2005 Quality Improvement Plan Outline for Nursing Facility Survey Process
Update: July 2005
January
- Expanded survey staff to include other disciplines: occupational therapist, physical therapist, additional occupational therapist or physical therapist and pharmacist to be added later.
- Initiated ongoing monthly review by division management of survey data monthly reports, information communicated to program managers, supervisors and staff.
February
- Facilitated meeting of supervisors addressed reducing variation in the survey process. Products include a general framework for conducting the survey process, including guidance for resolving survey issues consistently when internal structures do not adequately address or resolve survey questions, and a draft work plan.
March
- Began joint training on pressure ulcers for providers, surveyors, and stakeholders
April – May
- Conducted 10 additional workshops on pressure ulcers across the state
June
- Provided Life Safety Code training for provider facilities staff
July
- Quality Improvement Nurse Specialist joins staff
- Produce a single work plan that incorporates recommendations from the Management Analysis Division report, the Office of the Legislative Auditor report, the LTC Ad Hoc Committee, the supervisor’s retreat and which includes a
- Section on Quality Improvement in annual work plan
August
- Conduct additional Life Safety Code training sessions for provider facilities staff
- MDH Division management and all L & C supervisors participated in 360 review
September – October
- Joint training for surveyors, providers, stakeholders, StratisHealth on urinary incontinence
Ongoing
- Continue use of “mix/max” teams for surveying
- Monthly review by supervisors of results of mix/max teams
- Monthly review by supervisors (and subsequent sharing with staff) of average and mean numbers of deficiencies by team
- Participation in LTC Ad Hoc Committee, professional and provider associations
Future
- Use results of 360 degree reviews for Individual Development Plan development for supervisors
- Additional training initiatives; possible topics include Pain Assessment & Management, Nursing Assistant Awareness Program for Dental and Vision Care
- Produce video on the role of all parties involved in the survey process, including the provider, surveyor, consumer, advocates, etc. in the survey process
