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					                                                                                 Spring 2004
                                                                                 Volume 2, Issue 2




Quality Focus
Enhanced Quality Measures                                                           Websites worth
Since November 2002 when the            The enhanced post-acute care                   surfing
national Nursing Home Quality           measures posted are:
Initiative (NHQI) was launched, we                                                 South Dakota Foundation
                                         ♦ Percent of short stay residents            for Medical Care at
have said that quality measures are        who had moderate to severe pain
dynamic and will continue to be                                                       www.sdfmc.org
                                         ♦ Percent of short stay residents
refined as part of CMS’s ongoing                                                 You will find:
                                           with delirium
commitment to quality. In January                                                  • Quality Measures Resource
2004, CMS began reporting an             ♦ Percent of short stay residents           Manual
enhanced set of quality measures.          with pressure sores                     • Resources on pain,
                                                                                     pressure ulcers, and ADLs
These enhanced measures were            Of the 11 chronic care measures
endorsed by the National Quality        listed above, four of the measures
Forum, a voluntary standard setting,    are clinically related. These four             Medicare Quality
consensus-building organization         measures have been grouped into           Improvement Community at
representing providers, consumers,      two pairs. If one of the measures in
and researchers.                        a pair is selected, the other measure        www.medqic.org
                                        will also be displayed on the Nursing    You will find:
Enhanced chronic care measures                                                     • Facility Checklists
posted on Nursing Home Compare:         Home Compare website. The first set
                                                                                   • Quality Improvement
                                        of paired measures is percent of low         Worksheets
 ♦ Percent of residents whose need      risk residents who have pressure           • Resources on all 14
   for help with daily activities has   sores and percent of high risk               quality measures
   increased                            residents who have pressure sores.
 ♦ Percent of residents who have        The second set of paired measures is
   moderate to severe pain              percent of low risk residents who lose       The John A. Hartford
 ♦ Percent of residents who were        control of their bowels or bladders         Foundation Institute for
   physically restrained                and percent of residents who have/            Geriatric Nursing at
 ♦ Percent of residents who spent       had a catheter inserted and left in       www.hartfordign.org
   most of their time in bed or in a    their bladders.                          You will find:
   chair                                                                           • Katz Index (ADL)
                                        We encourage you to download the
 ♦ Percent of residents whose                                                      • Fall Risk Assessment
                                        revised Quality Measures Resource          • Nutrition and Hydration
   ability to move about in and         Manual (Version 4.0) which is                Assessment
   around their room got worse          available through www.sdfmc.org.           • Urinary Incontinence
 ♦ Percent of residents with a                                                       Assessment
   urinary tract infection              We also encourage you to visit www.        • Beers’ Criteria
                                        Medicare.gov/nhcompare/home.asp            • Many more resources
 ♦ Percent of residents who have
                                        and view your facility’s current
   become more depressed or
                                        quality measure scores. Please note
   anxious
                                        that the quality measure scores for            National Guideline
 ♦ Percent of high risk residents       all facilities are refreshed every              Clearinghouse
   who have pressure sores              quarter. We hope that you visit the
 ♦ Percent of low risk residents                                                   www.guideline.gov
                                        site regularly and track your quality
   who have pressure sores                                                       You will find:
                                        measures over time.                        • Evidence-based clinical
 ♦ Percent of low risk residents                                                     practice guidelines
   who lose control of their bowels     For more information contact
   or bladder                           Bernadette Nelson or Rhonda Streff
 ♦ Percent of residents who have/       at 605-336-3505 or send an email to:
   had a catheter inserted and left     Bernadette: bnelson@sdqio.sdps.org
   in their bladder                     Rhonda: rstreff@sdqio.sdps.org.
QM FOCUS: ADLs
Percent of residents whose need for help with
daily activities has increased
QM Description                                                falls, contractures, and muscle wasting can be
This measure reflects the percent of residents who            expected. Lack of attention to range of motion,
experienced a decline in their ability to perform at          activities, and restorative care can lead to more
least one of four late-loss activities of daily living        rapid decline in ADL function. Additional clinical
(ADLs). Activities of daily living are the activities         information regarding decline in ADLs, as well as
people must perform daily to function at their                quality improvement strategies for prevention of
highest level of independence. The ADLs measured              decline, can be found on CMS’s website at
in this QM are level of independence in eating,               www.MedQIC.org.
ability to move in bed, ability to move from one              MDS Assessments Used
chair to another, and ability to go to the bathroom
                                                                  • Target assessment: OBRA Full (AA8a = 01,
independently.
                                                                      02, 03, or 04) or Quarterly Assessment
Rationale for ADL QM                                                  (AA8a = 05 or 10). Latest assessment with
Personal mastery of activities of daily living and                    assessment reference date (A3a) within the
mobility are as crucial to functional independence                    3-month target period.
in the nursing home as they are in the community.                 • Prior assessment: AA8a = 01, 02, 03, 04, 05,
The nursing home is unique only in that most                          or 10. Assessment reference date (A3a) must
residents require help with self-care functions. ADL                  be in the window of 46 days to 165 days
dependence can lead to intense personal distress                      preceding the target assessment reference
such as invalidism, isolation, diminished self-worth,                 date.
and a loss of control over one's destiny. As inactivity
increases, complications such as pressure ulcers,



MDS ADL Definitions
             ADL Item                                    ADL Definition
                                      How a resident moves to and from a lying position, turns
           Bed Mobility - G1a
                                      side to side, and positions body while in bed.
                                      How the resident moves between surfaces, i.e., to/from bed,
                                      chair, wheelchair, standing position. Exclude from this
            Transfer – G1b
                                      definition movement to/from bath or toilet, which is
                                      covered under Toilet Use and Bathing.
                                      How the resident eats and drinks, regardless of skill.
             Eating – G1h             Includes intake of nourishment by other means (e.g., tube
                                      feeding, total parental nutrition).
                                      How the resident uses the toilet room, commode, bedpan,
            Toilet Use – G1i          or urinal, transfers on/off toilet, cleanses, changes pad,
                                      manages ostomy or catheter, and adjusts clothes.

          Walk in Room – G1c          How resident walks between locations in his/her room.


         Walk in Corridor – G1d       How resident walks in corridor on unit.


Page 2                                                                                                  Quality Focus
Team Building                                                        RESOURCES for LTC
                                                           The Adult Services and Aging's Ombudsman Program is
The formation of effective teams is imperative to the      a valuable resource for your facility as well as your
quality improvement process. It is important to            residents. Their most often requested inservices are
recognize that all teams go through a series of            Sexuality in the Long Term Care Setting, Competence
stages. These stages are forming, storming,                With Compassion (regarding abuse prevention), and
norming, and performing. Team leaders need to be           Resident Rights.
able to recognize these phases, understand that            The Ombudsman Program also has videos available on
they are normal, and use that understanding to             topics such as restraints, Alzheimer's disease, dementia,
relate them to the team process.                           sundowning, confidentiality, resident rights, Parkinson's
                                                           disease, Eden Alternative, conflict resolution, depression
Stage 1 – Forming                                          in the elderly, abuse, neglect, and care of the dying.
Team members are excited and have high                     If you would like more information, or a listing of all
expectations about the prospects of the project.           available video resources for your use in staff/resident/
They are also a little anxious about how they might        family education, phone (605) 773-3656 or e-mail
fit in, and what will be expected of them. Many will       Jeff Askew at Jeff.Askew@state.sd.us or write to
sit back and size up the situation. Very few will take           Adult Services and Aging's Ombudsman Program
the initiative to jump right in. They will depend on             Dept of Social Services
the team leader for direction and structure. Team                701 Governors Drive
leaders need to provide members with a good                      Pierre, SD 57501-2291
orientation and a clear framework for the team to
operate. Team leaders should help the team define
their goals, and clarify roles so the team has a clear
                                                         At this stage, the team leader needs to help
understanding of their mission. This is a stage
                                                         members develop new skills and support
where individuals start to become team members.
                                                         improvements. The leader encourages members to
Stage 2 – Storming                                       take on more power, gradually shifting leadership to
Storming, the most difficult stage, begins after the     the team.
team members realize that teamwork is not as easy        Stage 4 – Performing
as it seems. Disappointment and disillusionment
                                                         The team is ready to focus on its mission. The team
set in, they argue with each other, and they
                                                         members start to solve problems and implement
become testy or overzealous. Cliques can form,
                                                         changes, which is exciting and energizing. The team
power struggles ensue, and anger can be directed
                                                         is working interdependently. There is satisfaction in
at the team leader. Often there is the feeling that
                                                         their progress. Team members recognize each
the team may dissolve. Productivity stalls. The
                                                         others’ strengths and weaknesses. There is
team becomes distracted because of its internal
                                                         constructive self-change. The team leader must
problems. Members are expressing resistance to
                                                         avoid trying to exert control at this stage when the
working collaboratively with each other, but they
                                                         team is building openness to change. By updating
are also beginning to understand each other.
                                                         methods and procedures to support cooperation,
The role of the leader is to allow team members to       the leader will assist the team to understand and
discuss issues, work through differing opinions, and     manage change and will display the success of the
resolve conflict. The leader helps the team to use       team to senior management, other teams, and
feedback and problem solving techniques to resolve       coworkers. With the right tools, the team will be
issues. This really is a productive stage. When the      able to monitor progress and thus to celebrate its
team works through these tough times, they develop       achievements.
self-esteem and confidence in their ability to work
                                                         Teams move through these stages at different
together and share control. The worst thing the
                                                         speeds. A team could go through the stages several
team leader can do at this stage is to jump in and
                                                         times, especially if membership changes. Team
solve the problems for the team.
                                                         leaders must be patient and supportive of the team
Stage 3 – Norming                                        as it moves through the stages. All teams have high
During this stage, the members are becoming a            and low cycles. No matter how well the team works
team, accepting the ground rules, and                    together, progress is never smooth. It’s the leader’s
understanding their roles and those of other             responsibility to provide the direction and support
members. They experience team cohesion, and              to develop a high performance team.
their level of satisfaction increases as they begin to                        This material was adapted from
solve problems and work toward a common goal.                                 Quality Insights of Pennsylvania –
                                                                              Nursing Home Insights – May 2003
Spring 2004                                                                                                     Page 3
NHQI Advisory
Committee
Jeff Askew
    SD Ombudsman Program
Tony Berg, MD
   Winner Regional Healthcare
   Center - Long Term Care
David Brechtelsbauer, MD
   SD Medical Directors Assn.
Mark Deak
   Executive Director, SDHCA
Loren Diekman
   CEO, Jenkins Living Center
Jane R. Mort, Pharm.D.
   Professor of Clinical Pharmacy
   SDSU, College of Pharmacy
Cynthia Riddle
   State Program Coordinator
   CMS, Denver Regional Office
Ken Senger
   Senior Vice President,
   SDAHO
Dan Thayer
   SD Department of Health
   Health Care Facilities                                 Pharmacist’s Corner
   Licensure and Certification                                       Pharmacist’s Corner will be a regular feature in the
                                                                     Quality Focus. The complete article can be found on
Sam Wilson
  Associate Director for
                                                                     SDFMC’s website at www.sdfmc.org/NursingHomes/
  Advocacy, AARP                                                     PharmacistsCorner/Index.cfm

Mark Hoven
   CEO, SDFMC                                   Depression and Activities
Jay Lewis                                            of Daily Living                        Jane Mort, Pharm.D. authors the
   Vice President, SDFMC                                                                    Pharmacist’s Corner. Dr. Mort
                                                         Jane Mort, Pharm.D.                has ten years experience as a
Bernadette Nelson                                                                           long term care consultant
   NHQI Project Manager, SDFMC                  Is there a relationship between ADLs        pharmacist. For the past six
                                                and depression? How are facilities          years she has worked with the
Rhonda Streff                                                                               Geriatric Assessment Team at
   NHQI Assistant Project
                                                following up on depression
                                                management? Even if a resident is on        Rapid City Regional Hospital.
   Manager, SDFMC                                                                           Currently she teaches the
                                                antidepressant therapy, can you be          geriatrics component of the
Gerald Tracy, MD                                sure that his/her ADLs are not affected     pharmacy curriculum at SDSU
   Medical Director, SDFMC                      by depression? Without you having to        College of Pharmacy in
Vicki Wheeler                                   collect any additional information,         Brookings, South Dakota.
   Communications Director,                     what useful piece of information can        Dr. Mort has been at SDSU for 18
   SDFMC                                        you learn about depression                  years, published over 40 articles,
                                                management in your facility?                and given 70 presentations in
                                                                                            the United States. Dr. Mort is the
                                                Find the answers to these questions in      current Chair-elect of the
This material was prepared by SDFMC under
                                                the article Depression and Activities of    American Association of Colleges
a contract with the Centers for Medicare &
Medicaid Services (CMS). The contents pre-      Daily Living in the Pharmacist’s            of Pharmacy, Geriatric Pharmacy
sented do not necessarily reflect CMS policy.
                                                Corner under Nursing Homes on               Special Interest Group.
Item 7SOW-SD-04-18 April 2004
                                                SDFMC’s website (www.sdfmc.org).

				
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