Brief Report: National Nursing Home Improvement Collaborative Outcomes Congress

By Sharon Eloranta, a George W. Merck Fellow at the Institute for Healthcare Improvement, describes the success of a National Nursing Home Improvement Collaborative which made great strides in reducing complications associated with nursing home care.
This Monday, November 15, I had the privilege to attend the Outcomes Congress for the National Nursing Home Improvement Collaborative. This initiative, run by Qualis Health, was the first Centers for Medicare and Medicaid Services (CMS)-sponsored national application of the Breakthrough Series Model to nursing homes, and focused improving pressure ulcer care. It was also unique in that given CMS’s interest in spread (there are 16,000 nursing homes in the United States, and CMS wants the lessons from the Collaborative to spread to 100 percent), we developed a way to introduce spread concepts beginning with pre-work, as well as tools to document, manage, and measure spread. 
Each Quality Improvement Organization (QIO) and each of six not-for-profit nursing home corporate organizations were invited to bring one nursing home to the Collaborative and to partner with them in this initiative. The QIOs and CQPs (corporate quality partners) had separate one-day meetings following each of the three two-day learning sessions, during which the QIOs and CQPs focused on spread: How to, what works, what doesn’t, etc. In total, 56 teams signed up to participate in the Collaborative, and of those, four withdrew before the end of the 13 month period.  Attendance at the sessions averaged 400 participants. Approximately 40 additional observers attended the Outcomes Congress.
The change package was developed by Qualis Health and then revised by a technical expert panel comprising AHCPR guideline authors Barbara Braden and Nancy Bergstrom, end-of-life expert Joanne Lynn, Brown University geriatrician Dave Gifford, former Evangelical Lutheran Good Samaritan CEO Judy Ryan, and others.  In its final version, the change package included as its major foci organizational commitment, assessment and monitoring (including prevention and treatment), and community relationships. The goal of the Collaborative was to improve pressure ulcer outcomes while maintaining optimal quality of life for nursing home residents.
Under the able leadership of co-chairs Joanne and Nancy, the teams went through an incredible process of growth and learning.  They had to learn to use a registry, to track, analyze and report data, to use the Model for Improvement, and to do PDSA cycles. This Collaborative was the first I have ever seen in which NONE of the participants were familiar with these techniques at the outset of the initiative.  The QIOs and CQPs were immeasurably helpful partners to their nursing homes in many ways.
The outcomes measures for this initiative were: 
  • Number of days between new nosocomial pressure ulcers
  • Prevalence of pressure ulcers (per 100 resident days)
  • Percent of wounds with evidence of healing
We also used the publicly reported pressure ulcer measure (see ;“nursing home compare”) although these measures suffer from time lag and other issues.  The set of process measures included:
  • Percent of residents receiving assessment using the Braden scale within 24 hours of admission
  • Percent of pressure ulcers having a PUSH tool score documented weekly
  • Percent of at-risk residents having appropriate pressure-relieving devices on bed/chair (two measures) etc. 
Balancing measures included:
  • Staff satisfaction
  • Staff retention
  • Cost
So what finally happened? Several major take-home points:
  1. Overall, the teams were able to reduce the incidence of new nosocomial pressure ulcers significantly.
  2. Teams made many gains in the process measures, especially in the use of the Braden scale within 24 hours of admission.
  3. Prevalence of pressure ulcers, particularly stage II, did not improve, prompting a great deal of discussion, but not depression. Many participants believe that this reflects the fact that pressure ulcers are not a “nursing home issue,” rather, a community issue, and that hospitals, home health agencies, and physicians need to become involved in skin care at all times. To make a debilitated elder lie on a hard gurney in an Emergency Department for hours to days at a time is uncaring to say the least, and potentially abusive.
  4. Evidence of healing quickly got better and then leveled off, perhaps reflecting the healing of the “easy” ulcers. 
  5. Nursing homes found that involving their CNAs (certified nursing assistants) was the most important thing that they could do for their residents.
  6. Nursing homes made great changes on budgets ranging from zero to generous.
  7. Spread did occur: Accumulated evidence shows that nearly every team had spread at least one idea or concept to another floor, another building in its corporation, a competitor across the street. Many of the teams had been contacted by hospitals in their areas for ideas and leadership around the “community partnership” area of the change package. Several excellent transfer sheets have been developed and spread for use in transferring nursing home residents to and from care sites external to the nursing home.  Example of a change:  One nursing home got a local dialysis facility to purchase pressure relieving surfaces for 100 percent of the dialysis chairs!
Best of all, at the Outcomes Congress, it was clear that these teams were proud of themselves and what they would accomplished, and as with all Collaboratives, they did not want to lose the fellowship of the rest of the teams. The storyboards were the best I had ever seen (we did a contest with some rubber duckies and other prizes)…tears were in many eyes at the end when Joanne, Nancy, Giff, and Judy reminded us all about the human value added by this work. Joanne stated that she would rather have “the right to die without holes in my skin” than a fancy defibrillator or cures for cancer, since one way or another we will all likely need long term care at some point in our lives…a tremendous experience.
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