Long-term care administrators constantly strive to find new ways to provide optimal care for residents. Sometimes, though, it may not be entirely clear how that can be achieved. In his appearance on the LTC Heroes podcast, Mark Klyczek, the president and CEO of Virginia Health Services, gave us a practical strategy to improve your facility’s overall evaluation: predicting quality outcomes.
We begin this guide by discussing quality outcomes and the benefits of predicting them. We then look back at the improvement of quality outcomes over time. Finally, we provide measures for deriving an effective action plan and share suggestions from Klyczek for achieving a sustainable system for improving quality outcomes.
Quality Outcomes and the Importance of Prediction
Quality outcomes are the criteria in your long-term care facility that directly affect your evaluation and score. There has been an increasing acceptance in the US healthcare industry of the idea that sharing quality data is needed to stimulate providers’ efforts for improving the quality of care. Improved individual outcomes measurement tools have facilitated the uptake in public reporting of comparative quality data.
There are conventionally two ways to improve quality outcomes:
Change within your LTC facility that is the result of implementing a system that predicts quality outcomes. The key to predicting quality outcomes is identifying your facility’s important criteria and evaluating them at each point at which they can be affected by staff actions, change in management, or other potential disruptions.
Change related to the LTC industry in general, like changes in Medicare/Medicaid, CMS, or innovative technology and tools designed to improve quality of care. For instance, technology that streamlines financial and medical records is accelerating improvements in quality of care by giving nurses and doctors more time with their residents.
The benefits of improving quality outcomes include:
- Better outcomes for residents
- Content employees
- Fulfilled customers who will then provide referrals.
- More financial aid for your facility, because higher-quality care facilities often receive more funding than those with lower scores on surveys like Medicare periodic resident evaluations (PREs), which happen every 12 months or so.
Why Prediction Matters
Predictions help evaluate a facility’s quality outcomes and save time when mapping out how to improve the quality of care. According to Klyczek, “In many cases, quality is aggravating because what’s reported publicly is at least six months behind.” By this he means that the evaluation of your facility will be posted on the CMS website six months later, not taking into account the changes or improvements done in the meantime. That is where prediction comes into play.
Predicting quality outcomes helps ensure that your long-term care facility continues to improve in its quality outcomes. It is also crucial that your CMS evaluation viewed by potential customers and competitors reflects the most up-to-date quality of care provided in your facility. To predict quality outcomes, it is important to understand how these measures work and how they impact your facility.
How Prediction Works
To predict quality outcomes, you need to look at your quality process as the MDS submits them that same day or week, not six months later. With this process in place, you’ll be able to detect quality problems as they arise and respond quickly with corrective actions. As the saying goes, “a journey of one thousand miles begins with just a single step”.
Start by looking at your quality measures and deciding which are most important to you. This is a judgment call, as each facility has its own desired outcome. Looking at commonalities between departments can also give you an overall idea of what needs to be fixed in general.
Here are some questions to ask yourself when predicting quality outcomes:
- What is the desired outcome for each clinical measure?
- Is there a way to define success or failure in advance, such that their parameters and metrics are clear for all?
- What are the consequences of not meeting our goal?
- How can the quality of care improve for residents already struggling with their health status and functional abilities?
Once you answer these questions, it is time to create a plan. This plan could include making changes to your current system or asking for help from other organizations and professionals.
To implement a successful plan to improve quality outcomes, we first need to understand how quality outcomes work, why they matter, and how they’ve changed over time. We’ll start by taking a brief look at the history of the quality of care in the U.S.
An Overview of Quality History in Nursing Homes
Federal and state regulations help determine the nature of nursing home quality as a result of licensing requirements, inspections, and payments received from federal and state programs.
The following brief history of nursing homes over the last century reveals the mixed nature of quality of care:
- Early 1900s: Nursing homes were first built in response to changing social needs and expectations for long term health care, though they weren’t well designed or organized.
- 1920s – 1940s: A surge of public concern coupled with increasing pressure from federal agencies led to major changes in nursing home design and management practices by the late 1930s
- 1950s – 1960s: The trend was towards increasing specialization, that is, more hospitals developed institutional wings catering exclusively to specific medical conditions like stroke victims or people recovering from hip fractures. These became known as “skilled nursing facilities” (SNFs). Subsequent refinements allowed SNF patients to bypass hospital stays altogether following their treatments at the hospital.
Since the 1960s, the quality and expectations of LTC facilities have increased dramatically. Long-term care facilities have evolved tremendously and now serve a variety of purposes for their communities, including the provision of custodial services for an aging population, long-term rehabilitation, and skilled nursing treatment. LTC facilities must know the details of how evaluations and scores are assigned so that they can consistently make improvements to the quality of their care.
CMS Quality Measures: Understanding Variables and the Metrics
Today, quality health care is a high priority for our government, specifically the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS). Government subsidies will be allocated according to standards that include quality improvement, pay-for-reporting programs, and public reporting.
The CMS officially defines quality measures as: “tools that help us measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care.” The site adds that goals include “effective, safe, efficient, patient-centered, equitable, and timely care.”
Here are the steps to take to analyze data in the quality outcomes cycle:
- Download the Medicare technical guidance tool.
- Understand how points/scores are assigned.
- Look at the quality process as the Minimum Data Sets (MDS) are being submitted that day or that week.
- Let an expert look at the data and summarize the findings.
- Assign the administrator an action plan based on the data. The key here is to find commonalities across the facility that are easy to improve. Start small and increase the interventions as you go.
How to Improve Quality Outcomes
When tracking outcomes and reactions for residents’ needs (complaints), there are several things one must consider, including:
- location within the home or family member/caretaker
- type of resident-behavioral health diagnosis
- whether they’re receiving treatment from hospital staff or through behavioral health providers at their community-based organization
- medications prescribed by psychiatric specialists
There also needs to be coordination between behavioral health providers, the medical team, and nursing staff. If you can work together to see these issues in advance, then you’re on your way to predicting quality outcomes!
Virginia Health Services‘ Klyczek points out that, oftentimes, it will be a handful of residents causing an issue with quality measures. “If you get on top of those, you can see a marked improvement in your quality,” he remarked. This is why you need to be critical of data and identify the very specific issues at hand in order to prevent affecting the overall score of the facility.
Pro Tip: Let a data expert look at the numbers and provide his or her own analysis. It’s easy for facilities to become myopic and focus on the data without properly contextualizing it, which is why a fresh set of eyes is crucial.
There are several quality measures that you can track to measure your performance daily and also understand how the overall facility is performing, including:
- Infection rates
- Incidents per resident day (IPRD)
- Percent change in IPRD over time
- Resident falls with injury rate per 1000 days of residency
- Percentage completion for each regulatory requirement by the date due
Provider Data Catalog makes it easier for you to search and download our publicly reported data. There are other tools and programs available to help your facility measure its quality outcomes. Many long-term care software systems provide QRP and infection tracking features.
Action Plans, Root Cause Analysis, and Policy Interventions
Long-term care facilities including skilled nursing, assisted living, CCRCs, and other types of facilities must derive an action plan that can track progress, note failures, and change policies as appropriate. Your facility won’t get from 0 to 100 right away, and that is normal; small steps are necessary for creating a sustainable system.
One crucial step in an action plan is communicating with your staff and stakeholders the what, why, when, and how of the process. Act as a team, ask for their opinions, and make sure their suggestions and ideas are being heard. This is a system that needs a team to be successful and sustainable.
Root cause analysis (RCA) is an important part of any action plan designed to improve your facility’s quality of care, as it helps identify the causes of quality problems as well as potential solutions.
Pro Tip: Klyczek recommends using the RCA tool from The Institute for Healthcare Improvement (IHI) website. Additionally, he suggests that before starting to implement any intervention you use the action hierarchy tool to determine what will make a measurable and meaningful difference.
Another part of a good action plan is policy interventions, or, changes to how your facility performs its work, such as hiring new staff, implementing additional training programs, or adopting national guidelines. These types of interventions can help prevent undesirable outcomes by establishing clear expectations for residents’ behaviors and providing the resources they need to succeed on their own.
Klyczek’s approach to these interventions is to operate on the expectation that quality outcomes of care are achievable and to use a systematic process for defining what changes need to be made. He recommends prioritizing interventions on smaller actions that have the greatest potential impact. Additionally, he points out that it’s the administrator’s job to look at the data analysis provided by the data expert and translate those into a clear plan of action.
Here are some key strategies for deriving an achievable action plan:
- Establishing a process for quality improvement. Having an organized plan helps you identify your priorities and determine what is most urgent.
- Improving existing processes that work well but need some tweaking or new resources. Don’t spend time trying something completely new when there is already a good system in place. Just make it better!
- Building on other organizations’ strengths by teaming up with them to share expertise and promote collaborative efforts among all stakeholders involved in LTC facilities.
- Creating new processes and practices or modifying existing ones to reach your desired outcomes. For example, if you want more residents being monitored for falls, then create a system that tracks when there are falls in the facility so staff can be alerted and intervene quickly with treatment as needed.
- Setting measurable goals to determine the quality of care – this is done by identifying what matters most to residents (e.g., pain management) and creating an action plan on how such services will improve or become available (for instance, they may need additional nurses). The key here is focusing on specific areas where improvement needs to occur first before tackling everything at once.
Quality Reporting Program (QRP) for Long-Term Care Facilities
After deriving an action plan, you must be proactive in anticipating quality outcomes and making necessary changes to your LTC facility. That means you need to understand how the quality reporting program improves the success of a facility.
The QRP is a system that allows LTC facilities to report quality measures quarterly, in advance of the survey. This tool will also allow you to predict your outcomes by giving you more time to use those results and improve your facility’s performance before they are reported publicly.
These QRP reports can be submitted to CMS through an online secure web interface (SSWI) at any point during the year for review. However, it is best not to submit them more than once every quarter. Furthermore, the SSWI tracks a facility’s progress toward its goal for each metric by calculating trend data and presenting it graphically. This provides valuable information to help spot deviations from expectations that should be investigated either proactively or reactively.
When adopting this new reporting program, the metrics you use to measure your quality outcomes should reflect what matters most within your organization and what will make the biggest impact with the smallest change. Then develop outcome goals based on how well you think your current LTC providers have been performing.
The Largest Impact with the Least Amount of Change
Some care managers and health care professionals may expect too much from themselves, aspiring to eliminate all bad outcomes for clients on their watches. However, smaller and smarter steps will often produce more sustainable and significant change.
It is important to have attainable and timely goals. The last thing you want is to overwhelm your staff with unreasonable expectations. The staff’s priority will always be the resident’s well-being, which is why it is crucial to work on incremental changes to avoid confusing your staff and residents. Communication is key. You need to be transparent with your staff so they know where the facility is headed and the next steps required.
Klyczek notes that there is no one way to produce high-quality long-term care facilities because the circumstances will vary from facility to facility depending on size, location, and the type of care provided. However, he does mention “a few common denominators” that will help you determine where to start implementing or modifying your facility’s practices.
Keeping the System Sustainable
It is important to create a system that works but that can also last and adapt as the facility develops. For example, a change of management, new ownership, or changes in the number of residents may require a reevaluation. According to Klyczek, the key to being sustainable is to have “nice, incremental growth.”
What can you do to make your quality plan sustainable?
- Have a clear strategy for executing and communicating about improvements related to quality measures.
- Define objectives and key performance indicators (KPIs) that will measure progress on those targets.
- Establish an effective evaluation system that includes input from all stakeholders to identify improvement opportunities.
- Create a long-term sustainability vision so everyone knows what success looks like over time. This is especially important if facility changes happen, such as management turnover or new ownerships. The vision needs to be easily documented and communicated by every stakeholder involved in making decisions at any given moment.
- Establish clear and constant communication with your staff and stakeholders.
Team Engagement: Delegation
Keeping your staff happy and engaged will decrease your turnover rate and make the implementation of this system sustainable. Facilities can’t afford to let people, as the team is integral to providing quality service for patients at this stage of their lives. According to McKnight’s, “The turnover rate in long-term care is a significant problem, with rates ranging from 55% to 75% for nurses and aides and sometimes over 100% for aides alone.” This, according to Klyczek, is due to a lack of engagement. He said:
“Team engagement is one of the most important things that we have facing long term care and healthcare in general because the staffing situation in most facilities or organizations is not great.”
It is, then, of utmost importance that you establish a strong team and keep them engaged. Team members will have trouble staying motivated or exerting themselves on behalf of your organization if they feel their contributions are not appreciated or that they aren’t being heard. Quality outcomes and sustained success begin with supporting those providing the care. A happy staff usually equates to happy residents.
Summary: To achieve sustained success, long-term care facilities must understand how the evaluation process works and how scores are assigned. This must be kept in mind when creating and implementing an action plan to improve the quality of care over time. The management and staff at a facility need to work together throughout the process.
The benefits of improving quality include:
- Better outcomes for residents
- Content employees
- Fulfilled customers who will then provide referrals.
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