Tuesday, November 8, 2016

Updated Requirements of Participation...An Exercise in Performance Excellence

By Kimberly M. Gimmarro | Quality Specialist, Botsford Commons – A Beaumont Community | Farmington Hills MI, and member of the AHCA/NCAL National Quality Award Program Board of Examiners |

A key requirement of the 2017 Final Rule is its overarching theme – know your residents, know their needs, provide staff that can meet them. The similarities between the AHCA/NCAL National Quality Award Programs Bronze and Silver Criteria and new Facility Assessment from the revised Requirements of Participation (ROP) are nothing short of striking. Let’s crosswalk it.

“We require facilities to conduct, document, and annually review a facility-wide assessment to determine what resources are necessary to care for its residents competently…”
•    Bronze/Organization Profile: P.1b(2) What are your KEY markets, PATIENT and other CUSTOMER groups, and STAKEHOLDER groups as appropriate? What are their KEY requirements and expectations of your HEALTH CARE SERVICES, PATIENT and other CUSTOMER support services, and operations?
•    Silver: 1.1 Senior Leadership: HOW do your SENIOR LEADERS lead the organization? 1.1a HOW do SENIOR LEADERS’ personal actions build an organization that is successful now and in the future? 1.1b HOW do SENIOR LEADERS communicate with and engage the entire WORKFORCE and KEY CUSTOMERS? 1.1c HOW do SENIOR LEADERS create a focus on action to achieve the organization’s MISSION? 3.1 Voice of the Customer: HOW do you obtain information from your CUSTOMERS? 3.1a HOW do you listen to, interact with, and observe CUSTOMERS to obtain actionable information? 3.1b HOW do you determine CUSTOMER satisfaction, dissatisfaction, and engagement? 3.1c HOW do you obtain information on CUSTOMERS’ satisfaction with your organization relative to other organizations including direct competitors, if available? 3.2 Customer Engagement:
HOW do you engage CUSTOMERS by serving their needs and building relationships?
3.2a HOW do you determine your HEALTH CARE SERVICE offerings? 3.2b HOW do you build and manage CUSTOMER relationships? 3.2c HOW do you manage CUSTOMER complaints?

during both day-to-day operations and emergencies….”
•    Silver: 6.2 Operational Effectiveness: HOW do you ensure EFFECTIVE management of your operations? 6.2a HOW do you control the overall costs of your operations? 6.2b HOW do you provide a safe workplace and operating environment? 6.2c HOW do you ensure that your organization is prepared for potential disasters or emergencies?

“Facilities are required to address in the facility assessment the facility’s resident population (that is, number of residents, overall types of care and staff competencies required by the residents, and cultural aspects),…”
•    Bronze/Organization Profile: P.1a(1) What are your main HEALTH CARE SERVICE offerings? What is the relative importance of each to your success? P.1a(2) What are your stated MISSION, VISION and VALUES? What are your organization’s CORE COMPETENCIES, and what is their relationship to your MISSION? P.1b(2) What are your
KEY markets, PATIENT and other CUSTOMER groups, and STAKEHOLDER groups as appropriate? What are their KEY requirements and expectations of your HEALTH CARE SERVICES, PATIENT and other CUSTOMER support services, and operations?
    Silver: 5.1 Workforce Environment: HOW do you build an EFFECTIVE and supportive WORKFORCE environment? 5.1a HOW do you manage your WORKFORCE CAPABILITY and CAPACITY needs?

resources (for example, equipment, and overall personnel),…”
•    Bronze/Organization Profile: P.1a(4) Assets: What are your major facilities, technologies, and equipment?
•    Silver: 4.2 Knowledge Management, Information, and Information Technology: HOW do you manage your organizational KNOWLEDGE ASSETS, information, and information technology infrastructure? 4.2c How do you ensure hardware and software reliability?
5.1b HOW do you recruit, manage, and retain your WORKFORCE? 5.1c HOW do you
provide supportive benefits and ensure workplace health and security for your WORKFORCE? 5.2a HOW do you foster an organizational culture that is characterized by open communication, HIGH PERFORMANCE, and an engaged WORKFORCE? 5.2b HOW do you assess WORKFORCE ENGAGEMENT? 5.2c HOW does your performance management system support HIGH PERFORMANCE and WORKFORCE ENGAGEMENT?
5.2d HOW does your LEARNING and development system support the organization’s needs and the personal development of your WORKFORCE members, managers, and leaders?

and a facility-based and community-based risk assessment.
    Bronze: P.2a(1) What are your KEY STRATEGIC CHALLENGES and ADVANTAGES in the areas of health care services, operations, societal responsibilities, and WORKFORCE?
    Silver: 2.1 Strategy Development: How do you develop your strategy? 2.1a HOW do you develop your strategic plan to achieve ongoing success and organizational
improvement? 2.1b What are your organization’s KEY STRATEGIC OBJECTIVES, their related GOALS, and the timetable for achieving them? 2.1c HOW do your STRATEGIC OBJECTIVES address your STRATEGIC ADVANTAGES and CHALLENGES? 2.2 Strategy Implementation: HOW do you implement your strategy? 2.2a HOW do you translate your STRATEGIC OBJECTIVES into ACTION PLANS? 2.2b What are your KEY ACTION PLANS and MEASURES you use to track progress on these action plans? 2.2c HOW do you DEPLOY your ACTION PLANS?

“We are requiring all LTC facilities to develop, implement, and maintain an effective comprehensive, data-driven QAPI program that focuses on systems of care, outcomes of care and quality of life.
    Bronze/Organizational Profile: P.2c(1) What are the KEY elements of your PERFORMANCE improvement system, including your PROCESSES for evaluation and improvement of KEY organizational projects and PROCESSES? P.2a(3) What KEY sources
of COMPARATIVE DATA are available from within the health care industry? What limitations, if any, affect your ability to obtain or use these data?
    Silver: 4.1 Measurement, Analysis and Improvement of Organizational Performance: HOW do you measure, analyze, and then improve organizational PERFORMANCE? 4.1a HOW do you use DATA (and information) to track daily operations and analyze overall organizational PERFORMANCE? 4.1b HOW do you use COMPARATIVE DATA and information? 4.1c HOW do you review and improve your organization’s PERFORMANCE?
4.1d What are your KEY PERFORMANCE MEASURES? 4.2a HOW do you ensure the
quality and security of organizational DATA and information? 4.2b HOW do you ensure the availability of organizational DATA and information? 5.2d HOW does your LEARNING and development system support the organization’s needs and the personal development of your WORKFORCE members, managers, and leaders? 6.1d HOW do you improve your KEY HEALTHCARE services and KEY WORK PROCESSES?

There you have it!  It’s all wrapped up in the Bronze and Silver National Quality Award Criteria.  May I suggest you get a jump on your facility assessment by participating in the National Quality Award Program? In addition to that, studies have shown that recipients of the National Quality Award Program perform better than their peers in a wide array of outcomes[1][2].

The Intent to Apply process is now open for the 2017 AHCA/NCAL National Quality Award Program. The deadline to submit an ITA payment is November 17th at 8pm EST. The ITA is not mandatory to apply, but members who submit benefit by saving money on their overall application fee and receive weekly tips on submitting a successful application.

The deadline to apply for a 2017 Quality Award is January 26, 2017. The criteria and resources are available on the Quality Award website and now is the time to start writing those applications!

For more information and educational resources about the Requirements of Participation, just visit ahcancalED!

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