The Development of Person-Centered Care Criteria and

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					The Development of Person-Centered
Care Criteria and Measurement Tools:
Process and Content of a
Multidisciplinary Enterprise

      AHCA Quality Symposium
          San Antonio, TX
         February 18, 2011
           Michael Lepore, PhD
Director of Quality, Research, & Evaluation
    Investigator in Community Health
             Brown University

 Planetree           Brown             My                 IDEAS
 • Heidi Gil         University        InnerView          Institute
 • Susan             • Susan Miller,   • Vivian Tellis-   • Maggie
   Frampton,           PhD               Nayak, PhD         Calkins,
   PhD               • Michael         • Mary Tellis-       PhD
 • Christy             Lepore, PhD       Nayak            • Jennifer
   Davies                                                   Brush
 • Affiliate sites
      Research Support

   The Commonwealth Fund
    ◦ Developing Systems to Support Person-Centered Care:
     Optimizing Planetree’s Continuing Care Designation
     Criteria and Measurement Strategies
   A note on language
For the purpose of this presentation, the terms
 person-centered care and person-centeredness
 are used, though other terms also are recognized
 (patient-centered, resident-centered, family-centered,
 relationship-centered, etc.)
   Person-centered care (PCC) criteria and measures
    ◦ Why develop PCC criteria and measures?
    ◦ How were PCC criteria and measures developed?
    ◦ What are the PCC criteria and measures?
    ◦ How can we use the PCC criteria and measures?
Why develop PCC
criteria and measures?
Why develop PCC criteria and measures?
   The Institute of Medicine identified PCC as a
    healthcare priority
   What is person-centered care?
    ◦ “health care that establishes a partnership among
      practitioners, patients, and their families (when
      appropriate) to ensure that decisions respect patients
      wants, needs, and preferences and that patients have the
      education and support they require to make decisions and
      participate in their own care.” (IOM, 2001, Envisioning a
      National Healthcare Quality Agenda)
    Why develop PCC
    criteria and measures?                   Homelike

   PCC is a complex           Resident                         Close
    concept requiring          direction                    relationships
    multiple dimensions
    of culture change
MJ Koren (2010). Person-      improvement
Centered Care For Nursing       processes
Home Residents: The                         Collaborative
Culture-Change Movement.                      decision
Health Affairs, 29: 312-317                   making
Why develop PCC criteria and measures?

   Benchmark performance internally / longitudinally

   Benchmark performance externally / in comparison
    to competitors

   Understand relationship between PCC and other
    factors (e.g., financial, regulatory performance)
Why develop PCC criteria and measures?

   Long-term care executives call for new measures
    ◦ “I think measurement is key. We have to develop new
      measurements if we want new outcomes. And people
      pay attention to what we’re measuring, and many of
      the current measurements are still good, but we need
      additional measurements.”
      Long-Term Care Improvement Guide
       (available for free download at
How were PCC criteria
and measures developed?
How were PCC criteria developed?
         • Preliminary criteria developed through focus
           groups and expert committee from Planetree,
Step 1     My InnerView, IHI, Joint Commission, etc

         • Preliminary criteria crosswalked with PCC
           measurement tools & literature (evidence base)
Step 2   • Recommendations made for revision (e.g., drop,
           add, merge, split)

         • Criteria revisions reviewed by research team &
           representatives from affiliated LTC sites
Step 3
         • Consensus on criteria established
                A plan for caring touch is developed and
                implemented as appropriate. (Exceptions include
Original        behavioral health patients.) Examples of caring
                touch include massage, healing touch, therapeutic
                touch and Reiki.

                CAHPS Resident Surveys:
                What number would you use to rate how gentle
                the nursing home staff were when they helped
or Literature

                …Beyond implementation of formal caring touch
Revised         programs, patients’/residents’ daily care is
                provided with gentleness.
Multi-Method Evaluation Protocol

             Self        Focus
         Assessment      Groups

           Quality      Satisfaction
         Profile (QP)     Survey
How were PCC measures developed?
         • Preliminary Quality Profile measures suggested
           based on review of existing satisfaction and PCC
Step 1     measurement tools and literature

         • Providers interviewed about measurement needs
           and surveyed about feasibility and importance of
Step 2     preliminary measures

         • Measures reviewed by research team &
           representatives from affiliated provider sites
Step 3
         • Consensus reached on Quality Profile measures
Originally  % of residents who did not die alone (some one
Recommended was within 10 feet some time during the last
Measure     hour) during the month

                                     Importance          Feasibility
                 Nursing home           2.25                3.57
Response from    Assisted living          3                   1
                (Not at all)                                      (Very)

Revised         % of residents who died in place (not transferred
Measure         to the hospital in the 7 days prior to death)
What are the PCC
criteria and measures?
What are the PCC criteria?

     Criterion          2       Criterion
         3                          1

Eleven core
each with           Component
specific criteria
Planetree Components of Person-Centered Care
Component I. Structures &     Component V. Nutrition Program
Functions Necessary for
                              Component VI. Healing
                              Environment: Architecture & Design
Development & Maintenance
of Resident-Centered          Component VII. Arts Program /
Concepts & Practices          Meaningful Activities / Entertainment
Component II. Human           Component VIII. Spirituality &
Interactions / Independence   Diversity
Dignity & Choice
                              Component IX. Integrative
Component III. Resident       Therapies / Paths to Well-Being
Choice & Responsibility
                              Component X. Healthy
Component IV. Family          Communities / Enhancement of Life's
Involvement                   Journey
                  Component XI. Measurement
What are the PCC criteria?
                       centered care    Resident, family
A multi-disciplinary
                       coordinator is     & staff focus
task force oversees
                         designated          groups are
practices                                    conducted

                       I. Structures
                       & Functions
What are the PCC criteria?
                             Staff have the
A comprehensive            opportunity for
presentation on PCC       personalizing care          Numerous
concepts, practices &       in partnership     opportunities are
initiatives is provided   with each resident   provided for staff
for all new staff &                                 celebration,
residents as a part of                                 reward &
orientation                                          recognition

                           II. Human
What are the PCC criteria?
                  A process is in place
                   for sharing clinical   A process is in
 Residents are
                 information, including     place to fully
 provided with
                 the medical record &          disclose &
                     care plan, with       apologize for
                        residents          unanticipated
                                           outcomes to

                    III. Resident
                      Choice &
What are the PCC criteria?
  A process            Partner with
  aligned with each    families in all   Flexible, 24-
  resident’s             aspects of              hour,
  preferences is in      residents’         resident-
  place to contact          care             directed
  family to                                   visiting
  communicate                                   hours

                        IV. Family
What are the PCC criteria?
                   Fresh, healthy food
                     at appropriate
 24-hour access    temperatures, & a      Residents have
 to a variety of     variety of food     opportunities to
 foods &                 choices            participate in
 beverages                                 meal planning

                    V. Nutrition
What are the PCC measures?

   Quality Profile (QP) includes quantitative metrics
    for evaluating an organization’s performance with
    regard to important elements of PCC as
    identified in the literature and from providers
    ◦ QP to be completed on last Friday of month
What are the PCC measures?

   The measures, like the criteria, are designed to
    teach and to motivate, not merely to avoid
    lapses in quality
    ◦ They beckon affiliates to rise up to the challenge and
      to reach for excellence

    ◦ Some measures relate to specific criteria, and some
      are more global (e.g., relating to org. health)
          A multi-disciplinary task force is established to
          oversee and assist with implementation and
          maintenance of patient-/resident-centered
          practices, which includes a mix of non-
          supervisory and management staff, including a
          combination of clinical and non-clinical staff, and
          meets regularly (every 4-6 weeks) on an ongoing
          basis. In continuing care environments, this task
          force also includes residents and family

            Numerator: Cumulative meetings this year
            Denominator: Data month (1-12)
          Processes are in place for evaluating, identifying
          and effectively integrating into the care plan
          what is important to each resident, based on
Criterion his/her identity, decision-making ability, and
          mastery skills, and what is meaningful to that
          resident in the living environment and in daily

             % of care plans completed in which the resident
          A model of care delivery or work design is
          adopted that embraces continuity, consistency
          and accountability-based care, and allows staff
          the opportunity and responsibility for
          personalizing care in partnership with each

            % of care plans completed in which a CNA
          A comprehensive formalized approach for
          partnering with families in all aspects of the
          patient’s/ resident’s care, and tailored to the
          needs and abilities of the organization and its
          facility, is developed. An example is a Care
          Partner Program.

Measure     % of care plans in which families participated
          Residents are given an opportunity to
          participate, as appropriate, in a retreat
          experience or an equivalent to assist with
Criterion internalizing resident-centered care concepts
          and to enhance sensitivity to the needs of the
          entire community. Resident retreats are
          conducted at a minimum annually.

Measure     % of residents that have completed the retreat
            A flexible transportation system is
            provided that enables residents to satisfy
            personal wishes, to participate in off-site
            activities and to volunteer.

            % of residents (who are not unable to leave
            site due, for instance, to health)
            participating in off-site activities promoting
            personal growth, such as volunteering,
            political or religious activities, arts and
            leisure, etc
            Leadership includes approaches that motivate
            and inspire others, promote positive morale,
            mentor and enhance performance of others,
            recognize the knowledge and decision-making
            authority of others and model organizational

            % of supervisors that are specifically trained to
            mentor on the person-centered approach.
            All staff, including off-shift, part-time, prn,
            providers and support staff are given an
            opportunity to participate in a minimum of
            eight hours of patient-/resident-centered staff
            retreat experiences or an equivalent, with a
            minimum concurrent completion rate of 85%.

Measure     % of staff that have completed the retreat
            Continuing education to reinforce and
            revitalize staff engagement in patient-
            /resident-centered behaviors and practices
Criterion   and build competence around the
            community’s evolving needs is offered on an
            ongoing basis to all staff in meaningful ways
            determined by the organization.

            Numerator:      # of staff who have been
                            participated in advanced
Measure                     training opportunities

            Denominator: Total # of staff
           Residents’ wellness needs are approached
          holistically. Examples include the provision of
          wellness programs, such as nutrition counseling
          and stress management and implementation of
          (or access to) programs that support residents in
          chronic disease management. Residents have
          convenient access to physical and mental fitness
          opportunities, as well as to podiatry, vision,
          hearing, and dental services, and psychological
          and pharmaceutical consultation.

            % of residents that participated in one or more
            organized wellness activities
Additional PCC measures

        Measures broadly related to PCC,
         but not tied to specific criteria
Concept          Measure

                 % of new employee interviews in which line
                 staff participate (dietary, housekeeping,

Resident         % of CNA hiring decisions made in which a
Empowerment      resident participated

Resident Health % of residents that participated in one or
& Wellness      more organized wellness activities
Concept       Measure

End of Life   % of residents with advance care wishes
Care          documented

              % of residents who died in place (not
End of Life
              transferred to hospital in the 7 days prior to

              # of events for residents that specifically and
Emotional     primarily address topics of loss (e.g., loss of
Support       mobility/driving, vision or hearing; grief
Services      management; mental status changes;
Concept      Measures

             % of nursing shifts (RN, LPN, CNA) covered by
             agency staff

             % of staff consistently assigned to the same
             residents (Advancing Excellence measure)
Care         Turnover of staff

             Absenteeism: %of nursing staff who did not
             report to work as scheduled
Concept(s)       Measure

                 Tenure of DON(s)

                 Tenure of Administrator(s)

Stability &      Tenure of nursing staff (average months of
Consistent       service of all nursing staff)
Concept          Measure

Organizational   Occupancy rate (Census): % of
Health           units/apartments that are occupied

                 # of vacant positions

                 # of staff injuries
   Person-centered care criteria established
    through review of literature and provider
    experiences and views
   Multi-method system for evaluating person-
    centered care established
   Quantitative instrument for measuring
    person-centered care established
    Next Steps
   Identify sites to formally pilot measures
    ◦ Provide sites data collection measurement guides
      (e.g., worksheets for measures)
    ◦ Provide sites mentoring in data use
   Test measurement instrument
    ◦ Validity, Reliability, Harmonization/Transportability
For guidance in achieving
  person-centered care,
  the Long Term Care
  Improvement Guide is
  available for free
  download at


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