Long Term Care Administration

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Long Term Care Administration

• Thursday, April 2, 2009
• Week 13 - Chapters 11 14
• Quality and Governance

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The Quality Factor in LTC

• W. Edwards Deming

• Deming is widely credited with improving
  production in the United States during World War
  II, although he is perhaps best known for his
  work in Japan.
• There, from 1950 onward he taught top management
  how to improve design, service, product quality,
  testing and sales, markets through various
  methods, including statistical methods.

William Edwards Deming was an
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The Quality Factor in LTC

• Deming's philosophy
• 'a'-versus-'b' comparison
• (a) When people and organizations focus
  primarily on quality, quality defined by the
  following ratio then quality tends to increase
  and costs fall over time.
• (b) However, when people and organizations focus
  primarily on cost, then costs tend to rise and
  quality declines over time.

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The Quality Factor in LTC

• Dr. W. Edwards Deming taught that by adopting
  appropriate principles of management,
  organizations can increase quality and
  simultaneously reduce costs.
• By reducing waste, rework, staff attrition and
  litigation while increasing customer loyalty.
• The key is to practice continual improvement and
  think of manufacturing as a system, not as bits
  and pieces.

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The Quality Factor in LTC
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The Quality Factor in LTC

• Three main Quality Processes
• Quality Assurance (QA)
• Continuous Quality Improvement (CQI)
• Total Quality Management (TQM)

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The Quality Factor in LTC

• Quality Assurance (QA)
• The emphasis in traditional quality assurance is
  on monitoring whether the appropriate things are
  being done correctly.
• Actions are taken to correct the problem with the
  focus on individual performance.
• Focus on departmental level and reactive.

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The Quality Factor in LTC

• Continuous Quality Improvement (CQI)
• Improving processes with full staff involvement,
  integrated organization wide.
• Client focused, process, performance.
• Working teams to identify and prioritize areas
  for improvement and measure the results of
  improvements.
• Proactive, goal to become even better.

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The Quality Factor in LTC

• Total Quality Management (TQM)
• Process for meeting and exceeding customer
  requirements.
• Concept includes employees within the
  organization as a critical customer group.
• Philosophy and new way of doing business.

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The Quality Factor in LTC

• Risk Management (RM)
• Identification of risk factors.
• Elimination of risk.
• Minimization of the effects created by incidents
  that do occur with the facility.
• Change or possibility of danger, loss, or injury.

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The Quality Factor in LTC

• Risk Management (RM)
• Well being of staff and public
• Property
• Reputation
• Environment
• Organizational functioning
• Financial stability
• Market Share
• Other things of value

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The Quality Factor in LTC

• Canadian Council on Health Services Accreditation
  (CCHSA) 4 Principles
• Establish culture of quality care service.
• Leadership, organizational teamwork.
• Improve processes, achieve results.
• Meet needs and exceed expectations of clients.

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The Quality Factor in LTC

• Defining Quality
• What is Quality?

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The Quality Factor in LTC

• CCHSA Definition of Quality
• The degree of excellence, extent to which the
  organization meets clients needs and exceeds
  their expectations.
• Four Quality Dimensions.
• Responsiveness, effectiveness, work life and
  client/community focus.

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The Quality Factor in LTC

• John Carver
• Quality never stands still.
• Degree clients expectations are met or exceeded.
• Inspire leaders, changing concept of excellence.
• Clients of today and tomorrow.

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The Quality Factor in LTC

• Defining Standards
• Desired and achievable level of performance
  against which actual performance can be compared.

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The Quality Factor in LTC

• Standards of Practice
• Authoritative statements that describes the level
  of service, or performance common to all members
  of a profession.
• Focus on the behaviour of the provider, and give
  direction to address the legal and professional
  basis of practice.

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The Quality Factor in LTC

• Municipal Bylaws and Codes
• Set fire and safety standards and building codes.
• Building codes help prevent accidents.
• Fire codes help prevent death from fires.

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The Quality Factor in LTC

• Provincial Standards
• BC Adult Care Regulations
• Grant Licenses to operate LTC.
• Compliance with minimal standards.
• Reviewed by inspection process.
• Annual onsite inpection.

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The Quality Factor in LTC

• Health Professional Bodies
• Set standards for professional practice.
• RNs, MDs, PT, OT, SW.
• Set codes of ethics.
• License professionals.
• Monitor practices.
• Regulate the profdession.

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The Quality Factor in LTC

• Performance Measures (CCHSA)
• There are three types of performance measures
• accreditation requirements (standards)
• indicators
• instruments (e.g. survey tool or audit)

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The Quality Factor in LTC

• Quality Indicators
• Performance measurement tool, screen, or flag
  that is used as a guide to monitor, evaluate, and
  improve the quality of client service delivery,
  support services, leadership and partnerships.
• Indicators relate to structure, processes and
  outcomes.

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The Quality Factor in LTC

• Benchmarking (Goldwasser)
• Assess current performance relative to other
  organizations.
• Discover and understand new ideas and methods to
  improve processes and practices.
• Identify aggressive, yet achievable, future
  performance targets.

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The Quality Factor in LTC

• Quality of Life for Residents
• Promotion of individuality and choice.
• Mission, values, vision - statements.
• Resident-centred programs and services.
• Standards of Quality of Life.
• Clients perspective on Quality of Life.

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The Quality Factor in LTC

• Use of Restraints
• Restraint free environment.
• Minimal restraint.
• No restraint.
• Better quality of life for residents.

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Quality Factor in LTC

• Freedom of Choice Family Decision Making
• Challenging situations evolve where staff weigh
  the risks to the resident against the residents
  right to choose versus the family members who may
  contradict the residents requests.

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Quality Factor in LTC

• Cultural Aspects of Care and Service
• Education of staff.
• Develop an awareness of the cultural
  sensitivities in ethnic and native population
  groups.
• Diversity programs.
• How do the needs of groups get met?

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The Quality Factor in LTC

• Elder Abuse
• Free from any fear of abuse from staff or other
  residents.
• Policies and procedure must be in place to report
  abuse, deal with it quickly, ensure compliance to
  the policies is upheld.
• Responsibility of the governing body to set
  policies.

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The Quality Factor in LTC

• Sexuality
• Provide an environment that enables residents to
  express their sexuality.
• Staff attitudes toward sexuality.
• Privacy and space for this essential human need
  to be expressed, especially in a long term care
  facility.

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The Quality Factor in LTC

• Environmental Considerations
• Literature reviews to learn what is happening in
  the field.
• Discussing new theories of care delivery.
• Bring residents and families into the discussion.
• Explore better opportunities.

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The Quality Factor in LTC

• Improving Communication
• Open lines of communication is best.
• Investigate ways for residents to interact with
  the community.
• Involve residents on committees.
• Rights of residents.

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The Quality Factor in LTC

• Challenges
• Quality is a living organism.
• Pursuit of quality is a courtship.
• Ever changing face of quality.
• Client change, definition of satisfaction care
  and service changes.
• Demand for quality will increase.

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Governance and Advocacy

• Governance Effectiveness
• Ultimate responsibility is to ensure the
  well-being of the clients the facility serves.
• Ability to govern.
• Level of operational understanding.
• Impact of decisions.
• Measure effectiveness of their actions.

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Governance and Advocacy

• Governance Effectiveness Questionnaire
• The goals, expectations and concerns of
  individual Board members are appropriately
  communicated to the Chair of the Board and CEO. 
   
• Our Board has the appropriate mix of members,
  skills, experience and other characteristics to
  be effective.
• All Directors attend at least 75 of Board
  meetings or have a valid excuse for
  non-attendance.
• Meeting agendas include all relevant and
  high-priority issues and allocate time
  appropriately.
• Directors study and understand relevant
  information in order to utilize their meeting
  time effectively and make informed decisions.

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Governance and Advocacy

• Elected Versus Appointed Board Members
• Representative of the community.
• Avoid single issue or fixed ideological position
  irresponsible governance.
• Expertise in specific areas law, medicine
• Extended orientation to fully contribute.
• Number one priority enhance organization.

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Governance and Advocacy

• Governance Rules and Practices
• Vancouver Coastal Health is committed to being
  open and accountable to the public we serve.
• Increasingly, in both the public and private
  sector, there is a growing trend towards
  enhancing corporate governance practices.
• We have responded by significantly reviewing
  these practices and improving our level of
  disclosure. We are committed to taking part in a
  continual review and updating process following
  the Board Resourcing and Development Office
  (BRDO) provincial best practice guidelines.

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Governance and Advocacy

• The governance rules and practices of VCH are set
  out in the Board Manual that explains how the
  Board of VCH conducts business.
• It includes a Code of Conduct for Directors, VCH
  By Laws and Terms of Reference for the Board, the
  Chair, the CEO and Board Committees.

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Governance and Advocacy

• BC Board Resourcing and Development Office
• Establishes guidelines for all provincial
  appointments to agencies
• Ensures that all provincial appointments are made
  on the basis of merit following an open,
  transparent and consistent appointment process
• Ensures that appointees receive appropriate
  orientation and ongoing professional development
  with respect to agency governance issues

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Governance and Advocacy

• Integration with Regional Authorities
• What are the pros and cons for acute care, long
  term care and community care under one governance
  structure?

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Governance and Advocacy

• Roles and Responsibilities of the Board
• Set strategic direction.
• Develops operational policies.
• Makes critical decisions about the type of
  organization it governs.
• Ensures sufficient resources are in place.
• Accountable for its actions and decisions.

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Governance and Advocacy

• Roles and Responsibility of the Board, cont..
• Selection and evaluates the CEO.
• Achievement of goals and objectives.
• Advocate for the client.
• Ensures all interactions, services, programs are
  high quality and maintain the dignity of the
  individual client.
• Role as evaluator and critic.

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Governance and Advocacy

• Roles and Responsibility of the Board, cont..
• Decision on model of governance.
• Decision on philosophy of care.

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Governance and Advocacy

• Mission as the Central Focus
• Single most influential document.
• Primary source that guides a governing board,
  management and staff.
• Complements and gives direction to the
  organizations strategic plan and sets the
  framework for its annual goals and objectives.

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Sample Mission Statement

• To provide quality of life and quality of care to
  residents who come to us for long-term
  residential or short-term rehabilitative care.
• We assist residents to achieve their highest
  possible level of physical, psychosocial and
  spiritual potential, always working to protect
  and enhance their dignity.
• We seek to continually improve the services we
  provide.

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Sample Mission Statement

• To be a thriving healthcare community in which
  the individual needs and desires of the residents
  direct and shape daily life.

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Governance and Advocacy

• Carver Model - Policy Governance
• Board is the stewards of the organization.
• Focus on making high level policy.
• Four key policy areas
• Restriction or limitations of the CEO.
• Development of outcomes.
• Process of governance, board effectiveness.
• Accountability of staff.

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Governance and Advocacy

• Philosophy of Care
• Client-centredness critically evaluates the
  organizations processes so that resources are
  assigned based on client needs.
• Individual needs of the resident take precedence
  over the needs of the delivers of the service.

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Governance and Advocacy

• Governance and Accountability
• Trusteeship - honour trust placed on them by the
  public.
• Leadership make difficult decisions in a time
  of uncertainty and change.
• Accountability clear policy direction.
• Responsibility efficiently and effectively.

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Governance and Advocacy

• Governance and Quality of Life
• Ensure quality of life for its clients is the
  best that it can be, and evaluated.
• How do you quantify feelings?
• How do you measure depression, pain or quality of
  life?
• What significant improvements to quality of life
  have occurred in the past year?

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Governance and Advocacy

• Governance and Quality of Life, cont
• Choice in the daily life of residents.
• Dining routine, dietary choices, control over
  their room location.
• Are staff aware of the residents right to
  choose?
• Regular dialogue for residents and staff.

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Governance and Advocacy

• Governance and Quality of Life, cont
• Baycrest Geriatric Health Care System has hired
  an ombudsperson first long-term care facilities
  in Ontario to establish this role.
• Mary Ward joined Baycrest in November. Reporting
  directly to the president and CEO, Ward will
  investigate complaints from clients and family
  members in an impartial fashion and facilitate
  resolution.

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Governance and Advocacy

• Effective Residents Council
• Improve communication within their homes.
• Help identify problems early when it is easier to
  correct them.
• Serve as a sounding board for new ideas.
• Help individuals speak out about concerns and
  help overcome fear of retaliation.
• Improve the atmosphere of the nursing home.
• Promote friendship.

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Governance and Advocacy

• Family Councils
• Forum for friends and families of residents in
  long-term care to share experiences, learn and
  exchange information.
• Family councils provide a valuable mechanism
  for dialogue, support, education and processing
  concerns.

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Governance and Advocacy

• Future Directions for Governance
• Role is to improve the health and well-being in
  the community served by the eldercare
  organization.