Nursing Home Quality Initiative Newsletter - Fall 2007

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Are you a part of a group or a team? Can you tell the difference?

Throughout the Nursing Home Quality Initiative (NHQI) IPRO's quality improvement coordinators (QICs) have been working with multidisciplinary nursing home staffs formulating teams to enhance quality improvement (QI) programs and improve the chronic pain, physical restraint, depression/mood worsening, and high-risk pressure ulcer quality measure (QM) rates.

Groups Teams
Members work independently and they often are not working towards the same goal. Members work interdependently and work toward both personal and team goals with an understanding that these goals are accomplished best by mutual support.
Members focus mostly on themselves because they are not involved in the planning of the group's objectives and goals. Members feel a sense of ownership toward their role in the team as the commit themselves to goals hey helped create.
Members are given their tasks or told what their duty/job is; suggestions are not encouraged. Members collaborate together and use their talent and experience to contribute to the success of the team's objectives.
Members are very cautious about what they say and are afraid to ask questions. They may not fully understand what is taking place in the group. Members base their success on trust and encourage all members to express their opinions, and varying views and ask questions.
Members do not trust each other's motives because they do not fully understand the role each members plays in their group. Members make a conscious effort to be honest, respectful, and listen to every person's point of view.
Members may have a lot to contribute but are held back because of closed relationship with each member. Members are encouraged to offer their skills and knowledge, and in turn each member is able to contribute to the group's success.
Members are bothered by differing opinions or disagreements because they are considered a threat. There is no group support to help resolve problems. Members see conflict as a part of human nature and react by treating it as an opportunity to hear about new ideas and opinions. Everybody works toward a constructive resolution of issues.
Members may or may not participate in group decision-making and conformity is valued more then positive results. Members participate equally in decision-making, but each member understands that the leader might need to make the final decision if the team cannot come to a consensus agreement.
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Successful Teams

We are proud to highlight some of the facilities that have worked with IPRO in the 8th Scope of Work who have adopted the teamwork concept, and as a result experienced considerable successful Quality Improvement (QI) outcomes.

Mary Manning Walsh Home

Mary Manning Walsh Home (New York, NY), under the encouragement and support of its administrator Sister Sean William O'Brien, has been very active in the Centers for Medicare & Medicaid Services (CMS) NHQI 7th and 8th Scopes of Work (SOW). The facility regularly uses IPRO generated materials, suggested guidelines and recommendations, and participates in IPROs NHQI collaborative, openly sharing materials developed with others.

Our Lady of Mercy Life Center

Our Lady of Mercy Life Center (Guilderland, NY) has shown consistent involvement with IPRO sponsored activities, is willing to try new tools, share quality practices and is always open to new ideasfor improvement. The facility has shown improvement in the clinical quality measures (Q2 04-Q4 06) as follows: High-Risk Pressure Ulcers - 75%, improvement Chronic Pain - 63% improvement, Physical Restraints - 27% improvement Depression/Mood Worsening - 60% improvement. Our Lady of Mercy Life Center credits their QI accomplishment to their interdisciplinary team approach to QI activities, systems and processes of care. Colin McCarty, Quality Improvement Specialist, notes that his facility has benefited from focusing on education and supervision, and the enhancement of key areas of opportunity for improvement. The facility attributes the improvements in the clinical quality measures to an ongoing emphasis on education and process improvement. The Our Lady of Mercy Life Center team monitors their process improvement efforts on a monthly basis using data analysis and medical record review and is extremely proud of the effectiveness of their intervention and accomplishments to date.Our Lady of Mercy Life Center.

St. Johnsville Rehabilitation and Nursing Center

St. Johnsville Rehabilitation and nursing Center (St. Johnsville, NY) remains active in IPRO sponsored QI activities, has utilized the IPRO generated pressure ulcer and falls tracking tools, developed an aggressive pain management program and has adopted a systems-wide team approach to ongoing QI activities. This facility has shown improvement in the clinical quality measures (Q2 04-Q4 06) as follows: High-Risk Pressure Ulcers - 47% improvement, Chronic Pain - consistently remained at 0%, Physical Restraints - 50% improvement, Depression/Mood Worsening - 58% improvement. Lisa Volk, Administrator, notes, the focus of the interdisciplinary team at St. Johnsville is to improve the quality of life for the residents they serve. Ms. Volk also comments that the tools and guidance provided by IPRO's NHQI team has helped the St. Johnsville team succeed with their QI efforts. St. Johnsville attributes their high-risk pressure ulcer QI rates to the interaction of the skin team consisting of interdisciplinary staff members who are committed to the ongoing assessment and treatment of pressure ulcers based on quality practices. The team is active in weekly pressure area skin rounds whereby consistent assessment, evaluation, intervention and treatment of wounds is coordinated. In addition, St. Johnsville attributes the reduction of the number of residents who are physically restrained with a team approach to assessing and reviewing monthly QI/QM data and developing creative strategies to reduce overall percentages. Use of the IPRO generated falls tracking tool has assisted the team with assessing and evaluating fall trends and the implementation of timely QI intervention. As for the chronic pain quality measure, to accurately capture residents' pain frequency and intensity levels, St. Johnsville QI teams focus their efforts on assuring accurate pain assessment and MDS coding. This is done through the provision of educational sessions, resources and materials, which give staff the tools necessary to accurately and efficiently recognize the verbal and non-verbal signs of residents who are/are not experiencing pain.

Sea View Hospital Rehabilitation Center & Home

Sea View Hospital Rehabilitation Center and Home (Staten Island, NY), as earned Recognition of Achievement for their QI progress throughout the CMS NHQI 8th SOW. As part of an Identified Participant Group (IPG) of Nursing Homes working with IPRO, Sea View has demonstrated true collaboration and accomplishment throughout their QI journey. According to Violet Huie, Administrator, the dedicated and hardworking staff at Sea View strives to provide quality care and quality of life to the residents living in the facility. The organization-wide commitment to QI, and sharing successful practices has helped Sea View meet their goals as follows: Sea View visited and collaborated with several long-term care facilities with successful restraint reduction programs, formed teams consisting of diverse interdisciplinary staff, adopted quality practices, revised policies and procedures, performed aggressive literature review, and conducted educational programs that included the sit-for-in-service's model whereby staff were restrained for the duration of the education session.

Restraints

Sea View's efforts to eliminate the percent of residents who were physically restrained has resulted in a 62% improvement from Q2 04 to the most recent, Q4 06. To achieve this improvement, Sea View visited and collaborated with several long-term care facilities with successful restraint reduction programs, formed teams consisting of diverse interdisciplinary staff, adopted quality practices, revised policies and procedures, performed aggressive literature review, and conducted educational programs that included the sit-for-in-service's model whereby staff were restrained for the duration of the education session.

Chronic Care Pain

Reducing the percent of residents who had moderate to severe pain was also a focus at Sea View. The inclusion and participation by all levels of staff, initiation of non-pharmacological methods to alleviate pain, revision of pain assessment protocols and tools helped Sea View achieve a 39% improvement from Q2 04 to Q4 06. From the improvement noted, it is evident that Sea View is well on the way to attaining their goal of optimizing pain relief, sustaining/improving residents' level of functioning, and enhancing residents' quality of life.

High-Risk Pressure Ulcers

Looking to reduce the percent of residents with pressure sores, Sea View's interdisciplinary team took action. Attaining the goal incorporated on-going education, revising current practice, implementing weekly wound rounds, adopting a gold standard risk assessment protocol, enhancing the wound product formulary, and purchasing of specialized support surfaces. Sea View's intervention is going in the right direction as they have shown a 33% improvement from Q2 04 to Q4 06 for high-risk residents with pressure sores.

Depression/Mood Worsening

Sea View recognized the interdisciplinary team approach was essential for reducing the percent of residents who have become more depressed or anxious. The QI interventions included enhanced education, adoption of the IPRO generated Mood Scale Score worksheet and the Cornell Depression scale, enhanced screening protocols, and policy revisions. Through on-going quality intervention, Sea View has noted a 29% improvement from Q2 04 to Q4 06 in reducing the number of residents who have become more depressed or anxious.

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Are you part of a group or part of a team? How to move from GROUPS to TEAMS.

After analyzing the chart on the cover page, it should be clear which category (groups or teams) is most essential to QI and quality of life in long-term care. Appreciating that cohesive teams are the catalyst to effective QI, one might ask how can a group of staff members be transitioned facility to move from groups to teams?
CHARACTERISTIC GROUPS OF STAFF MEMBERS TEAMS
Goals and decisions Make by the leadership Made jointly by team and leadership
Goal Leadership's primary goal is to get the job done Team leader works to get results and develop team members
Work Each staff person is responsible for their own work Team members feel responsible for everyone's contribution
Assignments Made by leadership Made jointly by leadership and members of the team
Role of Staff Primarily to carry out assignments Team members initiate action, make suggestions and help with planning
Communications Close meetings, primarily between the leader and a staff member Open to all team members
Differences and conflicts Avoided or smoothed over Regarded as enriching and are worked through
Critical feedback Rare and anxiety provoking Regarded as essential to improvement
Primary virtues Loyalty and being a "good soldier" Trust, helping and creativity
Sharing of data Data shared on a need to know basis All relevant data shared
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Useful References and Web Sites

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