quality in long-term care

I have attached what you need. 

**please read the instructions carefully**

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

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

A. Note how your selected nursing facility rates in each of the following quality measurement categories:

a. Health Inspections:

 

Above Average

b. Staffing: Above Average

c. Quality Measures:  Above Average

 

1. Explore the website further and review the data for each measurement category. Then answer the following

1. Which of these performance measures do you believe is most important to potential customers of healthcare services?  Why?

I chose BOWLING GREEN NURSING AND REHABILITATION CENTER because one of my mother’s friend been there and when I asked her she said they have the best service for the caregivers and their safety is better than the others that she has visited before. I totally believe that the most important performance measures for the customers of healthcare is the Staffing. Staffing is the major concern because they have the most impact on the patient. Staffing they always have to be with the patients and take care of them because the patient will feel save and comfort if the get the best quality of care from the staff.

1. Which performance measure is least important to the consumers?  Why?

I think the least important performance fro the consumers is the Health Inspections because if the facility provides the best environment for the patient then they won’t need heath inspections at all.

1. Should consumers use this website as part of their process to select a nursing facility? Why or why not? 

Absolutely Yes, sometimes patient does not have more information about a certain facility that they are looking for, but not internet made it so much easier fro the patient to search and found the facility’s website and read about it. So yes, it’s very important for each facility to have their own website and put all the information that the patient need to know about.

1. What other factors, data, information or methods should a consumer seek out and utilize when choosing a nursing facility?

There are a lot of ways to do when choosing a nursing facility but if I was looking for a nursing facility I will look fir a reference or a friend that I trust and who is been there and ask about their service. I also will look for the location of the facility because there are not safe location where the facility is located at, so it’s very important to checkout the location before.

 

1. If you have visited this nursing facility, do you agree with the ratings it has received by CMS?

I have not been there at all, but I agreed after I asked my mother’s friend about it and I heard good thinks about it.