Construct Solid Business Practices That Support Your Purpose
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A well-run nursing home excels as a business yet feels like home. It seeks ways to effectively manage the bottom line with integrity and with the resident as the focus. It runs efficient operations, invests in equipment and supplies to provide the highest quality care, and ensures that its physical and outdoor environments are comfortable and inviting.
Change concepts for this strategy include:
- Seek strategic and creative approaches to expand your resource base to meet your mission and serve your residents.
- Maximize your efficiency.
- Ensure you are making the most of your physical assets.
Contact us with any questions at
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Ideas for High-Risk Residents with Pressure Ulcers (Long-Stay)
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The quality measure (QM) for pressure ulcers captures the percentage of long-stay, high-risk residents with Stage II-IV pressure ulcers. Central to this measure is identifying residents at high risk and ensuring that they are coded as such and included in the measure denominator. Residents are defined as high-risk if they meet one or more of the following three criteria.
- Impaired bed mobility or transfer indicated by either or both of the following:
- 1.1. Bed mobility, self-performance (GG0110A1) = (3, 4, 7, 8)
- 1.2. Transfer, self-performance (G0110B1) = (3, 4, 7, 8).
- Comatose (B0100 = [1])
- Malnutrition or at risk of malnutrition (I5600 = [1]) (checked)
Learn more about the calculation of this QM on page 23 of the
Minimum Data Set (MDS) 3.0 Quality Measures User's Manual (v10 3-25-2016).
Performance Improvement Project (PIP) teams should identify which residents have triggered high risk for pressure ulcer development, as well as residents who have documented Stage II-IV pressure ulcers, and review and revise their care plans accordingly.
Additionally, PIP teams should explore critical factors contributing to the development or worsening of pressure ulcers. They should devise strategies to improve processes related to identifying risk, prevention, assessment, and treatment.
Next month: Urinary Tract Infections Tips/Change Ideas
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QAPI Corner
STEP 7: Develop a Strategy for Collecting and Using QAPI Data
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Your QAPI team will decide what data to monitor routinely. Data from your facility CASPER Quality Measure Report is a good place to start! To determine which items to act on--and in what order--analyze the data in this report and:
- Set targets for performance for the areas on which you are working.
- Identify benchmarks for performance.
- Develop an improvement plan for the data you collect.
- Determine who reviews the data and how often.
Remember: Collecting information is not helpful unless it is actually used to drive improvement!
Next month: Identify Your Gaps and Opportunities
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Clostridium difficile Infection (CDI) Prevention Cohort Members
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Announcements and Information
- To submit your Annual Facility Survey for calendar year 01/01/2016 to 12/31/2016, login to the NHSN using your Secure Access Management Services (SAMS) grid card credentials.
- HSAG recommends printing a copy of your completed 2015 Annual Facility Survey that was completed during the enrollment process to use as a reference when completing the 2016 survey, as most of the information will be the same.
- To print a copy of your 2015 Annual Facility Survey, log into NHSN using your SAMS grid card credentials, select the "Surveys" tab on the left navigation bar, select "Find", select 2015 from the "Survey Year" drop-down menu, select "Find", then select "Print Form."
- To submit the 2016 Annual Facility Survey, select the "Surveys" tab on the left navigation bar select "Add", select 2016 for the "Survey Year", and enter your facility data. Mandatory fields are marked with an asterisk (*). Do not forget to select "Save" at the end of the survey.
- CDI data for April due by May 10, 2017.
- Login to NHSN using your SAMS grid card credentials to submit your CDI LabID events (if applicable) and summary data (total resident days for the month, resident admissions, and residents admitted on CDI treatment)
- Do not forget to check "Report No Events" under the C. difficile row if there were no positive labs collected within your facility for the month of February.
- Resolve Alerts: Review the "Alerts tab and complete missing and/or incomplete data.
Additional Resources
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HSAG Resource Spotlight
What You Should Know for 2017-2018 Influenza Season
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Influenza (flu) is a contagious respiratory illness that can be severe and life-threatening, especially for older adults. This time of year is called "flu season." In the United States, most seasonal flu activity typically occurs between October and May. Flu activity most commonly peaks in the United States between December and February.
Adults at or over 65 years of age and residents of nursing homes and other long-term care facilities are among those at highest risk for developing flu complications that can result in being hospitalized and occasionally in death. The Centers for Disease Control and Prevention (CDC) recommends a yearly flu vaccine for everyone 6 months of age and older as the first and most important step in protecting against this serious disease.
People should begin getting vaccinated soon after the flu vaccine becomes available. However, as long as flu viruses are circulating in the community, it's not too late to get vaccinated.
Access all of the CMS tools for QAPI from one easy-to-use electronic resource library.
Visit this site for all of the information you need to protect yourself, your loved ones, and your patients during flu season.
Learn more.
Refer to this toolkit as a guide to increasing flu vaccination among healthcare personnel in long-term care settings.
Refer to this site for an overview of the influenza quality measure, MDS coding requirements, and more.
Learn more.
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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.2-04242017-01
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Register Today for the Next Florida NNHQCC Learning Session!
Miami
(Today is the last day to register for this session.)
April 26, 2017
8 a.m. to 12 Noon ET
East Orlando
May 18, 2017
8 a.m. to 12 Noon ET
Tallahassee
June 7, 2017
8 a.m. to 12 Noon ET
Tampa
June 20, 2017
8 a.m. to 12 Noon
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Upcoming Events
Florida NNHQCC Webinar:
Infection Control in
Long-Term Care
Thursday, May 4, 2017
USF Byrd Alzheimer's Institute 19th Annual Geriatric Health Care Conference
Tampa, FL
June 13 to 15, 2017
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Have you completed your QAPI Self- Assessment?
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Access archived issues of the QCC newsletter at:
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