Responding to Baldrige Results Criteria and LeTC

Transcription

1 Responding to Baldrige Results Criteria and LeTC Mary Tess Crotty, Genesis HealthCare Deborah Urbank, Elderwood Health Care at Lakewood Silver Webinar #1: Understanding the new Silver criteria Gold Webinar #1: Introduction to the Baldrige Criteria Silver/Gold Webinar #2: Tips for writing an application Silver/Gold Webinar #3: Responding to Baldrige Process Criteria (Categories 1 6) and ADLI Silver/Gold Webinar #4: Responding to Baldrige Results Criteria (Category 7) and LeTCI Silver/Gold Webinar #5: The Scoring of Applications Silver/Gold Webinar #6: Using LTC Trend TrackerSM to apply for the Quality Award program Applicants must download these materials before listening to this webinar Results Scoring Guidelines Applicants: Silver Instructions, Application and Criteria Packet Silver Silver Criteria (pages 23 40) Gold Applicants: Baldrige Health Care for Performance Excellence Criteria Criteria (pages 4 26)

2 Identifying the best results to report Guidelines for responding to results criteria Writing from a LeTCI perspective Results are 45% of the possible score so start Early and Provide Space ASK What results does our Organizational Profile promise? What results support our Key Strategic Objectives and Action Plans? Where do we get comparative data? How has our performance improvement system contributed to these results? Organizational Profile Examples P.1.a(1) Health Care Services You say: Short Stay services with Cardiac specialty, one long term unit, one secure unit for memory care, one AL unit and outpatient rehab Examiners look for: Graphs with data over time for clinical and process of care indicators for cardiac patients, dementia care, long-term, AL and rehab, especially outpatient. If it s your organization s main service, we will need to see results.

3 Organizational Profile Examples Organizational Profile P.1.b(1) Customers and Stakeholders You say: Short Stay Patients, Long Term Residents, Families, Physicians, and the Community Examiners look for: Data and trends over time in Satisfaction, Dissatisfaction, Engagement measures and results for short stay patients, long term residents, families, physicians and the community. Strategy Implementation Examples 2.2 Strategy Implemenation, you say.. Strategic Objective Be the first choice for cardiologists for post-acute care Action Plan Prebook 10 post-surgeries a month; implement care paths for 3 cardiac groups; track outcomes and present to hospital quarterly Examiner looks for: pre-book targets and results; quarterly cardiac outcomes Comparative Data You say the interdisciplinary team has had a major focus on preventing weight loss. Your results are the number of people without weight loss and decrease in supplement use. Examiner looks for Compared to what? Possibilities: your own performance (weakest), your division s, your state s, your company s, one competitor, a level from published research, national publicly reported (strongest).

4 Performance Improvement System You say use PDCA within a Quality Team structure, with the team meeting monthly and projects that address key indicators. Examiner looks for thresholds for performance in key areas, methods for ongoing monitoring, specific actions taken by appropriate staff, results within a meaningful timeframe. links among strategy, results and performance improvement activities. Basic Overall Gold address the Overall Level of the Requirements, including segments requested. Scores in the C and D bands and even E. Silver consider the Overall Level, but concentrate on the specific directions in the Silver Criteria. Score in the B and C Bands.

5 Segments are naturally occurring groups of employees, patients, stakeholders. Results criteria ask for segmentation. Possibilities include (but not limited to) Employees: part time (mother s hours), non- English speaking hourly workers, Baylor Plan nurses. Any group you need to adapt your work systems to accommodate unique to you. Patients: short stay, memory support, dialysis. Groups that have unique needs and require special programs unique to your organization. Writing to score LeTCI Levels Trends Comparison Integration Levels: meaningful value Trends : appropriate time period Comparisons : appropriate, similar, benchmarks Integration : measures identified in your Organizational Profile and Process Items; harmonized to support goals

6 A meaningful level uses a scale that is recognizable and that can be interpreted Raw numbers should be used rarely and only for internal process indicators. Employee Terminations as raw numbers Turnover using AHCA Formula Raw Numbers Terminations Nursing Other Normalized with Percentages Employee Turnover AHCA Quality Award Formula 50% 40% 30% 20% 10% 0% 42% 38% 23% 21% A trend requires at least three data points Data points should be appropriate (Monthly, Quarterly, Yearly) to the data Good levels must be clearly marked. E.g., Turnover would be marked Good Satisfaction would be Good. The Examiner will interpret your trends as beneficial or negative. If your trend is variable, a trend line will help show the direction.

7 Good Employee Turnover AHCA Quality Award Formula 50% 40% 30% 20% 10% 0% 42% 38% 23% 21% Good Employee Satisfaction - Willing to Recommend for Job (with Trend Line) % Good & Excellent 100% 80% 60% 40% 20% 0% 80% 70% 58% 62% 46% Most data means nothing without a comparison. Include a comparison in every graph. Examiners evaluate the comparison this way: The larger and more public the comparison, the stronger A meaningful external comparison (outside your industry) can be very strong Internal to your organization is weakest, but may not be available elsewhere. Explain that in your data sections--p2a(3) and 4.1a(2).

8 Compared to National Average Percentile ranking is stronger comparison. Good % Good & Excellent 100% 80% 60% 40% 20% 0% Employee Satisfaction - Willing to Recommend for Job 76 th Percentile 46% 58% 70% 62% 80% 68% MIV National Results describe what you indicated was important to your organization. Providing your length of stay for short stay patients is not integrated if you explained your focus is on AL and Memory Support, with four dedicated short stay beds. Providing only C.N.A turnover and retention statistics is not integrated if your strategic focus is RN Recruitment and Retention. How your data overall addresses the criteria Levels, Trends, Comparisons and Integration. Each of the five Results Criteria get an individual score. Indicate how you achieved your results cross-referencing is fine. 7.1 carries the most points aim to at the Gold level, provide every relevant health care result segmenting as appropriate; at the Silver level, provide 3 clinical indicators and your survey results.

9 Intent to Apply Process Opens November 1, 2011 Intent to Apply Deadline January 12, 2012 Applications Accepted Online January 16, 2012 Silver/Gold Application Deadline March 1, 2012 Silver/Gold Applicant Notification July 16, 2012 AHCA/NCAL Annual Convention & Expo October 7-10, 2012 All deadlines listed are at 8 p.m. EST; applications submitted after 8 p.m. EST on the designated deadline will not be accepted