be used to determine if new strategies are successful in improving the outcome. e. Determine what data are needed and how to collect the data for measurement. f. Get the right people involved in development and testing. 2. Do a. Using a small scale pilot project, run the test of the new or redesigned process. b. Collect data. c. Document observations, both expected and unexpected. 3. Study a. Analyze data and test results. b. Determine whether the change was successful. c. Identify challenges, barriers, and lessons learned. d. Summarize what you learned from the test. e. Share results with everyone impacted and get feedback. 4. Act a. If needed, modify and re-test the change. b. If successful, spread the change to other units. c. If unsuccessful, abandon it and develop a new approach to test. www.ccmemedicare.org 15

Appendix 7: Dashboard A dashboard provides an easy at-a-glance view of key performance indicators identified by the QAPI Steering Committee as critical to successful provision of quality care. While some data measures will be common throughout all nursing homes, each facility s dashboard is unique based on its mission, values, and goals. Dashboards are visual summaries of key trends, comparisons, and exceptions. In order to be effective, dashboards must be simple with minimal distractions and be organized within the visual presentation of information. Dashboards come in many forms and may use a variety of numbers and graphs. Examples of visual tools used to illustrate data on a dashboard include a pie chart, bar chart, funnel, line graph, or run chart. To be useful, the data in dashboards must include real time data. Teams need current information. Dashboards also show historical trends of the organization s key performance indicators. This allows teams to make sound, informed decisions in a timely manner. 16 www.ccmemedicare.org

Tools and Examples www.ccmemedicare.org 17

Five Whys Worksheet Accurately state the problem. PROBLEM: Why is this happening? Enter all the reasons why. You may need more boxes. For each reason, begin asking WHY. REASON #1 REASON #2 REASON #3 WHY? WHY? WHY? WHY? WHY? WHY? WHY? WHY? WHY? WHY? WHY? WHY? 18 www.ccmemedicare.org

Five Whys Worksheet Example Accurately state the problem. PROBLEM: Rise in number of facility-acquired Stage III pressure ulcers from 0 to 3 on Unit One during September 2012. Why is this happening? Enter all the reasons why. You may need more boxes. For each reason, begin asking WHY. REASON #1 Poor positioning REASON #2 Lack of consistent skin inspection by frontline staff REASON #3 Low protein and caloric intake of high-risk residents WHY? Lack of accessible positioning equipment WHY? Charge nurse does not hold CNA accountable. WHY? Not enough attention during mealtimes to individual residents WHY? Supplies not on unit and difficult to obtain WHY? Skin condition not part of routine shift reports WHY? Insufficient staffing for so many residents that need mealtime assistance WHY? Few extra pillows and many old cushions WHY? No longer using pink skin inspection sheet WHY? Lack of support from other staff during busy times and staff schedules WHY? Low priority for administration WHY? Not a priority; too many other things going on WHY? Always been this way www.ccmemedicare.org 19

Root Cause Analysis Using the Fishbone Diagram Ideas for Brainstorming: 1. Staff Factors Lack of knowledge and training, staffing levels, scheduling, lack of communication, low accountability, poor teamwork 2. Care Methods Processes not followed, lack of documentation, shift-to-shift breakdown, insufficient rounding, low anticipation of resident needs 3. Environmental Factors Lack of safety inspection and correction of hazards 4. Equipment Factors Broken or lost equipment, incorrect devices in use, insufficient supply, low budget priority 20 www.ccmemedicare.org

Fishbone Diagram Example Ideas for Brainstorming: 1. Staff Factors Lack of knowledge and training, staffing levels, scheduling, lack of communication, low accountability, poor teamwork 2. Care Methods Processes not followed, lack of documentation, shift-to-shift breakdown, insufficient rounding, low anticipation of resident needs 3. Environmental Factors Lack of safety inspection and correction of hazards 4. Equipment Factors Broken or lost equipment, incorrect devices in use, insufficient supply, low budget priority Poor communication about high risk residents Staff Factors Frontline staff doesn t know latest care plan changes After a fall, not sure what to do next Cluttered resident rooms and bathrooms Families bring in stuff, lack of storage space for equipment Environment safety inspection sporadic, no accountability Everyone treated the same, everyone has alarms Everything is a priority Care Methods No way to tell who needs what and when Wheelchairs and walkers are a mess Parts are worn or missing and not enough to go around No one responsible Not enough 1-to-1 supervision Increased rate of falls from 12 percent to 20 percent in last three months on Unit B Environmental Factors Equipment Factors www.ccmemedicare.org 21

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Remove Mrs. Brown s chair alarm for 7 days during the day shift with no increase in falls. No alarm will be used from 7 a.m. 7 p.m. and she will not experience a fall. a. Round using 4 Ps every hour. b. Engage her in group activities outside her room. c. Contact therapy staff, and initiate restorative program for ambulation, strengthening, and balance. Remove alarm. Mrs. Brown Discuss schedule with CNAs and plan hourly rounding. Notify activities director to assess and engage resident. Notify restorative staff to enroll resident and begin program. ADON Alarm will not be used. No falls will occur. Number of falls Use of alarm from 7 a.m. 7 p.m. 24 www.ccmemedicare.org

Alarm was removed for one week, and the three strategies were implemented. Mrs. Brown had no falls. It was difficult for staff to round every hour. Mrs. Brown did not stay in group activities. Staff identified more specific toileting patterns, pain, and personal needs through 4 Ps rounding process. Results matched observations, and new resident needs were identified. Adopt and modify. Remove alarm permanently. Activities staff to explore more of Mrs. Brown s personal history and engage in more meaningful activities. Staff to anticipate toileting and positioning needs identified during rounding. Routine pain medication for pain identified during rounding. Restorative program to continue. www.ccmemedicare.org 25

Goal-Setting Worksheet Goal setting is important for any measurement related to performance improvement. This worksheet is intended to help teams establish appropriate goals for individual measures and also for performance improvement projects. Goals should be clearly stated and describe what the organization or team intends to accomplish. Use this worksheet to establish a goal by following the SMART formula outlined below. Note that setting a goal does not involve describing what steps will be taken to achieve the goal. It is helpful to post the written goal somewhere visible and regularly communicate the goal during meetings in order to stay focused and remind caregivers that everyone is working toward the same goal. Describe the problem to be solved: Use the SMART formula to develop a goal: SPECIFIC: Describe the goal in terms of three W questions. What do we want to accomplish? Who will be involved and who will be affected? Where will it take place? MEASURABLE: Describe how you will know if the goal is reached. What is the measure you will use? What is the current data figure (i.e., count, percent, rate) for that measure? What do you want to increase/decrease that number to? 26 www.ccmemedicare.org

ATTAINABLE: Defend the rationale for setting the goal measure above. Did you base the measure figure you want to attain on a particular best practice or average score or benchmark? Is the goal measure set at the right mark to be challenging without being unreasonable? RELEVANT: Describe how the goal fits into your QI Plan. Briefly describe how the goal being set will address the problem stated above. TIME-BOUND: Define the timeline for achieving the goal. What is the target date for achieving this goal? GOAL STATEMENT: www.ccmemedicare.org 27

Goal-Setting Worksheet Example Goal setting is important for any measurement related to performance improvement. This worksheet is intended to help teams establish appropriate goals for individual measures and also for performance improvement projects. Goals should be clearly stated and describe what the organization or team intends to accomplish. Use this worksheet to establish a goal by following the SMART formula outlined below. Note that setting a goal does not involve describing what steps will be taken to achieve the goal. It is helpful to post the written goal somewhere visible and regularly communicate the goal during meetings in order to stay focused and remind caregivers that everyone is working toward the same goal. Describe the problem to be solved: Our retention of newly hired CNAs is low. This causes interruptions in resident care and negatively affects staff performance. Use the SMART formula to develop a goal: SPECIFIC: Describe the goal in terms of three W questions: What do we want to accomplish? Reduce turnover rate of new CNAs Who will be involved and who will be affected? Nursing staff and those responsible for the hiring process Where will it take place? During the interview and hiring process MEASURABLE: Describe how you will know if the goal is reached. What is the measure you will use? Number of CNA terminations within 6 months of hire What is the current data figure (i.e., count, percent, rate) for that measure? 50 percent turnover What do you want to increase/decrease that number to? Decrease to 25 percent 28 www.ccmemedicare.org

ATTAINABLE: Defend the rationale for setting the goal measure above. Did you base the measure figure you want to attain on a particular best practice or average score or benchmark? Internal trends and corporate benchmark Is the goal measure set at the right mark to be challenging without being unreasonable? Yes RELEVANT: Describe how the goal fits into your QI Plan. Briefly describe how the goal being set will address the problem stated above. Will improve consistency of care, help improve communication and build teamwork, and improve quality of resident care TIME-BOUND: Define the timeline for achieving the goal. What is the target date for achieving this goal? Within the next six months GOAL STATEMENT: We will reduce the percentage of CNA terminations within the first 6 months of their hire date by 25 percent over the next 6 months as documented by the DON in employee records. Goal statement examples: 1. Increase the number of long-term residents with a vaccination against both influenza and pneumococcal disease documented in their medical record from 61 percent to 90 percent by December 31, 2013. 2. For the next 30 days, hold a 5 10 minute team huddle using the Post-Fall Investigation form within one hour after 100 percent of resident falls on Unit B. This huddle will be directed by the charge nurse and attended by unit CNAs, therapy, ADON, and nurse supervisor. The ADON will track all huddles and falls during this period. 3. Reduce the number of facility acquired Stage III pressure ulcers in long-stay residents from 6 to 0 by December 31, 2013, as documented in the medical record and internal monitoring sheet. www.ccmemedicare.org 29

Dashboard Examples 30 www.ccmemedicare.org

References: Bowers B, Nolet K, Roberts T, Esmond S. Implementing Change in Long-Term Care: A Practical Guide to Transformation. University Wisconsin Madison School of Nursing; 2007. http://www.nhqualitycampaign.org/files/implementation_manual_part_1_final.pdf. Accessed March 8, 2013. Centers for Medicare and Medicaid Services. Nursing Home Quality Assurance and Performance Improvement. http://www.cms.gov/medicare/provider-enrollment-and-certification/ surveycertificationgeninfo/qapi.htmlassurance. Accessed March 7, 2013. Institute for Health Care Improvement (IHI). How to Improve. http://www.ihi.org/knowledge/pages/ HowtoImprove/default.aspx. Accessed March 7, 2013. Isabella Corporation Project. Getting Better All the Time: Working Together for Continuous Improvement. New York: Cobble Hill Health Center and Isabella Geriatric Center; 2010. http://www.susanwehrymd.com/files/gettingbetterall-the-time.pdf. Accessed March 8, 2013. Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009. New York State Office of Mental Health, Office of Quality Management website. Quality Improvement Plan Template. http://www.omh.ny.gov/omhweb/cqi/plan_template.html. Accessed January 3, 2013. Planetree and Picker Institute. Long-Term Care Improvement Guide. Planetree Project Team. 2010. http://pickerinstitute.org/publications-and-resources/. Accessed March 8, 2013. www.ccmemedicare.org 31

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100 Regency Forest Drive, Suite 200, Cary, NC 27518 800-682-2650 246 Stoneridge Drive, Suite 200, Columbia, SC 29210 800-922-3089 www.ccmemedicare.org