1

a tour of new features

A CNM’s Guide to Quality: Introducing the New CNM Quality

and Process Improvement Sub-Unit

Sherri Jones, MS, MBA, RDN, LDN, FADA – Sub-Unit Chair

Cindy Hamilton, MS, RD, LD – Sub-Unit Vice Chair

April 6, 2014

Session Objectives

1. Explain the role that quality plays in today’s

healthcare environment

2. Identify the vision and goals for the new CNM

Quality and Process Improvement Sub-Unit

3. Utilize the current sub-unit resources

4. Formulate key quality measures/monitors you

wish to utilize in your facility

Audience participation throughout presentation.Audience participation throughout presentation.

Note the Note the “Session Worksheet”“Session Worksheet” on the table… on the table…

Opening Questions

Show of hands…

1. How many of you were already

aware of the new QPI Sub-Unit?

2. How many of you have visited the

QPI section of the CNM website?

3. Who is subscribed to the special QPI

electronic mailing list (listserv)?

• The Health care system in the USA is “broken”

• Institute of Medicine: “Crossing the Quality

Chasm” the 2nd report of the IOM –

published in 2001

• Identified 6 Aims of Quality in health care

“Fundamental reform of health care is needed “Fundamental reform of health care is needed

to ensure that all Americans receive care that is to ensure that all Americans receive care that is

safesafe,, effectiveeffective,, patient centeredpatient centered,, timelytimely,,

efficientefficient,, and and equitableequitable.”.”

Why Does Quality Matter?

2

Today’s Health Care Environment

• October 2012 the Patient Protection and Affordable

Care Act was approved (Health Care Reform)

• Centers for Medicare and Medicaid Services (CMS)

implemented a new hospital Value Based

Purchasing (VBP) program

• Accountable Care Organizations established

– Organizations that are accountable to the patients and

third party payers for the quality, appropriateness and

efficiency of the healthcare provided

Accountable Care – Financials $$

Slide compliments of Dr. M. Reidy, UPMC

Value Based Purchasing is promoting “quality” outcomes

with “financial” consequences

VBP is moving from Quantity/Volume-based to Quality/Value-based care

Value Based Purchasing (VBP)

Volume-Based Value-Based

• Paid by patient

admission

• Paid by service

provided

• Paid for meeting

Evidence Based care

• Paid for outcomes

(mortality)

• Paid for prevention of

safety events

• Paid for Patient

SatisfactionSlide compliments of Dr. M. Reidy, UPMC

Value Based Purchasing

How Hospitals Get Reimbursed!!

Slide compliments of Dr. M. Reidy, UPMC

3

Why Create the QPI Sub-Unit?

• Changing healthcare environment

– Pay for Performance (Quality versus Quantity)

• Showcase importance of Clinical Nutrition

– Improve patient outcomes/prevent HACs

• Assure regulatory compliance

– Assess current state/implement improvements

• Questions/Issues posted on CNM EML

– Inquire about quality monitors

– Process improvement projects

Sub-Unit Purpose and Goals

Purpose: To educate (and equip) Clinical Nutrition Managers

on the various healthcare quality standards, measures, and

process improvement methodologies.

Goals:

• Increase awareness of the impact Quality and continual PI

has in today’s healthcare arena

• Keep CMNs abreast of the quality management initiatives

and resources from the Academy + partner with QMC

• Provide a forum for sharing Quality and PI tools and ideas

• Highlight successful quality/process improvement projects**PI Award Program Under Development

Partnership with Academy’s QMC

• Initial thoughts/proposal shared with Sharon McCauley

• Presented purpose/goals of sub-unit to the QMC’s face-to-face meeting August 17, 2013

• QMC considered sub-unit’s goals and countered with:

– Sub-Unit name change (delete “Management”)

– Contact Academy’s Research area for ANHII – data analysis

– Sub-Unit serve as resource to QMC (workgroups, etc)

– Investigate Six Sigma training/certification (similar to the Informatics 10x10)

• Oversight of the CNM SOPPs workgroup (revisions)

Sub-Unit Strategies/Deliverables

• Separate EML members can chose to “opt in” - done

• Dedicated QPI sub-unit section on the website - done

• QPI updates/articles in quarterly newsletter - done x 3

• Call for QM and PI tools/resources from members for the

existing CNM Resource Library - expanded section

• Educational session at annual CNM symposium - done

+ Quality posters area - *TBD

• Annually sponsored award/recognition to winning

CNM/team for quality improvement project - *TBD

4

CNM Website – Intro to Sub-Units

Available CNM SubAvailable CNM Sub--Units Units –– Viewable to AllViewable to All

SubSub--Units described to all Units described to all

who view the CNM websitewho view the CNM website

CNM Website – Intro to Sub-Units

Member Benefits Member Benefits –– Viewable to AllViewable to All

SubSub--Units also briefly Units also briefly

described under general CNM described under general CNM

Member BenefitsMember Benefits

Accessing QPI Website

Members Only Home PageMembers Only Home Page

QPI SubQPI Sub--Unit content and Unit content and

resources can only be accessed resources can only be accessed

from “Members Only” sectionfrom “Members Only” section

QPI Website

QPI Section Home PageQPI Section Home Page

Content SubContent Sub--CategoriesCategories::

EMLEML

GlossaryGlossary

Website LinksWebsite Links

Sample PI ProjectsSample PI Projects

5

QPI EML Signup

QPI SubQPI Sub--Unit Member Info >>> Will Change Title to EMLUnit Member Info >>> Will Change Title to EML

QPI Glossary of Terms

QPI SubQPI Sub--Unit Glossary of TermsUnit Glossary of Terms

Link to IHI

Quality Terms

Additional

Terms and

Definitions

Provided

QPI Other Website Links

Direct Links to Other Quality/Process Improvement WebsitesDirect Links to Other Quality/Process Improvement Websites

Additional

website

links

QPI Sample Process Improvement Projects

Sample Project Power PointsSample Project Power Points

6

Resource Library – Quality Impr. Resources

14 New 14 New

ResourcesResources

AddedAdded

Forms…..ArticlesForms…..Articles

PDSA worksheetsPDSA worksheets

Run Chart TemplateRun Chart Template

IOM ManualIOM Manual

and More…and More…

Under Category of Quality Improvement (Alphabetical Listing)Under Category of Quality Improvement (Alphabetical Listing)

Quality Improvement Award - Pending

Under development:

• Guidelines and application process to be developed

– SMART goal format � Aim statement

– Problem analysis � SWOT, Fishbone diagram, etc.

– Metrics with pre-/post- data outcomes

– Impact, Barriers, Lessons Learned, Next Steps…

• CNM members submit QI projects to the sub-unit

• QPI sub-unit forms a QI Project Committee

• Committee reviews and scores projects

• Winner selected and awarded prize and recognition

Quality Improvement Award – continued…

In Addition:

• Posters can be showcased at annual symposium

• Can expand the exhibits to include QI project posters

• Winner of QI project can be announced at symposium

(winner gets FREE registration to symposium)

• Maybe also consider a “People’s Choice Award” with

symposium attendees voting

Your Feedback? Grab your Session Worksheet…

Proposed Future Opportunity

Develop national Clinical Dietetic Quality Indicator

program similar to Nursing’s NDNQI (National

Database for Nursing Quality Indicators)

Why would this be beneficial?....

7

• Hospital Administrators ask for CNMs for justification

– Question need for the number of Dietitians (FTEs) budgeted

– Want to know if we matchup or ranking compared to other facilities

• There are no national comparative nutrition indicators, except for nutritionDay in the US for malnutrition

• Nursing has been comparing nursing sensitive indicators since 1998 with NDNQI (National Database of Nursing Quality Indicators)

• Goals of NDNQI

– Provide comparative information to hospitals for use in quality improvement activities

– Develop national data on the relationship between nurse staffing and patient outcomes

Don’t Know How We Compare To others? NDNQI Data Model

Adapted Donabedian’s conceptual framework

– Structure

• Measures of quantity and quality of nursing staff

• Hospital characteristics like Magnet recognition, teaching

status, bed size, etc.

– Process

• Measure aspects of nursing care (assessment/intervention)

– Outcome

• Patient outcomes related to quantity or quality of nursing

care

A. Donabedian, The Quality of Care, JAMA 1988:260 (12):1743-1748

Hospital Characteristics

For NDNQI Comparison Groups:

• Hospital Type

• Staffed Bed Size

• Teaching Status

• Location

�Metropolitan/Micro/Non

�Census Division

�State

• Magnet Status

• Case Mix Index

27

NDNQI Benchmarking Benefits

If a facility participates in NDNQI they get:

• Reports with trending data

• Used for

– Quality Improvement

– Focus on Best Practices

– Set Targets

– Monitor Interventions

– Resource Allocation

– Budget Planning

28

8

Possible Solution…ANDHII

ANDHII – Academy of Nutrition and Dietetics Health

Informatics Infrastructure

• Available to all Academy members

• Formatted to 4 step NCP and standardized language

from IDNT Reference Manual

• Data entry, clinical decision-making, data base for

report generation

• Primarily dropdown selections from NCP terminology

• Also free text capability

What about NutritionWhat about Nutrition--Related DRG (ICDRelated DRG (ICD--9) Terms? 9) Terms?

Would you want Nutrition DRGs captured in the data the RDNs enter? Would you want Nutrition DRGs captured in the data the RDNs enter?

Only Malnutrition DRGs or BMI/Other Nutrition Deficiencies?Only Malnutrition DRGs or BMI/Other Nutrition Deficiencies?

ANDHII Reports

• Reports can be developed for info of interest to CNMs

• Can run your own reports for:

– Comparison of your RDNs

– Patient outcomes data

• Inability at this time for national facility comparison

• Academy can create report templates

What templates would CNMs want?

ANDHII Report Templates

What information entered into ANDHII would CNMs want to know? Examples…

• Prevalence of each Nutrition Diagnosis

• Nutrition Diagnosis resolution average

• Prevalence of each Nutrition Intervention

• Each Nutrition Dx to corresponding Nutrition Intervention

• Compare actual Diet Order to Nutrition Prescriptions established by RDN

• Others…give us your feedback ���� Session Worksheet

Other Quality Measures

Per Academy’s Quality Management:

All measures address one or more quality

element or objective of safety, effectiveness,

patient-centeredness, timeliness, efficiency

and/or equity.

Three Types of Measures:

1. Outcome

2. Process

3. Structural

9

1) Outcome Measures

• Measures end results of a function or process

• Quantifiable data elements compared to goal

or benchmark values/trends

• Indicators of quality of care (services) provided

• Examples:� Increased po intake

� Pt/client weight loss

� Pt/client satisfaction scores

� Decreased length of stay

2) Process Measures

• Measures how often activities/actions are

done in a period of time

• Data compared to regulatory standards,

practice guidelines, policy and procedures

• Results of process improvement initiatives

• Examples:� Pts screened for nutrition risk within 24 hrs.

� Pts at tube feeding goal within 48 hrs.

� Tray accuracy

3) Structural Measures

• Measures “numbers” tracking (statistical data)

• Indicators of quantity, efficiency, cost/revenue

• Monitors effective use of resources/technology

to support or improve outcomes

• Examples:

� Staffing levels (FTE/bed)

� Meal food cost

� Staff productivity

� Staff competency

Considerations for Nutrition Measures

• Nutrition Risk Level (high/moderate/low)

• Nutrition Assessment / Intervention / Reassessment Cycle (frequency-timeframes)

• Consecutive NPO/Clear Liquid days

• Oral Nutrition Supplementation usage

• Nutrition Support Prevalence (oral diet vs NS)

• Ratio of Enteral Nutrition vs Parenteral Nutrition

• Days until reach Nutrition Support goal volume

10

Nutrition Measures…continued

• Patients with Pressure Ulcer followed by RDN

• Hospital LOS comparison (followed by RDN vs not)

• Patients educated by RDN and readmission rate

• RDN Education: Advanced Degree / Certification

• RDN to Dietetic Technician staffing ratio

What nutrition measures do you monitor?

Use your Session Worksheet…

In Conclusion…

If you have an interest in Quality or Process Improvement

• Visit the QPI website

• Sign up for the QPI EML

• Utilize QPI resources

• Consider submitting a QI Project for award program

• Participation in ANDHII

• Evaluate your nutrition measures

Literature Examples/References

Structural Measure

-Roberts S. Improving patient outcomes through registered dietitian order writing. Nutr Clin Prac. 2013;28:556-

565.

Process Measure

--SSchindler K et al. How nutritional risk is assessed and managed in European hospitals: A survey of 21,007

patients findings from the 2007-2008 cross-sectional nutritionDay survey. Clin Nutr. 2010;29552-559.

--Kiss CM et al. The impact of implementation of a nutrition support algorithm on nutrition care outcomes in an

intensive care unit. Nutr Clin Prac. 2012;27:793-801

Outcome Measure

-Hegazi R et al. Early jejunal feeding initiation and clinical outcomes in patients with severe acute pancreatitis.

JPEN J Parenter Enteral Nutr. 2011;35:91-96

-Braga M. et al. Preoperative oral arginine and n-3 fatty acid supplementation improves the metabolic host

response and outcome after colorectal resection for cancer. Surgery 2002;132:80-814.

Cost Reduction

-Phillips W et al. Economic impact of switching from an open to a closed enteral nutrition feeding system in an

acute care setting. Nutr Clin Prac. 2013;28:510

-Rollins C. Blind bedside placement of postpyloric feeding tubes by registered dietitians: success rates, outcomes

and cost effectiveness. Nutr Clin Prac. 2013;28:506-509

-Giannopoulis G, Merriman L. Malnutrition coding 101: Financial Impact and More. Nutr Clin Prac. 2013;28:698-

709.

What’s Your Message?Questions?

On Behalf of the

QPI Sub-Unit

Thank You !

Sub-Unit Chair: Sherri Jones, MS, MBA, RDN, LDN, FADA jonessl@upmc.edu

Sub-Unit Vice Chair: Cindy Hamilton, MS, RD, LD hamiltoc@ccf.org