Developing Quality Systems and Personnel

1
Developing Quality Systems and Personnel

• Putting the Pieces Together

2
Developing Quality Systems

• Objectives
• Identify components of quality validation review
  process
• Identify how to schedule and make assignments
• Identify how to review findings with team
• Identify how to monitor progress

3
Impetus for change

• Average number of deficiencies per standard
  survey increased
• Number of immediate jeopardy citations increased
• QIS survey process

4
Quality Validation Review

• Proactive
• Process oriented
• Collaborative
• Initiated 6 months prior to anticipated standard
  survey
• Follows 7 survey tasks
• Uses Critical Elements from QIS survey

5
Annual Timeline
6
Quality Validation ReviewScheduling and
Attendance

• Scheduling
• Six (6) months prior to anticipated standard
  survey
• Twice a year for higher risk centers

7
Quality Validation ReviewScheduling and
Attendance
8
Quality Validation ReviewAssignments
9
Quality Validation ReviewProcess

• Entrance conference
• Assignment review and completion target
• Follows 7 survey tasks
• Uses Critical Elements, QM/QI validation tools
• Preliminary exit with administrator, DON
• Conference with facility and regional or
  divisional management team
• Quality Milestone Action Plan development

10
Critical Element
11
QM/QI Validation Tool
12
Summary of findings

• Grouping of like findings by F tag
• Team conference
• Agreement on
• Citation or concern
• F tag
• Scope and severity
• Responsibility for POC QMAP
• Calculation of SFF points

13
Plan of Correction Development
14
Quality Milestone Action Plan
15
Monitoring

• Responsibility of facility to assure completion
  of plan of correction
• Regional consultant follow-up and assistance with
  education and audits
• Re-validation 90 days later (STAT)

16
Survey Training and Tools

• Re-validation of plan of correction from Quality
  Validation Review
• Clear previous citations
• Identify new citations
• Preparation of survey expandable file
• Education of staff regarding survey process

17
QVR to STAT to Survey

• QVR STAT SURVEY

2007 Average SFF points 181 92 51
2007 Range SFF points 28 386 18 312 0 - 74
2008 Average SFF points 153 53.6 23.04
2008 Range SFF points 19 419 14 208 0 - 94
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Facility Perspectives

• Views from a facility team
• Administrator Matthew Baad
• Director of Nursing Fran Brown

19
Developing Quality Personnel

• Objectives
• Identify components of the licensed nurse
  orientation program
• Identify the process steps needed for
  implementation
• Identify components of the preceptor training
  program

20
Before

• Turnover Rates 2007
• Licensed Nurses 51!!!

YIKES
21
Getting Ready for Change

• Infrastructure
• Human Resources
• Regional Nurse Educators
• Preceptors

22
Human Resources

• Considerations
• Role definition
• Education calendar
• General orientation schedule
• Mastering Caring Leadership
• Turnover and retention tracking system

23
Regional Nurse Educators

• Considerations
• Site selection
• Clinical skills labs
• Classroom settings
• Equipment and Supplies
• Skills validation process

24
Preceptors

• Considerations
• Compensation model
• Training sites
• Selection process
• Training
• Follow-up

25
Putting it all Together
Day Task Location
1 General Orientation Facility of hire
2 Mastering Caring Leadership Regional training center
3 Disease Management Physical Exam Series Regional training center
4-5 Clinical Skills Validation Regional training center
6 Preceptorship Classroom Facility of hire
7-10 Preceptorship On-the-unit Facility of hire
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After

• Turnover Rates
• Licensed Nurses 15!!!

yippee
27
Facility Perspectives

• Views from a facility team
• Director of Nursing
• Henrietta Makowski
• Regional Nurse Educator
• Rose Zlotecki

28
Thank You!

• Questions