Committing to Continuous Quality Improvement

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May 2004 11 A s a manager of a variety of food services and/or clini- cal care, a dietary manager needs to be concerned with quality. Quality is quite simply excellence in services and care. High-quality care meets or exceeds client expecta- tions.

It results in the best possible outcomes in a healthcare environment. Apopular approach to quality management is called con- tinuous quality improvement (CQI). The CQI approach has several characteristics: "CQI focuses on clients and what they need, rather than on workers or departments and what they do.

"CQI uses the systems approach to understanding how services are provided. Asystems approach defines a series of tasks that connect to make something happen. Connec- tions tend to cross departments, involving many people.

In other words, CQI proceeds on the assumption that the work of many individuals and/or departments comes together to create a system for accomplishing something the client needs. An example would be serving a meal tray, or obtaining laboratory blood tests. "Another premise of CQI is that the process of accom- plishing a task can be flawed, and usually can be improved.

"CQI also assumes that because of the systems and process focus, interdisciplinary teamwork is required to accom- plish results. ... more. less.

Furthermore, teamwork is required to test and manage quality. "CQI emphasizes using data that can be defined and meas- ured. It is objective and scientific. "CQI is a proactive, ongoing activity. In other words, we do not wait for a problem to occur. Instead, we analyze our processes for serving clients continuously, and look for ways to improve these processes. CQI uses some key terminology. One term is outcome. An outcome is the end result of work. In a healthcare environ- ment, a health outcome describes the consequences of clinical interventions. For instance, if members of the healthcare team work together to improve a client 9s nutritional status, what happens to that client 9s nutritional status is the outcome of the clinical care plan. Quality indicators (QIs) are measures of outcomes. According to CMS (Centers for Medicare & Med- icaid Services), an indicator is ca key clinical value or quality characteristic used to measure, over time, the performance, processes, and outcomes of an organization or some compo- nent of healthcare delivery. d As you can see by this definition, indicators are designed to facilitate collection and analysis of data. They are objective and measurable. Ageneral process for implementing CQI in healthcare uses two acronyms: FOCUS and PDCA. FOCUS means: F - Find a process to improve O - Organize to improve a process C - Clarify what is known U - Understand variation S - Select a process improvement Once you have selected a process to improve, the next acronym relates to the plan itself. PDCAmeans: P - Plan: Decide what you will do to improve the process. Decide what information you will collect, and how you will measure outcomes. Committing to Continuous Quality Improvement By Sue Grossbauer, RD A commitment to quality leads to excellence in service and client care. The CQI approach to quality is explained here, along with how this approach dovetails with CMS regulations. Key Terms N Activities of daily living (ADL): routine tasks for self-care, such as getting dressed or eating N Continuous quality improvement (CQI): a popular approach to quality management that focuses on sys- tems and processes and emphasizes teamwork N F-tags: labels for components of the CMS regulations N Outcome: the end result of work N Quality: excellence in services and care N Quality indicators (QIs): measures of outcomes continued on page 12 D - Do: Make the improvements. C - Check: Collect and review data, and evaluate how the plan is working. A - Act: Act on what you have learned. If you have made a successful improvement, make sure it becomes part of your policies and procedures. If not, try an alternate plan. Regulatory Influences on Quality Indicators Any institution subject to CMS regulations is concerned with many aspects of quality management as defined by these regulations. CMS lists specific quality indicators for use in ongoing monitoring. The regulations standardize these QIs as a quality evaluation tool for individual institutions, as well as for regulatory surveillance. Surveyors use a Resident Level QI Summary and a Facility QI Summary in reviews of long-term care facilities. The Resident Level QI Summary identifies current and past residents and shows applicable quality indicators. This Resident Summary can help man- agers in an institution focus on residents who need interven- tion. It may also help surveyors decide where to focus their 12DIETARYMANAGER Continuous Quality Improvement continued from page 11 Objectives: N To determine if the identified weight loss is avoidable or unavoidable; and N To determine the adequacy of the facility 9s response to the weight loss. Procedures: N Observations/interviews conducted as part of this proce- dure should be recorded. N Determine if the resident was assessed for conditions that may have put the resident at risk for unintended weight loss such as: cancer, renal disease, diabetes, depression, chronic obstructive pulmonary disease, Parkinson 9s, Alzheimer 9s, malnutrition, infection, dehydration, consti- pation, diarrhea, Body Mass Index (BMI) below 19, dys- phagia, chewing and swallowing problems, edentulous, ill fitting dentures, mouth pain, taste/sensory changes, bed- fast, totally dependent for eating, pressure ulcer, laborato- ry values indicative of malnutrition, and use of certain medications. NOTE: Amputation of a body part will contribute to a signif- icant decrease in previously targeted weight range. Establish new weight goals and then assess. NOTE: Body Mass Index (BMI) = weight (lbs.)/height (inch- es squared) X 705 N Determine if the facility has assessed the resident 9s nutri- tive and fluid requirements, dining assistance needs, and frequency of meals. N Review all related information and documentation to look for evidence of identified causes of the condition or problem. N Determine if the care plan was developed utilizing the clinical conditions and risk factors identified in the assess- ment for unintended weight loss. Were interventions, such as oral supplements, enteral feeding, alternative eating schedule, liberalized diet, nutrient supplements, adaptive utensils, assistance and/or increased time to eat developed to provide an aggressive program of consistent interven- tion by all appropriate staff? N Determine if the care plan was evaluated and revised based on the response, outcomes, and needs of the resident. NOTE: If a resident is at an end-of-life stage and has an advance directive, or the resident has reached an end-of-life stage, and all appropriate efforts have been made to encourage and provide intake, then the weight loss may be an expected outcome. Maintain the resident 9s comfort and quality of life. N Observe the delivery of care as described in the care plan. Determination of Compliance: N F325, Nutrition: Unintended weight loss is unavoidable if the facility properly assessed, care planned, implement- ed the care plan, evaluated the resident outcome, and revised the care plan as needed. N F309, Quality of Care: Resident who is in an end-of-life stage and palliative interventions are being implemented and revised as necessary. N F272, Comprehensive Assessments: Facilityassessed the factors that put the resident at risk for weight loss. N F279, Comprehensive Care Plans and F282, Provision of Care: Facility developed a care plan that includes measurable objectives and timetables to meet the resi- dent 9s needs and qualified persons implemented the plan. Source: CMS. Survey Procedures for Long Term Care Facilities (excerpt) [Figure1]CMS Investigative Protocol for Unintended Weight Loss attention. Based on QIs present, surveyors may pursue spe- cific investigations to understand whether quality issues exist. Likewise, facility managers can investigate these. For example, if there are many residents experiencing weight loss, a dietary manager should be one of the individuals ask- ing why this is occurring. CMS has designed investigative protocols for unintended weight loss, which appear in Figure 1. Another protocol, for hydration, appears in Figure 2. Yet another protocol, for the investigation of dining and food service, appears in Figure 3. If pressure ulcers are prevalent, another investigative protocol specifically for pressure ulcers may be used. An investigative protocol is a guide to examining quality as it relates to a specific quality indicator. The presence of a quality indicator is not necessarily problematic in and of itself. For example, tube feeding is a quality indicator. Tube feeding can be a positive step towards improving a client 9s May 2004 13 continued on page 14 Objectives: N To determine if the facility identified risk factors which lead to dehydration and developed an appropriate preven- tative care plan; and N To determine if the facility provided the resident with suf- ficient fluid intake to maintain proper hydration and health. Use: Use this protocol for the following situations: N Asampled resident who flagged for the sentinel event of dehydration on the Resident Level Summary; N Asampled resident who has one or more QI conditions identified on the Resident Level Summary, such as: fecal impaction, urinary tract infections, weight loss, tube feed- ing, decline in ADLs, or pressure ulcer N Aresident who has vomiting/diarrhea resulting in fluid loss, elevated temperatures and/or infectious processes, dependence on staff for fluid intake, use of medications including diuretics, laxatives, and cardiovascular agents, renal disease, dysphagia, a history of refusing fluids, lim- ited fluid intake, or poor thirst sensation. Procedures: N Determine if the resident was assessed to identify risk fac- tors that can lead to dehydration. NOTE: Ageneral guideline for determining baseline daily fluid needs is to multiply the resident 9s body weight in kilo- grams (kg) x 30 ml (2.2 lbs = 1 kg), except for residents with renal or cardiac distress, or other restrictions based on physi- cian orders. N Determine if an interdisciplinary care plan was developed. If the resident is receiving enteral nutritional support, determine if the tube feeding orders included a sufficient amount of free water. N Observe the care delivery. What is the resident 9s response to the interventions? Was the correct type of fluid provid- ed to a resident with dysphagia? Is the resident able to reach, pour, and drink fluids without assistance, and is the resident consuming sufficient fluids? If the resident refus- es water, are alternative fluids offered that are tolerable to the resident? Are the resident 9s beverage preferences iden- tified and honored at meals? Do staff encourage the resi- dent to drink? Are staff providing fluids during and between meals? N Look for identified causes of the condition or problem. NOTE: If a resident is at an end-of-life stage and has an advance directive, or the resident has reached an end-of-life stage, and all appropriate efforts have been made to encour- age and provide intake, then the weight loss may be an expected outcome. Maintain the resident 9s comfort and qual- ity of life. N Determine if the care plan is evaluated and revised based on the response, outcomes, and needs of the resident. Determination of Compliance: N F327,Hydration: Facility properly assessed, care planned, implemented the care plan, evaluated the resi- dent outcome, and revised the care plan as needed. N F272, Comprehensive Assessments: Facility assessed factors that put the resident at risk for dehydration, whether chronic or acute. N F279, Comprehensive Care Plans and F282, Provision of Care: Facility developed a care plan that includes measurable objectives and timetables to meet the resi- dent 9s needs, and qualified persons implemented the resi- dent 9s care plan. Source: CMS. Survey Procedures for Long Term Care Facilities (excerpt) [Figure2] CMS Investigative Protocol for Hydration nutritional status. However, it is a red flag for investigation because we want to be sure the feeding is appropriate and necessary, and that it is being managed effectively. The investigative protocol helps managers evaluate these aspects of feeding. Investigative protocols are used by surveyors evaluating a facility, but should also be used by managers within the facility. AFacility QI Summary provides a sense of the overall quality of care in an institution. Statistical analysis also com- pares these results from one institution to another and assigns percentile rankings. Consumers may review this type of information when evaluating long-term care facilities. For example, Medicare maintains a public listing of quality find- ings for long-term care facilities nationwide, which members of the public may search on the Medicare Web site, www.cms.hhs.gov/quality/nhqi/. The first section of the CMS Quality of Care regulations looks at what are called activities of daily living (ADL), which are routine tasks for self-care, such as getting dressed or eating. The regulations place much emphasis on enabling the resident to maintain or improve these abilities, and pre- venting decline. The dietitian/dietary manager must identify risk factors for a decline in residents 9eating skills and show how these risk factors are being addressed. For example, enough staff time and assistance must be given to monitor residents 9eating abilities. Additionally, the use of appropriate assistive devices and seating arrangements/setting must be addressed. When appropriate, treatment and services must be provided to improve a resident 9s eating skills. Regulations appear in a document called Survey Proce- dures for Long Term Care Facilities. Besides providing investigative protocols such as those in Figures 1-3, this doc- ument provides a detailed investigative protocol for survey- ing dining services. CMS guidelines use cF-tag d numbers to identify specific guidance. For example, tags F321 and F322 address tube feeding. Tags F325 and F326 address nutrition. Tags F360 through F372 address dietary services, including staffing, menus, therapeutic diets, frequency of meals, and sanitation. Survey procedures are subject to revision, so please check with your facility administrator and/or the CMS Web site for current standards. Adietary manager is involved in many quality manage- ment issues. Remember that interdisciplinary effort is a strong focus of quality management. Thus, neither surveyors nor administrators divide up CMS regulations and hand a section to each manager. Instead, dietary managers can expect to work closely with nursing and other personnel to assure that a facility meets regulations and manages quality. The Survey Process As part of its enforcement effort, CMS and its contracted state agencies conduct on-site surveys of healthcare institu- tions. Each time a team of surveyors arrives to evaluate com- pliance of a healthcare facility with CMS regulations, all managers become involved. Asurvey is typically unan- nounced, and may occur on any day of the week. Astandard survey is designed to review compliance with CMS regula- tions, including all the detail of the various F-tags. According to guidance from CMS, surveyors are examining: "Compliance with residents 9rights and quality of life requirements "The accuracy of residents 9comprehensive assessments and the adequacy of care plans based on these assessments "The quality of care and services furnished, as measured by indicators of medical, nursing, rehabilitative care and drug therapy, dietary and nutrition services, activities and social participation, sanitation and infection control Continuous Quality Improvement continued from page 13 continued on page 16 14DIETARYMANAGER Key Points N High-quality care meets or exceeds client expecta- tions. It results in the best possible outcomes in a healthcare environment. N CQI focuses on clients and what they need, rather than on workers or departments and what they do. It uses a systems approach. It emphasizes using data that can be defined and measured. N Ageneral process for implementing CQI in health- care uses two acronyms: FOCUS and PDCA. N Quality indicators (QIs) are measures of outcomes. CMS defines specific quality indicators for monitor- ing and investigating. N AFacility QI Summary provides a sense of the over- all quality of care in an institution. N In CMS regulations, F-tags identify standards for nutrition, tube feeding, and dietary services. N As part of its enforcement effort, CMS and its con- tracted state agencies conduct on-site surveys of healthcare institutions. N Adietary manager needs to manage the entire quali- ty process from day to day, and assure that standards are being met. cAn investigative protocol is a guide to examining quality as it relates to a specific quality indicator. d May 2004 15 Objectives: N To determine if each resident is provided with nourishing, palatable, attractive meals that meet the resident 9s daily nutritional and special dietary needs; N To determine if each resident is provided services to main- tain or improve eating skills; and N To determine if the dining experience enhances the resi- dent 9s quality of life and is supportive of the resident 9s needs. Procedures: 1.During the meal service, observe the dining room and/or resident 9s room for the following: "Comfortable sound levels; "Adequate illumination, furnishings, ventilation; absence of odors; and sufficient space; "Tables adjusted to accommodate wheelchairs, etc.; and "Appropriate hygiene provided prior to meals. 2.Observe whether each resident is properly prepared for meals, for example: "Resident 9s eyeglasses, dentures, and/or hearing aids are in place; "Proper positioning in chair, wheelchair, gerichair, etc. at an appropriate distance from the table (tray table and bed at appropriate height and position); and "Assistive devices/utensils identified in care plans pro- vided and used as planned. 3.Observe the food service for: "Appropriateness of dishes and flatware for each resi- dent. (Single use disposable dining ware is not used except in an emergency and, other appropriate dining activities.) Each resident (except those with fluid restriction) has an appropriate place setting with water and napkin; "Whether meals are attractive, palatable, served at appropriate temperatures and are delivered to residents in a timely fashion. Ask: Did the meals arrive 30 min- utes or more past the scheduled meal time? If a substi- tute was needed, did it arrive more than 15 minutes after the request for a substitute? "Are diet cards, portion sizes, preferences, and condi- ment requests being honored? 4.Determine whether residents are being promptly assisted to eat or provided necessary assistance/cueing in a timely manner after their meal is served. "Note whether residents at the same table (or in resident rooms) are being served and assisted concurrently. 5.Determine if the meals served were palatable, attractive, nutritious and met the needs of the resident. Note whether the resident voiced concerns regarding the taste, tempera- ture, quality, quantity and appearance of the meal served; whether mechanically-altered diets, such as pureed, were prepared and served as separate entree items (except when combined food: such as stews, casseroles, etc.); whether attempts to determine the reason(s) for the refusal and a substitute of equal nutritive value was provided, if the res- ident refused/rejected food served; and whether food placement, colors, and textures were in keeping with the resident 9s needs or deficits (e.g., residents with vision or swallowing deficits). Sample Tray Procedure If residents complain about the palatability/temperature of food served, the survey team coordinator may request a test meal. Send the meal to the unit that is the greatest distance from the kitchen or to the affected unit or dining room. Check food temperature and palatability of the test meal at about the time the last resident on the unit is served and begins eating. 6.Observe for institutional medication pass practices that interfere with the quality of the residents 9dining experi- ence, e.g. Pain medications being given prior to meals so that meals could be eaten in comfort; Foods served are not routinely or unnecessarily used as a vehicle to administer medications. 7.Determine if the sampled resident consumed adequate amounts of food as planned. "Apoint system may be used as follows: Each food item served except for water, coffee, tea, or condi- ments equals one point. Example: Breakfast: juice, cereal, milk, bread and butter, coffee (no points) equals four points. If the resident consumes all four items in the amount served, the resident consumes 100% of breakfast. 8.If concerns are noted with meal service, preparation, qual- ity of meals, etc., interview the person(s) responsible for dietary services. NOTE: If concerns are identified in providing monitoring by supervisory staff during dining or concerns with assistance for residents to eat, evaluate nursing staffing. Determination of Compliance: N F364, Food: Each resident receives food prepared by methods that conserve nutritive value, palatable, attractive and at the proper temperatures. N F362, Dietary Services, Sufficient Staff: The facility has sufficient staff to prepare and serve palatable and attrac- tive, nutritionally adequate meals at proper temperatures. N F252, Environment: The facility provides homelike environment that enhances the resident 9s quality of life. N F464, Dining and Resident Activities: The facility pro- vides adequate lighting, ventilation, furnishings and space during the dining services. Source: CMS. Survey Procedures for Long Term Care Facilities (excerpt) [Figure 3] CMS Investigative Protocol for Dining and Food Service "The effectiveness of the physical environment to empow- er residents, accommodate resident needs, and maintain resident safety, including whether requested room vari- ances meet health, safety, and quality of life needs for the affected residents Because a survey could occur at any time, a dietary man- ager in a long-term care facility should always be prepared. In other words, a dietary manager needs to manage the entire quality process from day to day, and assure that standards are being met. Adietary manager needs to become very familiar with regulations that apply in the workplace, and monitor compliance and quality indicators. It is also important to keep up-to-date with changes in relevant regulations. At the time of a survey, a dietary manager may be asked to provide documentation and information pertinent to the sur- vey. Surveyors will focus on quality indicators. They will review medical records and interview residents. Part of the survey will include a detailed tour of dietary areas. Adietary manager should accompany a surveyor and cooperate fully. When the survey concludes, the survey team will state any deficiencies noted and reference F-tag numbers. If a problem is identified, the dietary manager and other members of the interdisciplinary team need to follow up promptly and effec- tively to correct them. In all, a dietary manager plays a critical role in assuring that quality of dietary services meets the needs of clients, and that the end results of care are excellent. I Sue Grossbauer, RD is a frequent contributor to DIETARYMANAGER magazine and serves as DMA 9s Web master. She is the author of several DMApublica- tions, including the brand new book, Medical Nutrition Therapy forDietary Managers, from which this article is excerpted. 16DIETARYMANAGER Continuous Quality Improvement continued from page 14 Get answers to your medical nutrition therapy questions. Master Track Nutrition and MNT series. " RENAL DIETS: This reference provides the CDM with in-depth information about the role of the kid- ney and medical nutrition therapy strategies to manage kidney disease. " DIABETES ANDCARBOHYDRATE COUNTING: Learn how carbohydrate counting can be a meal planning approach that gives the client more flexibility and better blood glucose control. " ALZHEIMER 9S DISEASE: This reference provides the CDM with strategies to assist these clients at each stage of Alzheimer 9s disease. " LEGAL ISSUES IN NUTRITION ASSESSMENT: Learn how to strengthen your charting and docu- mentation practices to prevent legal actions from occurring. " DINING WITH DYSPHAGIA: Meeting the nutritional needs of clients with impaired chewing and swallowing abilities can be a challenge. Learn about the normal swallow, swallowing problems, and the National Dysphagia Diet. This book also includes practical pointers for menu planning, food prepara- tion, and staff training. 3 Clock Hours Per Book " Cost: $20 Per Book " Available in Paper or On-line Order at: www.dmaonline.org/market OR (800) 323-1908

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