Florida Nursing Home Quality Care Connection

The Florida Nursing Home

Quality Care Connection

Are You Ready for the New Clostridium difficile Initiative?

C. difficile is a germ that causes major colon inflammation and deadly diarrhea. This is your opportunity to work with HSAG and other local/national experts to prevent and reduce C. difficile in nursing homes. This initiative will support nursing home submission of data in the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) databank, which will enable an analysis and creation of a national baseline for C. difficile in nursing homes.

Please contact [email protected] to join the initiative.

Healthcare-Acquired Infection Prevention Strategies

According to the Office of Disease Prevention and Health Promotion (http://health.gov/hcq/prevent-hai.asp), healthcare-acquired infections (HAIs) are infections that can be acquired while a patient is receiving treatment for another condition in a healthcare setting. HAIs can be acquired anywhere healthcare is delivered and can be caused by any infectious agent, including bacteria, fungi, and viruses.

To help nursing homes prevent healthcare-acquired infections, the National Nursing Home Quality Care Collaborative (NNHQCC) Change Package includes a six-point change bundle to help the multi-disciplinary quality improvement team support the function and well-being of residents. The six-points are as follows.

Promote hand hygiene.
Prevent transmission of infections by staff.
Prevent transmission of infections by all persons.
Establish and implement system-wide environmental cleaning policies.
Identify and treat infections appropriately.
Avoid indwelling catheter use unless appropriately indicated.

You can find specific action items for each of these six points in Attachment 4 of the NNHQCC Change Package.

Tips for Improving the Weight Loss Long-Stay Quality Measure

Th is measure reports the percentage of long-stay residents who lose too much weight. During the selected quarter, the percentage of long-stay residents who lost weight of 5 percent or more in the last month, or 10 percent or more in the last 6 months, were not on a physician-prescribed weight-loss regimen noted in a minimum data set (MDS) assessment.

When you are working with your staff members, you may want to consider the following questions.

Was the MDS coded per RAI requirements, comparing the resident's weight in the current observation period to his or her weight in the observation period of 30 or 180 days?
Does the dietician understand the RAI coding definition if he/she is coding this section of the MDS?
Does the maintenance crew calibrate the scales monthly for accuracy?
Are staff members checked for proficiency in performing weigh-ins?

If you would like more improvement tips and MDS coding insight, you can download the HSAG Weight Loss quality measure tip sheet by clicking here.

Please contact [email protected] if you have any questions.

QAPI Corner

Suggestions for Implementing QAPI Steps:

Now that we have gone through all 12 steps of QAPI, here are some suggestions to help you implement this program.

Define and promote leadership responsibility and accountability for your home. Leadership is key to promoting, instituting, and sustaining a QAPI program in your home.
Take your QAPI "Pulse" with a Self-Assessment. Discover where your home is with QAPI implementation. You can complete a QAPI self-assessment here.
Identify your organization's guiding principles. What is your home's "rudder" to keep your home moving straight and forward?
Conduct a QAPI awareness campaign. Everyone should know about your home's QAPI program.
Develop a strategy for collecting and using QAPI data. It's difficult to show improvement if you can't numerically measure it.
Take systemic action. In the heat of the moment, it's easy to make a quick decision. Many times, it's better to take a step back and make a decision based on logic and what's best in the long-run.

You can find more suggestions in the National Nursing Home Quality Care Collaborative Change Package.

HSAG Resource Spotlight

Steps to Prevent Healthcare-Associated Infections Infographic

This infographic outlines the 5 steps to prevent healthcare-associated infections in nursing homes from the National Nursing Home Quality Care Collaborative (NNHQCC) Change Package. Learn more.

MDS Coding Guidelines for Urinary Tract Infections

This handout provides Minimum Data Set (MDS) coding guidelines for UTIs. Learn more.

This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Florida, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. FL-11SOW-C.2-06302016-01

Upcoming Webinar

Staff Stability and
Consistent Assignment: Recruit, Engage, and Retain Staff While Promoting Resident-Centered Care

Thursday, July 14

2 p.m. to 3:15 p.m. ET

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Have you completed your QAPI Self-Assessment?