Advancing Excellence Helps Providers Boost Quality

January 14, 2015 | by Debra Wood, R.N.

Careful data collection and analysis, paired with tools and help from other providers, improve the quality of long-term care services and supports. Here is how the Advancing Excellence campaign is helping skilled nursing providers achieve their best.

Across the health care continuum, enhancing quality and care recipients’ experience has become a national focus. In the long-term care arena, the Advancing Excellence in America’s Nursing Homes campaign aims to help nursing homes and other organizations that offer long-term care services and supports improve quality and clinical outcomes.

“We are making nursing homes better places to live, work and visit,” says Douglas Pace, executive director of Advancing Excellence. “It’s about the people we care for, and it also has tremendous benefits for the staff who work there. We believe the cornerstone of any good building is a strong stable staff. Then the family members and others that come see the difference and an organization that believes in quality.”

The Advancing Excellence campaign launched in 2006, with support from LeadingAge and 27 other stakeholders.

“More than a decade ago, the quality of nursing home care was highly questionable as evidenced by numerous indicators,” says Larry Minnix, president and CEO of LeadingAge. “We, along with the two other provider associations, decided to create a national quality movement, called Quality First. From that movement emerged Advancing Excellence.”

A steering committee selected four clinical and four organizational goals and provided educational resources for participating facilities to achieve those objectives. The campaign established Local Area Networks of Excellence, called LANE, organizations to provide local leadership and guidance for the campaign at the state level.

“Over the last decade, nursing home quality has improved, and it’s been noted by CMS officials to us that Advancing Excellence is an outstanding example of how a public-private partnership can work to improve quality in health care,” Minnix says. “What we are encouraging now is for anyone with a nursing home to sign up. It’s time for everyone to get in the game, and by doing so, we will improve quality of care in demonstrative ways and improve our reputation.”

To date, 9,738 nursing homes, 62.3 percent of the nation’s licensed nursing homes, have registered and expressed a commitment to quality.

“We provide free online resources to help nursing homes in their evidence-based quality improvement programs,” Pace says.

Advancing Excellence receives funding through grants and dues. The Centers for Medicare & Medicaid Services (CMS) provides some funding for the website, which offers nursing homes free resources, data-collection tools and trend graphs.

The initiative recently began offering provider memberships, which allows nursing homes to participate in national workgroups and offer direction about the future of the campaign. The cost is $1 per licensed bed annually.

Parker Jewish Institute for Health Care and Rehabilitation in New Hyde Park, NY, joined, actively participates in the monthly meetings and has found its participation beneficial.

“It’s a wonderful supportive group for long-term care providers,” says Georgiene Kenny, vice president of quality management. She reports Advancing Excellence has adopted some Parker Jewish ideas, such as a recognition program that gives employees nominated by a co-worker or resident a gift card, plaque and parking space.

“On an organizational level, it has helped us,” adds Michael Rosenblut, president and CEO of Parker Jewish. “Two to three years ago, we took an Advancing Excellence template looking at competencies to retain all staff and RNs. Utilizing the template was helpful and gave us a level of comfort about having practices implemented to maintain the best team.”

Three years ago, Advancing Excellence developed nine clinical and organizational goals for nursing homes. Clinical goals include reducing infections, reducing inappropriate antipsychotic medication use by residents with dementia, reducing pain and pressure ulcers, and increasing mobility. Organizational goals focus on making consistent assignments, reducing avoidable hospitalizations, providing person-centered care and developing staff stability. Pace reports that organizational goals may be easier, initially, for some homes.

Twenty-six percent of homes have committed to working on two goals, at least one organizational, and are entering data at the Advancing Excellence website to track their progress. All of the information submitted is HIPAA-compliant and it does not include any resident-level data.

Mother Angeline McCrory Manor, a skilled nursing provider in Columbus, OH, has been submitting data to Advancing Excellence about the use of psychotropic medications, rehospitalizations and consistent staffing.

“We use the antipsychotic metric for quality assurance,” says Sr. Mary Rose Heery, assistant administrator at Mother Angeline. “It’s very concise in the information it provides and tracks for you.”

For rehospitalizations, the data helps analyze why residents were returned to the acute-care setting, explains Heery. The nurses complete a check sheet for later analysis. The data is available for online review by a variety of disciplines.

“Once we know why they are going to the hospital, we can do prevention — skill training, family education, early detection,” Heery says. “Anytime we can collaborate with interdisciplinary departments, it helps in resident outcomes.”

Advancing Excellence offers homes an opportunity to produce trend graphs. Continuing care retirement communities can use the tools for different units and internally benchmark between settings—for instance, how well the assisted living unit is providing consistent staffing compared to the nursing home unit. Later this year, when it has accumulated a critical mass of data, Advancing Excellence expects to offer benchmarking of the trend graphs against other homes working on that goal at the state and national level.

“As a provider, you want to participate to be able to show how you are using a dedicated quality improvement program in your community and have certain areas you are focusing on,” Pace says.

Heery appreciates the common language that Advancing Excellence provides, making it easier to discuss outcomes and progress with different homes within the Carmelite System, a health system comprised of long-term care communities in seven states and Ireland.

Episcopal Church Home in Louisville, KY, has used Advancing Excellence to reduce pressure ulcers and is now using the readmissions tool to track progress on unnecessary trips to the hospital. Kathy Shireman, director of clinical services at Episcopal Church Home, said it saves her hours of time researching best practices.

“Advancing Excellence gives me tools, standards for comparison and materials for developing protocols,” Shireman says. “I don’t have a corporate office to create things for me. This gives us a jump on keeping on track with methods of tracking and trending and formulating ideas, considering what other facilities might do and for implementation.”

Parker Jewish, on the other hand, has in-house quality improvement staff. Kenny says she uses the Advancing Excellence tools when introducing someone new to quality improvement and monitoring outcomes, such as readmissions and pressure ulcer healing rates.

“We’re proud to be a member, and it has had an impact on how we deliver care and control hospitalizations,” Rosenblut adds. “We’ve seen a decrease from 2013 to 2014 in acute care hospitalization.”

Among the resources Advancing Excellence has developed is a Circle of Success framework. It begins with exploring the goal and identifying baselines and setting targets. What follows is examining the process and asking probing questions and creating improvement through evidence-based practices, involving leaders and stakeholders. Then it ends by monitoring progress and sustaining the goal, celebrating success and starting again on a new goal.

“We are teaching them about root-cause analysis and asking probing questions,” Pace says.

Homes have begun to internally benchmark and conduct those analyses when metrics need improvement.

“Once you know where you are, you have to decide where you want to be and how you get there,” explains Carol Scott, field operations manager for Advancing Excellence. “Probing questions prompt each nursing home to ask why they are doing what they’re doing and start them thinking about what changes need to be made.”

Advancing Excellence has developed fact sheets to inform residents, families and staff about the quality improvement process. The campaign encourages homes to invite each of the stakeholders to participate.

“We believe in transparency and engagement of residents and family members and all levels of staff,” Pace says. “We want to see this as something proactive.”

Scott adds that for success, a home “needs buy-in from everyone. You need to have everyone giving ideas about how things could change.”

The Centers for Medicare & Medicaid Services developed the Quality Assurance Performance Improvement program in response to requirements from the Affordable Care Act to establish and implement such a program for nursing homes. It will address all systems of care and management practices.

CMS has developed a program of technical assistance that includes tools, resources and training materials to help nursing homes implement QAPI, which takes a systematic, comprehensive and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving, says Debbie Lyons, RN, a health insurance specialist at CMS in Baltimore.

“CMS believes that now is the time for nursing homes to get started with laying the foundation for QAPI,” Lyons adds. “CMS wants facilities to understand that although there is no regulation at this time, QAPI materials can help with all of their quality work.”

The Advancing Excellence tools were created to align with the CMS Quality Assurance Performance Improvement (QAPI) regulations. Pace explains that Advancing Excellence prepares a provider for participating in QAPI, and that it is complementary to, not in competition with, the LeadingAge Quality Metrics program.

(For more on Quality Metrics, see the article, “Running the Numbers: Quality Metrics, LeadingAge Insights Help Providers Keep Focus on Quality” in this issue.)

Kenny has found Advancing Excellence goals to be similar to those of CMS, which refers to QAPI as a “data-driven, proactive approach to improving the quality of life, care, and services in nursing homes.”

“Advancing Excellence provides excellent evidence-based tools and resources to help nursing homes improve their systems of care and service delivery by using QAPI principles as they work through the Advancing Excellence goals,” says Debbie Lyons, RN, a health insurance specialist at CMS in Baltimore. “They are supported in applying QAPI principles through implementation of performance improvement projects, using data, feedback, and conducting systematic analysis to develop systemic actions specific to the goals they’ve selected.”

Staff, residents, family members and the community can register their interest in improving the quality of life and quality of care in nursing homes by signing up on the Advancing Excellence website. People can also sign up for the monthly e-newsletter which contains the latest news and updates to the campaign.