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Setting the Stage for Clinical and Service Quality Improvement Jennifer Lundblad, PhD, MBA Jane Pederson, MD, MPH August 8, 2007: 

Setting the Stage for Clinical and Service Quality Improvement Jennifer Lundblad, PhD, MBA Jane Pederson, MD, MPH August 8, 2007

Goal and Objectives: 

Goal and Objectives Goal: “Learning and dialogue on current state, what’s possible, and how to get there” Objectives: Commission members will… Expand their perspective on what drives and sustains nursing home quality, including the role of culture and leadership Be able to describe the keys to clinical and service quality improvement

Who is Stratis Health?: 

Who is Stratis Health? Independent, non-profit organization Physicians, nurses, data analysts, quality improvement professionals on staff Serve full continuum of health care settings Work with providers and consumers to improve health care Serves as Medicare Quality Improvement Organization (QIO) for Minnesota

Multiple Converging Forces in Long-Term Care Quality: 

Multiple Converging Forces in Long-Term Care Quality Increasing attention to long-term care quality and culture over the past 5+ years: Transparency Technical Assistance for Improvement Culture Change

Converging Forces (cont.): 

Converging Forces (cont.) Transparency Medicare made nursing home-specific quality measures available (2002) In MN, DHS and MDH developed the Nursing Home Report Card (2006) National quality campaign launched (2007), “Advancing Excellence in America’s Nursing Homes” 46% of Minnesota NHs have signed on to date

Converging Forces (cont.): 

Converging Forces (cont.) Technical Assistance for Improvement Medicare began making technical assistance for improvement available to NHs via the QIO program (2002) In MN, Stratis Health launched statewide training and support (pain, pressure ulcers starting in 2002; added restraints and depression in 2005) In MN, Stratis Health invited NHs to participate in collaborative improvement initiatives (68 NHs from 2002-2005 and currently 53 NHs starting in 2005)

Converging Forces (cont.): 

Converging Forces (cont.) Culture Change St. Louis Accord launches national discussions and activity around changing cultures in nursing homes (2005) Minnesota Culture Change Coalition formed (2005) Offering educational programs, resources, momentum Pioneer Network hosts its national conference in Minnesota, with more than 1,000 participants (August 2007)

And has this changed NH quality?: 

And has this changed NH quality?

Underlying Question: 

Underlying Question How do we organize our systems around the people who live & work in nursing homes to bring Quality of Life? Steven Shields Video Clip

The Culture Change Journey: 

The Culture Change Journey

What is Culture Change?: 

What is Culture Change? Culture change in long term care is an ongoing transformation in the physical, organizational, and psycho-social-spiritual environments that is based on person-centered values. Culture change restores control to elders and those who work closest with them. Pioneer Network


Resident Centered Care Resident choice is a consideration in planning care Shows movement in culture change journey


Holistic Approach to Transformational Change HATCh™

Rule of Thumb: 

Rule of Thumb Ask Yourself/Team: Does this system (or the change we are considering) allow for greater power or input to be exercised by the resident or those closest to them? Will this system (or the change we are considering) heighten the quality of life, experience or lifestyle of the resident and staff?

Goal: Move Inward: 

Goal: Move Inward

Transformative Work Place Practice: 

Transformative Work Place Practice


Transformative Work Place Practices Establish relationships as the number one organizational priority High Quality Leadership A Culture of Valuing and Respecting Caregivers and Their Needs High Performance Human Resource Policies Motivational Work Organization and Care Practices Sufficient Staffing Ratios and Support for High Quality Care

Transformative Practice in the Environment: 

Transformative Practice in the Environment

Transformative Environmental Practices : 

The creation of sanctuary, shelter and peace that provides a sense of community, safety and free of unwanted intrusions The creation of beauty and comfort De-institutionalize the common rooms (bathrooms, living areas) Design for accessibility Attention to adequate lighting Provide for nature Demonstrate affection, validation and support Encourage personal items that reflect individuality personal space, shrines Shift towards neighborhoods, communities Transformative Environmental Practices

Transformative Care Practices: 

Transformative Care Practices


Transformative Care Practices Resident-inclusive choices Waking and sleeping Meals - service, delivery, variety Food preferences Daily routine Bathing - frequency, time, method Activities of daily living Activities Rituals & celebrations High quality clinical care with resident, family, staff input Innovative, creative care solutions “I” format care plans Community mourning


Beware! Artifacts: the trappings and superficial displays of culture change Having mailboxes and front doors, yet no one knocks or takes seriously the privacy it is meant to offer Fin, fur, and feather Food line buffet Memory boxes Brag board

Deep Culture Change: 

Deep Culture Change Ability to assimilate the three domains more and more deeply into the lives of residents Ability to provider broader and greater opportunity for the people who live and work in nursing homes to have power over their lives and lifestyles Puts into the hands of each individual the opportunities needed to live their best life


Rules Policies & procedures Disciplinary action Ensuring compliance Citations & deficiencies Establish a need for change Creating a shared vision for future Engaging all in the process Modeling & coaching staff Celebrating


0 Average state benchmark for best practice implementation … As adapted average changes…. What was once average becomes the outlier


This material was prepared under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 8SOW-MN-1aNH-07-37 08.2007 Stratis Health is a non-profit independent quality improvement organization that collaborates with providers and consumers to improve health care.

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