Nursing homes across the country receive a Nursing Home Quality Measure Composite Score derived from 13 Long-Stay Quality Measures. The composite score monitors quality from a systems view and serves a guide to identify areas for quality improvement change.
The Kadoka Nursing Home in Kadoka, SD, achieved the monthly composite score goal of 6.00 or below for January 2018. Heidi Coller, chief operating officer for Kadoka Nursing Home, reflected on how her team achieved their quality improvement goals using proven QAPI processes and tools. Below is Coller’s personal perspective on Kadoka Nursing Home’s success and ongoing quality improvement efforts.
Having worked at the Kadoka Nursing Home for over 16 years, I knew the facility, residents, and staff inside and out. However, after stepping into the chief operating officer role in March of 2017, I quickly realized I lacked a complete understanding of the looming challenges and struggles. Those challenges included a less than optimal financial situation, staff shortages and an uphill battle of funding maintenance for a very old building. Despite these challenges, I believed happy residents, compassionate staff and a history of positive surveys meant our center was and would be ready for anything. Then survey time came.
While we had fewer citations than the prior year, the center received its first civil money penalty (CMP) due to lack of documentation and understanding of the quality measures. As a new chief operating officer, joined by a new administrator and a director of nursing just returning from leave, the team had to roll up our sleeves and strategize a game plan. We knew our residents were safe, happy and loved, and we needed to identify and implement effective and efficient education, resources and tools facility-wide. Our QAPI meetings were already occurring using a proactive team approach, but we lacked the tools to properly document the process on paper.
In desperate need of assistance, we reached out to Nursing Home Program Manager Lori Hintz, RN, from the Great Plains Quality Innovation Network in September 2017. Lori educated our team on how to decipher data from the Certification and Survey Provider Enhanced Reporting (CASPER) Quality Measure Report and the Quality Measure Composite Score Report. We learned how to connect the data, set goals and make action plans to achieve those goals. The tools shared by Great Plains QIN were the gateway to process improvement.
Understanding and using the “Five Whys” root-cause analysis concept helped the team brainstorm and identify the real cause, which led to better actions to solve issues. Using the performance improvement project (PIP) template incorporates several QAPI problem solving strategies in one tool and provides for adequate documentation and less paperwork. Also, the Composite Score Predictor Calculator became a favorite tool to assist in identifying opportunity improvement areas and understanding how just one area of focus can improve your quality measures.
The team learned it is okay to challenge and question each other without hurting feelings or bruising egos; because, in the end, we all want what is best for our residents. Whitney Patterson, director of nursing commented to me, “The improvement of our quality measures was due to improved documentation and working as a team to identify areas of improvement needed, which affected both staff and residents in a positive way.”
In six short months, between August 2017 and January 2018, Kadoka Nursing Home’s quality measure composite score improved by 48% from a high of 10.54 to 5.14: a score surpassing the goal range of 6.0. The dramatic improvement in a short period of time further demonstrated the importance of using data to drive quality improvement efforts.
As we continue to work through the quality improvement process, our team realizes our quality measure numbers will change depending on the complexity of each resident residing in our facility. Our quality measure numbers may not always be peaches and cream. There will be some triggers out of our control, but we plan to focus on high-impact areas we can improve. We have a great team, great residents and a great community that drives our passion to make Kadoka Nursing Home the best it can be.
Great Plains QIN provides technical assistance aligning with the CMS National Nursing Home Quality Care Collaborative. Nursing homes participating in the collaborative share tools, knowledge and experiences for improving resident safety and clinical processes and reducing preventable healthcare conditions. Learn more about nursing home care initiatives on the Great Plains QIN website.