REFERENCE MANUAL
I.Basic Principles
Introduction
You may have
wondered how you can improve your facility, services, program, department, unit, or
organization, and to achieve your strategic goals and objectives. Or you may wonder how to
apply basic principles to your specific situation. Achieving your essential strategic
objectives requires the following five categories of approaches: 1) prepare and plan for
future, 2) improve quality , 3) improve customer satisfaction, 4) reduce costs, and 5)
eliminate waste. The purpose of this Section is to provide the basic
information to help you do this.
"Contents" lists topics covered in
this Section. This is followed by a list of major questions that will be addressed by the
topics in this Section.
The contents of this Section will be expanded
gradually over time. Highlighted items are most likely to be linked to more
detailed content. Refer back periodically for issues of interest. The monthly "Tips
and Information" columns will address various items prior to being transferred into
this Reference Manual.
Contents
1. The environment of care
a. Defining the environment
b. Health care reform
c. Changes in the care environment
d. Current and future challenges and
opportunities
e. Using this knowledge to influence
performance
2. The changing roles of the
long-term care continuum and practitioner
a. Concept of the care continuum
b. Changes in sites and levels of care
c. Shifting practitioner
roles and responsibilities
d. Changing role of medical
leadership
3. The paradox of change:
needed but resisted
a. Reasons why change is
essential
b. Reasons and varieties of resistance to change
c. Opportunities for bringing about
changes
d. Identifying obstacles to change
and improvement
4. Identifying common interests and
objectives
a. Concept of common interests
b. Specific common interests of all players in long-term
care
c. Important elements of high quality care
5. Essential
elements for optimum performance and service
a. Elements
related to improving overall care quality
b. Transforming attitudes
c. Optimizing systems and processes
d. Expanding knowledge and skills
e. Moving towards standards and guidelines
instead of mandates
6. Using this information
to help improve your organization and practice
a. Analyzing your facility or
situation
b. Identifying areas for
improvement
c. Selecting appropriate tools and
tactics
d. Monitoring and measuring
improvement
Issues Addressed in This Section
What is the "environment of care?"
What
is different or changing about the environment of care, and how is it shaping the future
of long-term care?
What is the meaning of health care reform?
What are the challenges and
opportunities for those in long-term care?
How can you understand and apply that
knowledge to influence the actions of the individuals delivering that care?
How are the roles of the long-term
care continuum, and various sites within that continuum, changing?
How are the roles of long-term-care
practitioners changing?
Why is change essential in long-term care?
Why
and how is change resisted?
How can we identify specific
obstacles to change and improvement?
What
are the common interests of all players in long-term care?
How can we bring about appropriate change?
What is needed to optimize
performance and service?
How can you apply these ideas to your
specific situation?
1. THE ENVIRONMENT OF CARE
The environment of care refers to the
social, political, regulatory, and economic climate within which service is being
delivered.
CURRENT AND FUTURE
CHALLENGES AND OPPORTUNITIES
Challenges
- A time of health care reform, with significant
change now and later
- A turning point for the long-term care industry
- True health care reform requires changed
attitudes, systems, processes, not just changes in insurance and access
- Many customary attitudes and approaches that enabled
people to get by before will not work in the future.
- Significant changes in care systems
of the future
- Both good quality and cost-effectiveness are
expected, not just one or the other
- New means of reimbursement include prospective
payment, managed care
- Greater consequences for inadequate performance
- Population receiving care gets older
and has more complex problems
- Inroads into traditional nursing home care by
other forms of service delivery
- More diverse work force requires more training and
guidance to become a cohesive unit
- Increased complexity of laws and regulations
regarding care, employment practices, oversight, etc.
- Challenge to define pertinent standards
Opportunities
- Rising importance and recognition of long-term
care
- Unprecedented opportunity to apply knowledge and skills to
improve lives of millions of individuals
- Great opportunity to help improve health care delivery
systems for the start of the next century
- Start of breakup of the old power structure of health care and
decline of hierarchical / authoritarian approach to management
- Flexibility to try new approaches
- Growing recognition of value of attracting and maintaining quality
individuals to provide services
- Unprecedented opportunity to create standards and
guidelines for effective practices and appropriate systems and processes to
implement them
- Availability of larger, more relevant knowledge base
- Potential for reasonable financial rewards and personal
satisfaction exists within long-term care continuum.
2. CHANGES IN ROLES
AND RESPONSIBILITIES
The roles and responsibilities of various
sites, individuals, and disciplines are changing significantly.
Changes in sites and levels of care
- Continuum of care: shift in roles and increase in options
- NFs have tremendous opportunities to play a central role
in the future health care system
Future for NFs lies in 2 options: 1) good
quality traditional LTC of those with high chronic illness / disability; 2) medically
oriented care for those with low to moderate acuity (subacute, etc.)
- Some NFs will serve as geriatric health care centers
- Still important role for good quality traditional nursing home care
- Provider networks must find optimal mix of care and costs
Shifting roles of
practitioners and other care providers
- Practitioners can assume a much greater
leadership role in health and personal care
- Shifting roles and expectations for physicians: more
collaboration, less "laissez-faire" (undirected independence)
- Medical directors: greater responsibilities, more respect
and appropriate reimbursement, greater liability for failing to try to solve
significant problems
- Far greater opportunities for a more meaningful leadership
role
- Expanded support for appropriate physician care in wider
spectrum of sites
- Physician and facility reimbursement more independent of
service site
3. THE PARADOX OF
CHANGE: NEEDED BUT FEARED
Challenge of change: Key Points
- Change is essential but formidable resistance must
still be overcome
Only some recognize the opportunities and
appreciate the challenges
- Fear of the unknown and comfort with the familiar
lead to retreat
- LTC owners / boards / administrators / clinical leadership often
lack understanding or skills to identify and address resistance, and sometimes
lead the retreat
Belief that changing too soon puts
one at a personal and competitive disadvantage because others will get ahead using
the same old methods
Fear that others will get ahead leads to reluctance
to try new approaches or retreat into authoritarian approach
Many benefit from status quo, including
tradition of authority-based rule, and do not want to relinquish it
- Struggles between the resistors and the overreactors,
between the "haves" and the "have-nots"
Macro and micro systems struggles
for power and influence: keeping out the "intruders"
- Individuals and organizations rush to position themselves for
the future, often without adequate understanding of why or how
Mergers and joint ventures proliferate,
threatening the influence and control of many current practitioners and other dedicated
individuals
- Not possible to escape change by simple acts of denial
or resistance
Change is like a tidal wave: a chance to
recognize it and deal appropriately rather than standing by defiantly and getting wiped
out
- Critical need to find the right balances and not
allow any one discipline, organization, or individual to dominate
Opportunities
- Growing recognition that old ways of doing business limit
opportunity for enhancing performance to meet future challenges
- More / more affordable technological support for effective change
- A little flexibility goes a long way, while refusal to budge keeps us
struggling constantly
Identifying Obstacles to
Change and Improvement
- Generic (universal, common) root causes of failures to
change and improve include:
Inappropriate regulatory
requirements / penalties
Territoriality / petty
power politics (multidisciplinary rather than interdisciplinary approach
)
Irrational or indifferent
authority
Denial of responsibility and failures
of accountability ("root cause exclusion")
Ineffective problem
solving
Inadequate knowledge base
Inadequate information systems
support
Excessive common variation
disguised as special variation
Inadequate or unclear
standards, guidelines, policies, procedures
Unclear roles, responsibilities
Inadequate resources
4. COMMON INTERESTS AND
OBJECTIVES
Common interests: Key points
- Many players with widely varying motivations,
backgrounds, and skills are involved in providing and managing long-term care
Self-protection and self-preservation narrow
vision and result in failure to recognize common interests
Enhancing mutual interests promotes
self-interest in the long run
We must recognize how historical approaches
have distorted common and self-interest.
- Roles and responsibilities of disciplines often either
self-defined or imposed
- Everyone's common interests
include: 1) well-trained, competent, flexible work force, 2) consistency /
predictability to allow individualized care, 3) providing appropriate care to
reasonably meet needs of those served, 4) satisfied care recipients and families,
5) personal satisfaction of practitioners and care providers, 6)
appropriate compliance with reasonable regulations and standards, 7) minimize
loss and legal liability , and 8) financial viability.
The key to self-interest lies in a solid foundation of common
support for effective performance at all levels, because only in this way can the care
be delivered both effectively and efficiently. Although we cannot change human
nature, we can improve performance.
Essential elements of high quality
care
- Essential elements of high quality care that should interest all participants
include:
Accessibility: ease with which a patient can obtain the care
he/she needs
Timeliness: degree to which care made available to a patient
when it is needed
Effectiveness: the degree to which the care rendered is provided
in the correct manner, given the current state of the art
Appropriateness: degree to which the care received matches
patient needs
Efficiency: degree to which the care received has the desired
effect with a minimum of possible effort, expense or waste
Continuity: degree to which the care needed by the patient is
coordinated effectively among practitioners and across organizations and time
Privacy: rights of patient to control distribution and release
of data concerning his/her illness, including information provided to health care
professionals and any additional information contained in the medical record and/or other
source documents.
Confidentiality: information the health care team obtains from
or about patient is considered to be privileged and thus, except in specified
circumstances, that may vary by illness and jurisdiction, cannot be disclosed to third
party without patient's consent.
Participation of patient and patient family: patient (or patient
family) involvement in the decision-making process in matters pertaining to his/her
health.
Safety of care environment: freedom from hazard or danger
Supportiveness of care environment: the degree to which
necessary spaces, equipment and medications are available to the patient when needed.
[Source: Adapted from JCAHO Accreditation manuals]
5. ESSENTIAL
ELEMENTS FOR OPTIMAL PERFORMANCE AND SERVICE
Key
concepts about the links between performance, process, and outcomes
- Outcomes arise from identifiable factors
- Patient/resident characteristics and processes are
principal factors affecting outcomes
- Mixing money and people is not enough to consistently produce
desired outcomes, without a formula to use both effectively.
Money is a motivator but it alone does not
ensure adequate results.
- It is possible and desirable to improve NF care
substantially and to effectively resolve common NF problems.
- Optimal quality service depends on the effective
collective performances of individuals. Optimal performance depends heavily
on optimal support from those at all levels of the organization
Effective policies, procedures, protocols promote
rather than inhibit desired performance, and are tied to systems and processes that
enable effective performance.
- Optimal service depends heavily on identifying common
objectives, essential tools to achieve those objectives, ways to overcome
obstacles to optimizing those elements.
Quality improvement programs are really
all about optimizing individual and collective performance, based on the following
approaches.
Transforming Attitudes
- Emphasize that achieving outcomes is a shared responsibility
- Vigorously enforce individual accountability
- Carefully assess and enhance knowledge and skills of those providing
NF care
- Attack rationalization disguised as justification
- Accept value of continual process improvement
Improving Systems and Processes
- Carefully define roles and responsibilities
- Clarify job expectations and performance criteria
- Evaluate performance and provide feedback
- Use policies and procedures to guide performance
- Employ effective problem solving methods to identify and address
problems
- Provide effective quality oversight
- Build effective utilization management and risk management into
routine activities
Expanding Knowledge and skills
- Target education and training to individual needs
- Create and use effective education and training methods
- Provide useful information resources
- Identify and use standards and guidelines
Moving Towards Standards and
Guidelines
- Understand the values and limits of standards and guidelines
- Employ effective strategies to get them used
- Provide and clarify their contents
6. HOW TO APPLY
THESE IDEAS TO YOUR SITUATION
You may have
wondered how you can improve your facility, services, program, department, unit, or
organization, and to achieve your strategic goals and objectives. Or you may wonder how to
apply basic principles to your specific situation.
Achieving your essential strategic objectives
requires the following five categories of approaches: 1) prepare and plan for future,
2) improve quality , 3) improve customer satisfaction, 4) reduce costs, and 5) eliminate
waste. All of them are important. They may be best achieved by using the following
strategies. You may find more details about their implementation by clicking on highlighted
links to other parts of this reference manual.
- STRATEGY 1: Try to influence the
actions of various individuals and disciplines by helping them understand the environment
in which everyone must function, and how that environment influences everyone's actions.
- STRATEGY 2: Help individuals understand their roles
and responsibilities by clarifying the changing roles of long-term care sites and
practitioners in the future care continuum.
- STRATEGY 3: Enable
change by identifying why it is needed and addressing why it is resisted.
- STRATEGY 4: Help all those involved in long-term
care to recognize their common interests and objectives.
- STRATEGY 5: Identify and agree upon essential
prerequisites for optimal performance, as the basis for optimal service
- STRATEGY 6: Identify ways to achieve
your essential strategic objectives to meet the
challenges and opportunities of the future
Strategy #1: Explain the Environment
Review the concepts in Section #1 above. Feel confident that you understand
the changing environment of care. For details, refer to the cross-references.
Strategy #2: Clarify roles and responsibilities
Review the concepts in
Section #2 above. Be sure that you understand the specific roles and responsibilities of
those in your program, discipline, unit, facility, department, and organization. For
details, refer to the cross-references.
Strategy #3: Enable change
Review the concepts in Section #3
above. Help identify internal and external obstacles to change and improvement in your
program, discipline, unit, facility, department, and organization, to allow for reducing
or eliminating them. For details, refer to the cross-references.
Strategy #4: Define common interests and objectives
Review the concepts in Section #4
above. Be sure that you understand and accept these common interests and objectives, so
you can help persuade others. For details, refer to the cross-references.
Strategy #5: Optimize performance
Review the concepts in Section #5
above. Be sure that you understand the principles of influencing and improving systems and
processes by affecting individual performance. of those in your program, discipline, unit,
facility, department, and organization. For details, refer to the cross-references.
For More Information Contact:
Long-Term Care Information
7801 Ruxwood Road; Baltimore,
MD 21204-3540
Tel: 410-825-4728
FAX: 410-825-4728
Internet:
information@ltcinfo.net
