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**please read the instructions carefully**
HCA 353, Assignment 1:
Must be in 12 point, Times New Roman with 1” margins. Length should be approximately 3-4 pages double spaced (excluding Title Page, Abstract page and References page) including your summary paper of research and your QAPI worksheet. Must follow all APA format requirements.
All questions must be responded to.
Reading:
Go to the Centers for Medicare and Medicaid Services (CMS) website and read about QAPI (Quality Assurance Process Improvement)
http://www.medicare.gov/NursingHomeCompare/About/What-Is-NHC.html
and the 5 elements of QAPI. These elements can also be found on the Joint Commission for Accreditation website at
http://www.jointcommission.org/assets/1/6/Crosswalk_TJC_QAPI_ncc
Assignment 1 Directions:
Use the same nursing facility you selected for Discussion Board 1 on the CMS Nursing Home Compare website (
http://www.medicare.gov/nursinghomecompare/search.html
).
For your chosen facility, select either
A.) an inspection result health deficiency OR
B.) a quality measure that is rated below the quality average for Kentucky or National.
*Note: I have provided an example of both Option A and Option B at the end of this document to help you understand what I am asking you to do.
1. Provide the name and location of the facility you selected.
2. Provide detail on what quality measure you have selected.
3. Provide a weblink to the quality measure you have selected.
4. Research: find at minimum of 2 full article references on Google Scholar that provide history or recommendations relative to the quality measure you selected. For example, you might choose residents that experienced pain as your quality measure to improve upon because your nursing home has a higher than average rating for that quality measure
You can find articles that talk about pain levels of residents, how to determine pain for non-communicating residents, alternative methods to pain reduction, etc. Summarize and cite these sources in 1-2 pages and how that information was utilized and beneficial to development of your QAPI Goal Setting Worksheet.
5. Utilizing the measure that you selected, complete a QAPI Goal Setting Worksheet for quality improvement. Your Goal Sheet should result in either no deficiencies on the next inspection process or improved quality rating percentage for the facility.
*
Your goals/action plans must be REALISTIC!!!!
Do not put that you will do a daily audit every shift of with every staff member because you cannot possibly do that unless within your document you state staff that will assist you in that process. Again, think about if what you have put is REALISTIC or not.
Remember to utilize appropriate data collection, measurement and evaluation methods as is discussed in your book Chapters 1, 3, and 4 for your Goal Setting Worksheet.
Example 1:
Health and Fire Safety Inspections, Option A:
1. I chose option A and my facility is zip code 42101, Signature Healthcare of Bowling Green, KY
https://www.medicare.gov/nursinghomecompare/search.html
2. I clicked on “health and fire safety inspections” then scrolled down to “nutrition and dietary: 1 deficiency found” and it stated:
“Nursing home failed to “Store, cook, and serve food in a safe and clean way”
3. Weblink is:
https://www.medicare.gov/nursinghomecompare/profile.html#profTab=1&ID=185089&Distn=13.1&loc=42101&lat=37.1184213&lng=-86.5400674
4. I would then write a 1-2 page (excluding title page, abstract and references) paper that is a summary of my research on regulations and training of staff related to required storing, cooking and serving of food in nursing facilities or health care facilities. I would write how that information was utilized in completion of my QAPI Goal Setting Worksheet and realistic expectations of staff, to include what human error can occur.
5. QAPI Goal Setting Worksheet: I would then attach my completed QAPI form on how to address this specific deficient practice in my building.
Example 2:
Qualty Measures, Option B
1. I chose option B and my facility is zip code 42101, Signature Healthcare of Bowling Green, KY
https://www.medicare.gov/nursinghomecompare/search.html
2. I clicked on Quality Measures and then scrolled down to long-stay residents and then selected
|
“Percent of long-stay residents experiencing one or more falls with major injury” because the facility’s percentage was higher (4.6) than both KY (3.5) and national (3.3) averages |
3. The weblink to this page is:
https://www.medicare.gov/nursinghomecompare/profile.html#profTab=3&ID=185089&Distn=13.1&loc=42101&lat=37.1184213&lng=-86.5400674
4. I would then write a 1-2 page (excluding title page, abstract and references) paper that is a summary of my research on regulations and training of staff related to required falls in nursing facilities or health care facilities, to include best practices, fall prevention techniques or recommendations for both oriented and confused residents and use of siderails and other interventions. I would write how that information was utilized in completion of my QAPI Goal Setting Worksheet and realistic expectations of staff, to include what human error can occur.
5. QAPI Goal Setting Worksheet: I would then attach my completed QAPI form on a realistic action plan to improve this percentage rating in my building, knowing that a rating of 0% is impossible because falls WILL happen. I cannot prevent them but can improve my percentage with a decrease in falls.
HCA 353 Assignment 1
Page 4 of 4
Assignment/Case Study Grading Guide:
Total available points is 50
*IMPORTANT NOTE:
any sources cited in assignments must be reputable websites (.org, .gov, etc) or available in full article/pdf on Google Scholar or WKU libraries. No blogs or random internet resources will be allowed and paper will be rejected.
10 points:
follows APA formatting to include items such as Running Header, page numbers, Title page, Abstract page, Times New Roman 12 point font, double spacing and References page with references and in text citing of sources in proper APA format.
10 points:
document has minimal grammar and spelling mistakes. All assignments are expected to be presented in a well presented and scholarly manner, attached Word document.
30 points: paper follows general guidelines and expectations. Student thoroughly and adequately addresses topics and questions in a scholarly manner, utilizing cited sources in a manner that further enhances the product submitted.
*Note: late submissions not accepted. Grade of zero (0) is given but assignment can be submitted as one allowed makeup/redo submission for this course.
Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor
does its completion ensure regulatory compliance.
QAPI Goal Setting Worksheet
Directions:
Goal setting is important for any measurement related to performance improvement. This worksheet is intended to help QAPI teams establish appropriate goals for individual measures and also for performance improvement projects. Goals should be clearly stated and describe what the organization or team intends to accomplish. Use this worksheet to establish a goal by following the SMART formula outlined below. Note that setting a goal does not involve describing what steps will be taken to achieve the goal.
[Example: We will increase the number of long-term residents with a vaccination against both influenza and pneumococcal disease documented in their medical record from 61 percent to 90 percent by December 31, 2017.]
1. Describe the business problem to be solved (Use the SMART formula below to develop a goal)
A. SPECIFIC
Describe the goal in terms of 3 ‘W’ questions:
· What do we want to accomplish?
· Who will be involved/affected (what staff, what residents, others)?
· Where will it take place?
B. MEASURABLE
Describe how you will know if the goal is reached:
· What is the measure you will use?
· What is the current data figure (i.e., count, percent, rate) for that measure?
· What do you want to increase/decrease that number to?
C. ATTAINABLE
Defend the rationale for setting the goal measure above:
· Did you base the measure or figure you want to attain on a particular best practice/average score/ benchmark?
· Is the goal measure set too low that it is not challenging enough?
· Does the goal measure require a stretch without being too unreasonable?
D. RELEVANT
Briefly describe how the goal will address the business problem stated above.
E. TIME-BOUND
Define the timeline for achieving the goal:
· What is the target date for achieving this goal?
· Write a goal statement, based on the SMART elements above. The goal should be descriptive, yet concise enough that it can be easily communicated and remembered. Use the example at the beginning for a reference on statement format and information.
Goal Statement:
Tip: It’s a good idea to post the written goal somewhere visible and regularly communicate the goal during meetings in order to stay focused and remind caregivers that everyone is working toward the same aim.
Page 1 of 3
Running head: NURSING
1
NURSING
4
Nursing
Student’s Name
Institution
Signature HealthCare of Bowling Green
When it comes to health inspections, this medical facility rates below average. It has only two stars. As per the information from medicare.gov, the latest inspection was done in 2017 in the month of January on the 27th.The number of health citations is twelve. When it comes to staffing, the rating is also below average as it is only rated by two stars. The total number of residents in the facility are 143.The information also shows that there are 176 certified beds in the facility. When it comes to quality measures, the ratings are on average(Pobee,2013). This is attributed to the fact that there are 3 stars in the quality measures.
Performance Measure that is best to Potential Customers
The measurement that is most important to healthcare customers is that on Health Inspections. This is because customers are able to know any issues that regard to complaints that have been filed and even any citations that result. With health inspection healthcare customer cannot go wrong as they will get to know when a how Medicaid and Medicare carried their inspections. As the healthcare professionals are inspecting the nursing homes, they look for safety citations that regard to health. This then gets to show that most of the healthcare customers cannot go wrong when they consider issues to do with health inspections(Aronovitz,2003).
Performance Measure that is least important to Consumers
There is no doubt that distance is a minor factor when it gets to the consumers. This is because distance only shows the distance as per how a nursing home is the ZIP code that has been given or a city that has been searched. The distance may mean nothing to consumers as they may opt to travel and get to the nursing home of their choice and which satisfies their needs in any way(Pobee,2013). Distance is also considered a less determinant factor when it comes to the customers of healthcare as they can use nursing home physical contacts and get to their preferred facility in order to receive the needed the service that they want.
Consumers and using the Medicare.org Website
Healthcare customers should put the proper use of Nursing Home Compare in order to get information that is detailed This is because the information is conducted by healthcare professionals that are well trained and who have attained the needed qualifications to look at a nursing home. As healthcare professional put into use this website, they also get to have the right information that regards to staffing, health inspections, quality measures among others. This will then make the healthcare customers know the right facility that they can get care.
Extra data, factors, information that a consumer should look for
Information that consumers should also look for is overall rating. This is because Medicare gives the rating as they look for overall information that pertains the nursing homes. Consumers of healthcare should look out for the number of nurses of any category be it registered or even certified nursing Assistants so that they can get to know how a nursing resident can get cared for. This then means that when the consumers have such information more so one that comes from the Medicare or Medicaid, they can be able to get the desired services from nursing homes.
Ratings by CMS
Looking at the ratings, there is no doubt that Signature Healthcare of Bowling Green deserves the ratings. This is because the ratings are awarded by professionals. These professionals cannot in any way be coerced to give information that is not correct(Aronovitz,2003). Furthermore, the information is awarded in consideration of all the information that the professionals in nursing get from the ground. Therefore, one can agree with the ratings awarded to this facility.
References
Aronovitz, L. (2003). Nursing homes: more can be done to protect residents from abuse.
Place of publication not identified: Diane Pub Co.
Pobee, K. (2013). Cut through the noise: nursing home care in the Baby Boomer Era : a
physician’s advice for confidently placing your mom, dad, spouse, or any senior
family member. Charleston, South Carolina: Advantage Media Group.
