Pioneer Network Director of Education
With the Phase 3 requirements from the Centers for Medicare and Medicaid Services (CMS) in full swing, Quality Assurance and Performance Improvement (QAPI) is a term that is deeply imbedded into the vocabulary of skilled care providers. Even those who work in Assisted Living and other care settings have felt the impact of these requirements and the initiatives that support it.
Nursing home teams are busy reviewing quality measures and internal performance measures, the first step in defining where quality improvement is needed in their community. This is perhaps the easiest step as once those needs are identified, the challenge comes in finding how to make the improvements happen.
Traditionally, the next step would be for a team of formal leaders to meet to review policies and procedures, research best practices in the literature and then develop a new process that would be brought to the direct care team through in-service training.
Certainly, there have been successes using this approach and a lot of quality practices have been put in place, but alas, many have not been sustained and a few years later, the team finds themselves “fixing” the same things. One of the goals of QAPI is to promote a better way, a way that supports sustainable change, and it’s about time!
QAPI needs to come out of the meeting room and into the neighborhood, into huddles and any place the residents and care team may be.
When QAPI really happens closest to the resident, it has been found to be effective, amazing and even fun. That can all happen when you find the “not so secret ingredient,” person centered care.
Team members from Stratis Health, the Quality Improvement Organization (QIO) in Minnesota, like QIOs thoughout the country, have been working diligently with nursing homes on QAPI. They’ll be sharing their work and the great outcomes they have seen at the 2019 Pioneering a New Culture of Aging Conference in August, but how about a sneak preview?
Let me tell you a story from Lake Ridge Care Center in Buffalo, MN a community celebrating their 100th Anniversary of serving older adults. As their administrator, Jason Nelson shared, there have been a lot of changes and much has evolved over those 100 years, and sometimes those changes didn’t always take them exactly where they wanted to be. Several years ago, they found themselves close to the bottom of the rankings in the state on the QM measure, Percent of Residents who were Walking as Well or Better. The community found that residents were not being assisted to walk, and therefore declining.
The care team took on the challenge — they needed to improve those QM scores, but more importantly, they needed to find a way to assure that residents had the opportunity to walk and that this could be sustained over time. Traditional methods for walking programs had not been working.
The care team knew they had to think outside of the box. They already had an exercise class at 11 am each weekday but getting residents to that program had not been successful; they needed a better way. Inspired by the movie “Happy Feet,” where all the penguins join together in a happy dance, they started a program called the “Daily Boogie Walk.”
Now, at 10:45 am each weekday, music starts to play over the community’s PA system (The only time this system is used is for emergency purposes; no overhead paging for Lake Ridge Care Center!). The music is from the ’50s to the ’80s, but the residents are always encouraged to let staff know what music they would like to hear; the request line is always open.
Just as others have found, there is power in music. In this program, the music provides a cue to residents and staff alike that there is some place to go. It only took a few weeks before residents were eagerly waiting for staff to come and help them to the exercise program. Residents who are not able to walk are encouraged or assisted to stand to the music. In some cases this has resulted in residents who had not walked in a long time taking a few steps.
Residents and staff have fun as they move and make their way through the halls to the beat of the music. The success comes from the total commitment of the interdisciplinary team. When the music plays, all departments join in the Boogie Walk with the residents, filling up the hallways.
Getting to the exercise class wasn’t the only goal or motivator for residents to participate in the Daily Boogie Walk. The team found that for some individuals, like one resident who is a big Johnny Cash fan, responding to his music preference was the key to get him to start boogieing!
Contests have been added to the fun, like measuring which resident walked the furthest distance over a 2-week period, with the winner being treated to lunch out in the community at the restaurant of their choice along with 3 guests of their choosing.
Residents aren’t the only ones motivated by contests. The staff had a Boogie Bingo game where the names of the residents were listed on bingo cards, and staff would have to accompany a resident on the daily boogie walk or a self-initiated “boogie walk,” and document it, in order to mark that square. Extra points were given for walks that occurred on evenings and weekends. Staff were even inspired to initiate the 10:45 a.m. boogie walk on weekends, even when there wasn’t a scheduled exercise class; even the nightshift staff were inspired and started helping residents walk to the bathroom more frequently.
So besides being fun, how is this person-centered approach to QAPI working out? Well, in the first two years of the program the community’s QM score for Residents Walking as Well or Better improved from 41% to 70% of residents walking, which improved the community’s rank in the state by 130 spots. The community continues the program with anticipated, continued growth in the measure.
The outcomes have been so much more than just raising the number on the QMs. Residents who were rarely getting up are now joining in the boogie walks. The number of residents triggering for unhealthy weight gain has decreased and, in fact, some have had some healthy weight loss due to their participation in the program. Staff is being pro-active, taking the initiative to walk with residents.
As Jason shared this story with me, we agreed that one of the best things to come from this program has been the new relationships that staff have developed with residents, and how the team has grown as everyone in the community from leadership, to direct care staff, to residents and even families, are a part of making a difference for the residents. They have learned that, as former NFL coach Chuck Noll said, “Champions are not champions because they do anything extraordinary, it’s because they do the ordinary stuff better than anyone else.”