9/20/2016 Bridging From Bronze To Silver Continuing The .

9/20/2016Bridging from Bronze toSilver Continuing the JourneySandy Kingsley, Director of QAPI, Wilmac Corp.Silver Quality Award ExaminerDawn Murr-Davidson, Director of Quality Initiatives, PHCASilver Quality Award ExaminerWhy should my organization take the next step in the QualityAward Journey?Quality Award Program ValueProposition Silver and Gold Quality Award recipients demonstrate betterresults than peers: Five Star Rating Health Outcomes Financial Performance1

9/20/2016Total Number of nze2014Silver20152016GoldNumber of Recipients3,4054952830 Day Hospital Readmissions30 Day Hospital ReadmissionsAHCA Members17.3Nation17.2Quality Award Recipients16.616.216.416.616.81717.217.430 HOSPITAL READMISSION RATES2

9/20/2016Off-Label Use of .5Off-Label Antipsychotic UseQuality Award RecipientsNationAHCA MembersFive Star Quality RatingAHCA MembersNationQuality Award Recipients051015202530354045% BY RATING5 Stars4 Stars3 Stars2 Stars1 StarFive Star Overall RatingAHCA MembersNationQuality Award Recipients05101520253035404550% BY RATING5 Stars4 Stars3 Stars2 Stars1 Star3

9/20/2016Occupancy Rate8685.485848382.28281.5818079Occupancy RateQuality Award RecipientsNationAHCA MembersGross Margin10.50.450Quality Award RecipientsNationAHCA Members-0.5GROSS MARGIN-1-1.5-1.7-2-2.5-3-3.5-3.5-44

9/20/2016Step 1: Learn about the BaldrigeFrameworkBaldrige FrameworkPromotes: Managing all components of your organization as aunified whole to achieve ongoing success (systems perspective)Purpose: Analyze organizational performance Quantify performance through results Identify areas for improvement or change5

9/20/2016Seven Critical Aspects of BaldrigeSix of Seven Critical Aspects are Interrelated ProcessesSeventh Aspect focus on ResultsNote: These critical aspects are known as the Core Elements on the Silver ApplicationBaldrige Focus Areas Core Values and Concepts: Baldrige is based on a set of beliefs andbehaviors which serve as the foundation for integrating key performanceand operational requirements with a results-oriented framework thatcreates a basis for action, feedback and ongoing success. Processes: Methods your organization uses to accomplish work. Results: Three pronged approach to examining resultso External Viewo Internal Viewo Future View Linkages: An essential element for understanding the connectionbetween the Health Care Criteria categories.Core Values and Concepts Systems perspectiveVisionary leadershipResident-focused excellenceValuing peopleOrganizational learning and agilityFocus on successManaging for innovationManagement by factSocietal responsibility and community healthEthics and transparencyDelivering value and resultsNote: These core values and concepts are questions throughoutthe Silver Application6

9/20/2016The Four Dimensions of Process Approach: How does your organization go about designing andselecting effective processes methods and measures? Deployment: How does your organization go about implementingyour approach consistently across the organization? Learning: How does your organization assess progress and capturenew knowledge, including looking for opportunities forimprovement and innovation? Does your organization review itsprocesses? Integration: How does your approach align with the needs of theorganization ensuring that measures, information and improvementsystems complement each other across the processes and workunits to achieve organizational goals?Note: These are the scoring criteria for each core element inthe Silver ApplicationResults Results include all areas important to your organization There are four dimensions to evaluating results:o Levels: Current performance on a meaningful measurement scaleo Trends: The direction and rate of change of your resultso Comparisons: Performance relative to that of other, appropriate organizations such ascompetitors or organizations similar to yours and to benchmarks or health care industryleaderso Integration: Are the results being tracked meaningful to the organization? Are the results being utilized to support organizational goals and to revise plans?Results: Key Terms Fact-Based: Data and information driveno Examiners need to validate results based on information in the application Systematic:o Consistent and repeatableo Based on datao Provide opportunity for evaluation, improvement, innovation and knowledge sharing Effective: Refers to the extent to which a process addresses(or appears to address) its intended purposeo Examiners determine whether the process is likely to do what the criteria require Learning: Refers to acquiring of new knowledge through factbased evaluation which leads to value-added cycles ofimprovement and innovation7

9/20/2016Linkages Linking the criteria categories are an essential element of thesystems perspectiveo Examples: Do processes connect to results? Is the need for data in the strategic planning process identified for improvingoperations? Is there a connection between the strategic plan and the workforce plan? Is there a link between market knowledge and the strategic plan? Does the resident and other key stakeholder data establish action plans?Step 2: Self-AssessmentSelf-Assessment Overview Self-assessment as an organization is important or we can endup like this picture. AHCA/NCAL is piloting a self-assessment The self-assessment consists of several sections Today we are providing an overview of a few samplequestions The Self-Assessment will serve as the foundation for the PHCASilver Workshop8

9/20/2016Self-Assessment Questions Organization has successfully achieved the Bronze LevelAward Organization is a member in good standing with AHCA/NCAL Item 2.1Category 2: Strategy Category examines HOW your organization developsSTRATEGIC OBJECTIVES and ACTION PLANS, implements themand MEASURES progress. Basic Item:o How do you develop strategy? Overall Item Requirement:o Do you presently have written strategic objectives, related to goals and a timetable forachieving them?o Do these Strategic objectives specifically ling to or address the strategic challenges ofyour organization?o Can you show evidence of evaluation of the strategy development process itself?9

9/20/2016Category 2: Strategy Considerations Deals with the overall organizational strategy Might include changes in HEALTH CARE SERVICE offerings,PROCESSES for patients and/or other CUSTOMERENGAGEMENT Describe the methods used to evaluate and improve theeffectiveness of the strategy development process Strategy development refers to your organization’s APPROACHto preparing for the future. STRATEGIC OBJECTIVES define in measurable terms what theorganization needs to achieve to be successful and shouldfocus on specific challenges, advantages and opportunitiesmost important to the organization.Category 2 ExampleStrategic Objective2.1aGoals 2.1aAction Plan 2.2bMeasure2.2bFig #Projection 2.2cAchieve excellentquality resultsAROH quality measureswill be at or below all stateand national benchmarksQMs will be reviewedmonthly by seniorleadership and QA processwill be employed tomitigate any negativetrends or isolatedincidentsQM MDS 3.0Casper reportingresults7.1-17.1-27.1-37.1-47.1-5At or belownationalbenchmark in 4out of 5 key areasAchieve excellentcustomer and familysatisfaction resultsCustomer satisfactionsurveys will maintain a90% or higher satisfactionratingABAQIS surveys will bereviewed as completedand analyzed duringmonthly QACustomerSatisfactionsurvey results7.2-190% or morePositive trend overpast 3 years.ABAQIS survey results toexceed 90% satisfactionand above nationalbenchmarksABAQIS surveys will bereviewed as completedand analyzed duringmonthly QAABAQIS surveyresults7.2-290% or morePositive trendsinceimplementationMaintain 25% or lessTurnover andMonthly QA all voluntaryandTurnover andRetention Rates7.2.2-17.2.2-2Trending at 25%and 80%Be the employer ofchoice in ourApplication Writing Tip: Use of Tables is very valuable and many times can assist theexaminer, BUT it is important to follow the technical guidelines for table usage. Item 2.110

9/20/2016Category 4: Measurement, Analysisand Improvement Category examines HOW the organization measures, analyzesand then improves the organizational PERFORMANCE Basic Item Requirement:o How do the organization measure and analyze and then improve organizationalperformance? Overall Item Requiremento How do you use DATA (and information) to track daily operations and analyze overallorganizational PERFORMANCE?o How do you use COMAPARATIVE DATA?o How do you review and improve your organization’s PERFORMANCE?o What are your KEY PERFORMANCE MEASURES?Category 4: Measurement, Analysis,and Improvement Considerations Describe the methods used to evaluate and improve the effectiveness of themeasurement, analysis and organizational performance improvement processPerformance analysis includes:o Examining PERFORMANCE TRENDS—organizational, health care industry, and comparisons;cause and effect relationships and correlationso Analysis should support performance reviews, help determine root causes and help setpriorities for resource useo DATA and information from the review of organizational PERFORMANCE should be used tosupport fact-based decisions Organizational Performance review should include KEY PERFORMANCE RESULTS,including those related to STRATEGIC OBJECTIVES and ACTION PLANSKey performance results should be reported in Category 7.Category 4: Example4.1.a. AROH measures, analyzes, reviews and improves performance through the use of data andinformation at all levels and in all parts of our organization during annual strategic planning, monthly QAmeetings, and during daily stand up meetings. The data reporting tools and benchmarks for performanceimprovement are established during the initial lauch of a PDSA during the QA process by the senior leadershipteam(see table P.1.b 3 and 2-1). The data and information is reviewed monthly during QA meetings to ensurethat they are relevant and useful and the measures and sources are appropriate to measure improvement. Forexample, the senior leadership team determined that utilizing monthly staff turnover reports and annualsatisfaction surveys were the best method and reporting tools to measure employee satisfaction andengagement. Other data could be analyzed including employee exit interviews and reasons for terminations todetermine root cause and develop action plans, but the actual trending of satisfaction would be based on theoverall turnover percentage. AROH also considers that outside information is highly important forbenchmarking quality and improvement throughout an organization and industry. Therfore, we utilize OHCAtrendtracker, CMS nursing home compare, MDS 3.0 quality measures and other non-Avamere sources tomeasure and trend our process and quality improvement. Spelling is not marked down on an application, but does impact the Examiners overall impression duringreview. Proof reading, proof reading, proof reading.Follow Technical requirements on the use of ACRONYMS or Spell Out11

9/20/2016Step 3: Formulate a PlanStep 3: Formulate a Plan Start Early Read the Application Conduct a Self-Assessmento Remember the Journey Utilize a Team ApproachCreate an Action PlanMark Calendars and Stay on TrackUtilize the videos available on the AHCA Web SiteAttend the PHCA WorkshopApplication Overview Elements of the Applicationo Organization Profileo Six Baldridge Interrelated Process Categorieso Seventh Baldrige Category—Results, Results, Results Review Application Deadlines and Feeso Page 4 of the Application Bookleto Intent to Apply Deadline: Thursday, November 17, 2016 at 8pm ESTo Application and Payment Deadline: Thursday, January 26, 2017 at 8pm EST Review Application Policies and Eligibilityo Page 6 of the Application Booklet Review Submission Processo Page 15 of the Application Booklet12