Your Medical Director Can Lead the QI Team

Abstract

LORRAINE TARNOVE is executive director of AMDA, which represents more than 7,000 medical directors, administrators, nurses, and other health professionals serving in long-term care settings.There has been much discussion in this column about projects and activities that you can pursue with your medical director to improve care and services for your residents. As we approach next month's conclusion of this year-long series, here is one more—developing and implementing quality improvement (QI) models.As with any innovation, a champion is needed to promote and facilitate the QI model. This must be someone who can get the project going, involve and motivate the interdisciplinary team (IDT), communicate a vision, and report successes. The medical director can be this champion, but he or she can't succeed without a strong relationship with the IDT and a team that communicates with and respects one another. AMDA encourages its physician members to be strong team leaders who know, respect, educate, and communicate with the IDT.Bringing Out the BestAn incident I once witnessed exemplifies what the medical director's relationship with team members should be. During a clinical practice guideline (CPG) consensus conference a few years ago, work group members were discussing some clinical issue and one practitioner started talking about something certified nursing assistants (CNAs) should do.The group leader, a medical director, turned to a CNA in the room and asked, “Can or could you do that? Is it practical? How could it be done?” The CNA looked surprised and responded rather shyly at first. But once she realized that the medical director was listening to her, she relaxed and began to speak more openly. Her insights were excellent and contributed to the discussion.So what does this have to do with QI models? Everything, because QI requires teamwork. As Robin Remsburg, PhD, GCNS, director of the School of Nursing and Associate Dean of the College of Health and Human Services at George Mason University, Fairfax, Va., observed during the recent AMDA Foundation Long-Term Care Research Network Fall Conference (see page 18) “transdisciplinary collaboration and cooperation” are necessary to make a QI model work.Medical Director at the QI HelmAccording to Dr. Remsburg, “The medical director is the ideal person to take the lead on QI models.” She explained, “Others in the facility look up to the medical director and count on his or her expertise. It means a lot for the medical director to personally engage other players on the team at all levels.”In a recent conversation, Dr. Remsburg explained that everyone has a valuable and important voice that must be considered in developing and implementing a QI model. Listening to her, I couldn't help but think about the conversation at the CPG consensus conference. “When the medical director engages caregivers, housekeeping staff, and other front-line workers to ask for their insights and opinions,” said Dr. Remsburg, “this sends a powerful message that can make a huge difference.”This strong relationship within the team is the first step in developing a QI model. “This is part of the culture of QI that must exist—or be created—before a model is developed and implemented,” said Dr. Remsburg. Not only is this the first step, but it is the most important. A facility can't implement any big change without a team that has a strong leader, works well together, communicates effectively, enjoys mutual respect and understanding, shares values and visions, and has processes in place for conflict resolution.Next StepsThe next step is to examine your QI data and determine what issues are most in need of improvement and which can benefit the most from it. “You have to have good data, and you need to know what this information means,” said Dr. Remsburg. “You need someone who can analyze and interpret the data effectively and accurately. Then you need to share it with everyone—including front-line staff—in a way that they can understand and relate to their own work and responsibilities.”The medical director can start by sitting down with an interdisciplinary—or transdisciplinary—group of facility opinion leaders to discuss the data and consider which goals are appropriate and realistic to address the clinical issue the facility wants to improve.One resource that can help with setting goals is the ongoing national Advancing Excellence in America's Nursing Homes campaign, in which a coalition of organizations is asking nursing facilities to work voluntarily on at least three of eight measurable quality goals. Facilities can choose from several goals, including reducing pressure ulcers, reducing the daily use of physical restraints, and improving the management of pain in long- and short-stay residents.To manage their efforts to improve quality, nursing facilities can set improvement targets in the Advancing Excellence campaign and then track their progress toward those targets. The campaign depends on dedicated, proactive leaders playing a central role in driving and coordinating nursing home improvement work at the local level (much as the medical director does in your facility).Participation in the campaign and its resources and tools may help focus attention on QI and provide a systematic approach to the facilitation of quality patient care and services. It also can raise visibility of QI efforts and offer a support network for facility leaders.CPGs Provide Proven PracticesAs Dr. Remsburg said, “You need evidence about what we know works and specific proven strategies. Clinical practice guidelines have these elements.” AMDA has 23 CPGs that address issues such as dementia, falls, dehydration, anemia, urinary incontinence, diabetes, depression, and pressure ulcers. If there is a CPG on the issue you choose to address, this can be a good starting point to identify processes or steps that might be effective and easy to initiate.To help determine how to make changes necessary to accomplish your goal, you can go back to the CPGs for guidance on proven processes and roles that relate to the area being addressed. For example, you can compare the algorithm in the CPG to the procedures you currently have in place and determine where there might be gaps or weaknesses that contribute to problems. AMDA also has CPG implementation kits with tools that the team can use as part of the QI model.Leaping Over HurdlesEstablishing and implementing a QI model is rewarding but not without its challenges. As Dr. Remsburg noted, “One of the hardest parts is creating a culture of safety in quality improvement. It takes some pretty committed and secure people who are not threatened by change.” QI can be scary because you have to look at what's gone wrong, where there are problems, and how things can be done better.Your medical director can help make QI less painful by tying the initiative to processes and not to people (thereby neither making it personal nor allowing for finger pointing), by creating a nonpunitive environment (everyone from the administrator on down needs to feel safe putting ideas on the table), and by taking a positive approach (focus on what is done right and how things can be better, as opposed to what is done wrong).Elsewhere, it is important to keep the team informed about progress toward goals. Nursing facilities often use story boards to do this. “United Way organizations often show the big thermometers to track fundraising. When you enable people to track and trend numbers, they get it and start thinking about what their contribution might be,” said Dr. Remsburg.As team leader, the medical director should encourage everyone to think outside of his or her own discipline. Dr. Remsburg noted, “A root cause analysis is helpful, but it needs to go beyond disciplines or departments and consider systemic changes. If you do this, you might find more sustainable and effective strategies.” For example, don't just focus on nurses if there are drug-administration problems. Look at where the carts are stored and how medications are organized and labeled. Examine prescribing systems, including the use of technology to send or track prescriptions.Walk, Talk, RepeatOnce changes and new processes are in place and working, you can't rest on your laurels. “It falls on the leadership to walk the walk and talk the talk,” said Dr. Remsburg. “The medical director needs to be visible in the facility, making rounds, visiting the nursing stations, and talking directly to staff.”This will be second nature for a medical director with strong team relationships who has created a culture of collegiality. It also will enable practitioners and staff to feel comfortable sharing opinions, expressing their fears or concerns, and making suggestions for ways to tweak the processes. LORRAINE TARNOVE is executive director of AMDA, which represents more than 7,000 medical directors, administrators, nurses, and other health professionals serving in long-term care settings. There has been much discussion in this column about projects and activities that you can pursue with your medical director to improve care and services for your residents. As we approach next month's conclusion of this year-long series, here is one more—developing and implementing quality improvement (QI) models. As with any innovation, a champion is needed to promote and facilitate the QI model. This must be someone who can get the project going, involve and motivate the interdisciplinary team (IDT), communicate a vision, and report successes. The medical director can be this champion, but he or she can't succeed without a strong relationship with the IDT and a team that communicates with and respects one another. AMDA encourages its physician members to be strong team leaders who know, respect, educate, and communicate with the IDT. Bringing Out the BestAn incident I once witnessed exemplifies what the medical director's relationship with team members should be. During a clinical practice guideline (CPG) consensus conference a few years ago, work group members were discussing some clinical issue and one practitioner started talking about something certified nursing assistants (CNAs) should do.The group leader, a medical director, turned to a CNA in the room and asked, “Can or could you do that? Is it practical? How could it be done?” The CNA looked surprised and responded rather shyly at first. But once she realized that the medical director was listening to her, she relaxed and began to speak more openly. Her insights were excellent and contributed to the discussion.So what does this have to do with QI models? Everything, because QI requires teamwork. As Robin Remsburg, PhD, GCNS, director of the School of Nursing and Associate Dean of the College of Health and Human Services at George Mason University, Fairfax, Va., observed during the recent AMDA Foundation Long-Term Care Research Network Fall Conference (see page 18) “transdisciplinary collaboration and cooperation” are necessary to make a QI model work. An incident I once witnessed exemplifies what the medical director's relationship with team members should be. During a clinical practice guideline (CPG) consensus conference a few years ago, work group members were discussing some clinical issue and one practitioner started talking about something certified nursing assistants (CNAs) should do. The group leader, a medical director, turned to a CNA in the room and asked, “Can or could you do that? Is it practical? How could it be done?” The CNA looked surprised and responded rather shyly at first. But once she realized that the medical director was listening to her, she relaxed and began to speak more openly. Her insights were excellent and contributed to the discussion. So what does this have to do with QI models? Everything, because QI requires teamwork. As Robin Remsburg, PhD, GCNS, director of the School of Nursing and Associate Dean of the College of Health and Human Services at George Mason University, Fairfax, Va., observed during the recent AMDA Foundation Long-Term Care Research Network Fall Conference (see page 18) “transdisciplinary collaboration and cooperation” are necessary to make a QI model work. Medical Director at the QI HelmAccording to Dr. Remsburg, “The medical director is the ideal person to take the lead on QI models.” She explained, “Others in the facility look up to the medical director and count on his or her expertise. It means a lot for the medical director to personally engage other players on the team at all levels.”In a recent conversation, Dr. Remsburg explained that everyone has a valuable and important voice that must be considered in developing and implementing a QI model. Listening to her, I couldn't help but think about the conversation at the CPG consensus conference. “When the medical director engages caregivers, housekeeping staff, and other front-line workers to ask for their insights and opinions,” said Dr. Remsburg, “this sends a powerful message that can make a huge difference.”This strong relationship within the team is the first step in developing a QI model. “This is part of the culture of QI that must exist—or be created—before a model is developed and implemented,” said Dr. Remsburg. Not only is this the first step, but it is the most important. A facility can't implement any big change without a team that has a strong leader, works well together, communicates effectively, enjoys mutual respect and understanding, shares values and visions, and has processes in place for conflict resolution. According to Dr. Remsburg, “The medical director is the ideal person to take the lead on QI models.” She explained, “Others in the facility look up to the medical director and count on his or her expertise. It means a lot for the medical director to personally engage other players on the team at all levels.” In a recent conversation, Dr. Remsburg explained that everyone has a valuable and important voice that must be considered in developing and implementing a QI model. Listening to her, I couldn't help but think about the conversation at the CPG consensus conference. “When the medical director engages caregivers, housekeeping staff, and other front-line workers to ask for their insights and opinions,” said Dr. Remsburg, “this sends a powerful message that can make a huge difference.” This strong relationship within the team is the first step in developing a QI model. “This is part of the culture of QI that must exist—or be created—before a model is developed and implemented,” said Dr. Remsburg. Not only is this the first step, but it is the most important. A facility can't implement any big change without a team that has a strong leader, works well together, communicates effectively, enjoys mutual respect and understanding, shares values and visions, and has processes in place for conflict resolution. Next StepsThe next step is to examine your QI data and determine what issues are most in need of improvement and which can benefit the most from it. “You have to have good data, and you need to know what this information means,” said Dr. Remsburg. “You need someone who can analyze and interpret the data effectively and accurately. Then you need to share it with everyone—including front-line staff—in a way that they can understand and relate to their own work and responsibilities.”The medical director can start by sitting down with an interdisciplinary—or transdisciplinary—group of facility opinion leaders to discuss the data and consider which goals are appropriate and realistic to address the clinical issue the facility wants to improve.One resource that can help with setting goals is the ongoing national Advancing Excellence in America's Nursing Homes campaign, in which a coalition of organizations is asking nursing facilities to work voluntarily on at least three of eight measurable quality goals. Facilities can choose from several goals, including reducing pressure ulcers, reducing the daily use of physical restraints, and improving the management of pain in long- and short-stay residents.To manage their efforts to improve quality, nursing facilities can set improvement targets in the Advancing Excellence campaign and then track their progress toward those targets. The campaign depends on dedicated, proactive leaders playing a central role in driving and coordinating nursing home improvement work at the local level (much as the medical director does in your facility).Participation in the campaign and its resources and tools may help focus attention on QI and provide a systematic approach to the facilitation of quality patient care and services. It also can raise visibility of QI efforts and offer a support network for facility leaders. The next step is to examine your QI data and determine what issues are most in need of improvement and which can benefit the most from it. “You have to have good data, and you need to know what this information means,” said Dr. Remsburg. “You need someone who can analyze and interpret the data effectively and accurately. Then you need to share it with everyone—including front-line staff—in a way that they can understand and relate to their own work and responsibilities.” The medical director can start by sitting down with an interdisciplinary—or transdisciplinary—group of facility opinion leaders to discuss the data and consider which goals are appropriate and realistic to address the clinical issue the facility wants to improve. One resource that can help with setting goals is the ongoing national Advancing Excellence in America's Nursing Homes campaign, in which a coalition of organizations is asking nursing facilities to work voluntarily on at least three of eight measurable quality goals. Facilities can choose from several goals, including reducing pressure ulcers, reducing the daily use of physical restraints, and improving the management of pain in long- and short-stay residents. To manage their efforts to improve quality, nursing facilities can set improvement targets in the Advancing Excellence campaign and then track their progress toward those targets. The campaign depends on dedicated, proactive leaders playing a central role in driving and coordinating nursing home improvement work at the local level (much as the medical director does in your facility). Participation in the campaign and its resources and tools may help focus attention on QI and provide a systematic approach to the facilitation of quality patient care and services. It also can raise visibility of QI efforts and offer a support network for facility leaders. CPGs Provide Proven PracticesAs Dr. Remsburg said, “You need evidence about what we know works and specific proven strategies. Clinical practice guidelines have these elements.” AMDA has 23 CPGs that address issues such as dementia, falls, dehydration, anemia, urinary incontinence, diabetes, depression, and pressure ulcers. If there is a CPG on the issue you choose to address, this can be a good starting point to identify processes or steps that might be effective and easy to initiate.To help determine how to make changes necessary to accomplish your goal, you can go back to the CPGs for guidance on proven processes and roles that relate to the area being addressed. For example, you can compare the algorithm in the CPG to the procedures you currently have in place and determine where there might be gaps or weaknesses that contribute to problems. AMDA also has CPG implementation kits with tools that the team can use as part of the QI model. As Dr. Remsburg said, “You need evidence about what we know works and specific proven strategies. Clinical practice guidelines have these elements.” AMDA has 23 CPGs that address issues such as dementia, falls, dehydration, anemia, urinary incontinence, diabetes, depression, and pressure ulcers. If there is a CPG on the issue you choose to address, this can be a good starting point to identify processes or steps that might be effective and easy to initiate. To help determine how to make changes necessary to accomplish your goal, you can go back to the CPGs for guidance on proven processes and roles that relate to the area being addressed. For example, you can compare the algorithm in the CPG to the procedures you currently have in place and determine where there might be gaps or weaknesses that contribute to problems. AMDA also has CPG implementation kits with tools that the team can use as part of the QI model. Leaping Over HurdlesEstablishing and implementing a QI model is rewarding but not without its challenges. As Dr. Remsburg noted, “One of the hardest parts is creating a culture of safety in quality improvement. It takes some pretty committed and secure people who are not threatened by change.” QI can be scary because you have to look at what's gone wrong, where there are problems, and how things can be done better.Your medical director can help make QI less painful by tying the initiative to processes and not to people (thereby neither making it personal nor allowing for finger pointing), by creating a nonpunitive environment (everyone from the administrator on down needs to feel safe putting ideas on the table), and by taking a positive approach (focus on what is done right and how things can be better, as opposed to what is done wrong).Elsewhere, it is important to keep the team informed about progress toward goals. Nursing facilities often use story boards to do this. “United Way organizations often show the big thermometers to track fundraising. When you enable people to track and trend numbers, they get it and start thinking about what their contribution might be,” said Dr. Remsburg.As team leader, the medical director should encourage everyone to think outside of his or her own discipline. Dr. Remsburg noted, “A root cause analysis is helpful, but it needs to go beyond disciplines or departments and consider systemic changes. If you do this, you might find more sustainable and effective strategies.” For example, don't just focus on nurses if there are drug-administration problems. Look at where the carts are stored and how medications are organized and labeled. Examine prescribing systems, including the use of technology to send or track prescriptions. Establishing and implementing a QI model is rewarding but not without its challenges. As Dr. Remsburg noted, “One of the hardest parts is creating a culture of safety in quality improvement. It takes some pretty committed and secure people who are not threatened by change.” QI can be scary because you have to look at what's gone wrong, where there are problems, and how things can be done better. Your medical director can help make QI less painful by tying the initiative to processes and not to people (thereby neither making it personal nor allowing for finger pointing), by creating a nonpunitive environment (everyone from the administrator on down needs to feel safe putting ideas on the table), and by taking a positive approach (focus on what is done right and how things can be better, as opposed to what is done wrong). Elsewhere, it is important to keep the team informed about progress toward goals. Nursing facilities often use story boards to do this. “United Way organizations often show the big thermometers to track fundraising. When you enable people to track and trend numbers, they get it and start thinking about what their contribution might be,” said Dr. Remsburg. As team leader, the medical director should encourage everyone to think outside of his or her own discipline. Dr. Remsburg noted, “A root cause analysis is helpful, but it needs to go beyond disciplines or departments and consider systemic changes. If you do this, you might find more sustainable and effective strategies.” For example, don't just focus on nurses if there are drug-administration problems. Look at where the carts are stored and how medications are organized and labeled. Examine prescribing systems, including the use of technology to send or track prescriptions. Walk, Talk, RepeatOnce changes and new processes are in place and working, you can't rest on your laurels. “It falls on the leadership to walk the walk and talk the talk,” said Dr. Remsburg. “The medical director needs to be visible in the facility, making rounds, visiting the nursing stations, and talking directly to staff.”This will be second nature for a medical director with strong team relationships who has created a culture of collegiality. It also will enable practitioners and staff to feel comfortable sharing opinions, expressing their fears or concerns, and making suggestions for ways to tweak the processes. Once changes and new processes are in place and working, you can't rest on your laurels. “It falls on the leadership to walk the walk and talk the talk,” said Dr. Remsburg. “The medical director needs to be visible in the facility, making rounds, visiting the nursing stations, and talking directly to staff.” This will be second nature for a medical director with strong team relationships who has created a culture of collegiality. It also will enable practitioners and staff to feel comfortable sharing opinions, expressing their fears or concerns, and making suggestions for ways to tweak the processes. ResourcesAdvancing Excellence in America's Nursing Homes Campaign: www.nhqualitycampaign.orgAMDA Clinical Practice Guidelines: www.amda.com/tools/guidelines.cfmAMDA CPG Implementation Tool Kits: www.amda.com/tools/toolkits.cfmPfaadt, M., “Using story boards to make your performance improvement plan come alive” (Home Care Manag. 1998;2:20–3). Advancing Excellence in America's Nursing Homes Campaign: www.nhqualitycampaign.org AMDA Clinical Practice Guidelines: www.amda.com/tools/guidelines.cfm AMDA CPG Implementation Tool Kits: www.amda.com/tools/toolkits.cfm Pfaadt, M., “Using story boards to make your performance improvement plan come alive” (Home Care Manag. 1998;2:20–3).