AAHSA Quality First Annual Report

Introduction

This summary represents the efforts of Niagara Lutheran Health System's (NLHS) Quality First program for the period of May 2004 — August 2005. It represents the initiative's highlights, statement of conditions and projection for the coming year.

Quality First — The First Year

Niagara Lutheran will celebrate 50 years of service next year. We have provided a wonderful example of a faith-based, mission-oriented service to the Western New York community over the past 49 years. Thousands have been touched by the care and compassion expressed by our staff, our volunteers and our Boards. We have served regardless of race, creed or financial ability. We serve with a wholehearted commitment to a vision of healthy, affordable and ethical aging services — caring heart and soul!

That commitment isn't limited to just today's seniors. Niagara Lutheran is committed to tomorrow's seniors as well. Today, 13% of Americans are 65 or older. By 2020 that number will grow to 17% and the fastest growing age cohort will be those over 85. A remarkable statistic is that 70% of Americans over the age of 65 will need some form of supportive service — home care, assisted living or skilled nursing. Niagara Lutheran's mission to provide for the physical, social and spiritual needs of the individuals we serve, in a Christian environment grows every day!

Quality First is a national initiative focused on achieving excellence in service. This program is a natural fit for Niagara Lutheran. Last year, we signed a covenant affirming the principles of Quality First. Over the past year, we have studied the services we offer. During this self-examination, we have found much to be very proud of and we have recognized that we have set very high standards of performance. The Quality First initiative is a work in progress. It raises the bar of excellence in all areas of service and that is part of what sets us apart from others.

The Process

In the spring of 2004, the Niagara Lutheran Executive Management Team reviewed the American Association of Homes and Services for the Aging's (AAHSA) Quality First (Q1) program. The team felt that the Q1 program goals and the mission of NLHS were consistent. After the review of the materials presented, the team designated a program coordinator and placed the Q1 process on the Board's agenda for review and approval. The Board during their May 2004 meeting unanimously approved NLHS's commitment and convened a workgroup to review and revise our mission statement. The staff was charged to develop a statement of the System's values, which had not previously existed. The Board also authorized the signing of the Q1 Covenant.

The Executive Management Team was presented with Quality First materials concerning the 10 Elements of Quality of the initiative. The overwhelming sense from the group was that the program must be focused and simple … that the top-to-bottom staff concern would be 'more work in an already busy work schedule'. The Executive Management Team completed the Q1 Self-Study questionnaire. After the Self-Study, the Team consolidated the 10 elements to six — Covenant/Mission, Governance/Accountability, Continuous Quality Improvement, Care/Services, Human Resources, and Consumer Satisfaction. Each member of the Team was assigned a work group and asked to form a team of employees and establish their priorities for the next 12 months based on the results of the self-study.

On July 27, 2004, the three entities of the Niagara Lutheran Health System and our sister organizations, the Lutheran Church Home and The GreenField Court signed the Covenant with residents and department heads attending. We were official!

The Executive Team developed a tracking log of the areas that each of the workgroups had identified as their action items. The Team also identified a high-, moderate- or low-priority for each of the items. In total 22 items were initially listed on the log. The Executive Team decided that they would review the results on a quarterly basis with a summary report to be issued at the end of the first year.

The Workgroups

The Workgroups, once their priorities were identified, were charged to take action, as they felt necessary. Any concerns regarding policy changes were to be referred to the Executive Management Team. Minutes of the meetings were to be sent to the Q1 Coordinator immediately following their meeting.

Here is a summary of each group's activities:

• Covenant/Mission
  The Board updated the NLHS mission in September 2004. The Executive Management Team reviewed and approved the values of the organization. Part of the communication of the mission and values has been — statement/values displayed in public areas of all NLHS facilities, business cards contains mission/values, all performance reviews focus on mission and values and the importance of each employee in bringing these values to the workplace, all business meeting agendas are to include mission/values — goal is to incorporate mission and values into every employee's attitude about their daily performance.
• Governance/Accountability
  The workgroup affirmed the financial reporting to the department heads, administrators, CEO/President and the Boards. Timely and accurate information must continue for the successful operation of the NLHS. The check and balance system was enhanced with the Board's approval of an Audit Committee with direct reporting from the independent auditors. Safety committee was reformatted with policy and procedures reviewed and updated. Focus on risk mitigation.
• Continuous Quality Improvement
  The workgroup reviewed the Quality Assurance audit tools used in both of the nursing facilities. The instrument was revised and standardized as possible. The QA team was enlarged at GreenField and both facilities have used results in a proactive way to ensure superior care. Mock DOH survey teams have been introduced in preparation for the annual survey. The CMS tracking of Nursing Home comparisons was reviewed and quarterly results for UTIs, pain and pressure sores are reported. GHRC was awarded IPRO award for improvement and procedure in the pressure sore area
• Care/Services
  The workgroup identified educational topics for life enhancement for employees. Monthly Wellness bulletin boards have been created. Topics feature area of interest for line staff, i.e. domestic violence, humor in the workplace, smoking cessation, etc. The group has also started informal luncheon meetings of departments to share a best practice internally and one that they have learned about that they may want to try.
• Human Resources
  The workgroup identified employee benefit education as an area for improvement. The HR department scheduled a benefit review contractor to set individual meetings with all NLHS employees to explain the package. Improve supervisor training — a six-session training program was established to enhance the manager's skill set including time management, coaching, goal settings and employee evaluations.
• Consumer Satisfaction
  Human interest and testimonials have been collected and placed in attractive lobby books for prospects — resident and employees. All policy/procedures for volunteers have been updated including Volunteer handbook and related materials. A new Volunteer Coordinator position was created to enhance our volunteer recruitment and retention efforts. Consumer satisfaction surveys have been reviewed and revised with an effort to standardized information. New format should be introduced this fall.

Much of the work of Quality First has deliberately been low key, behind the scenes and linked to other efforts within the organization. One of the principles of the NLHS Q1 effort is to identify the great work already going on within the organization. NLHS has many reasons to be very proud of our service. Q1 has reinforced that. The communication of the Q1 efforts with NLHS constituents have been through articles in the Guild Newsletter (volunteers), Niagara Network (employees), GreenField News (residents), and the HeartBeat (community). The progress of the Q1 workgroups has been shared at Departmental meeting at each of the entities.

Looking Ahead

As the first year ended, our Quality First efforts have yielded tangible results. The Niagara Lutheran Health System is stronger today in some measure due to the Q1 initiative. We have recognized our significant strengths and we have challenged ourselves to be better with a focus on our mission and our core values. As we begin our second year, our workgroups will be even more focused. From the original Self-Study and the efforts of the workgroups over the past 12 months we have set our goals on the following issues:

People First — In part due to the Quality First initiative the NLHS has embarked on a system wide customer service program called People First — Caring Heart and Soul. As we reviewed our services, it became apparent that we provide very good care to those we service. However, we found that Q1 opened the door of opportunity to improve our services from very good to outstanding. The area we saw the greatest opportunity was in taking the extra step in service delivery from the simple steps of hospitality to establishing clear performance expectations reinforced through employee coaching to achieve our service standards. People First is a System wide efforts compassing training, recognition and benchmarking our services. This program will embrace the principles of Quality First and establish our service as our area's provider of choice.

Governance — We have identified that the System is lacking in our connection to technology. Over the next year we will explore how the introduction of technology can enhance the quality of service and improve the cost effectiveness of those services. We are very mindful of the community's trust placed in our not-for-profit status. We will seek opportunities to support the needs our Western New York community within our mission.

Care/Services — We will focus on information sharing internally with our various departments joining together to share common concerns and solutions to improve our service using best practices from within and experiences from other long term care providers.

CQI — We will continue to work with IPRO at both our nursing facilities. This will provide our residents with expert consultation for continued care delivery with direct support of our line staff. We will also continue to monitor CMS standards in select areas and exceed national averages.

Human Resources — We will focus on the principle that our employees are our most valuable resource. Our Q1 efforts will reinforce the People First initiative. The HR workgroup will focus on a continued communication of employee benefits; enhance their work performance through orientation, training, and coaching.

Consumer Satisfaction — We will seek opportunities for the Health System to connect with the larger community through staff involvement in community organizations and activities. The NLHS web site will be updated with attention to consumer 'friendly' information. We will also strengthen our services through the use of a standardized corporate customer satisfaction survey process with results shared with our constituents and actions plans developed to enhance targeted services. Further, we will explore ways to benchmark our services to other national providers.

The Quality First program has provided Niagara Lutheran Health System with an opportunity to evaluate our services and our connection with the community. It has acted as a mirror reflecting the strengthens and weaknesses of our operations. The Quality First mirror has indicated that we are doing an exceptional job through a workforce dedicated to meeting the needs of those we serve. It has reflected the day in and day out caring for God's people often in the most trying of circumstances. It has shown the small human kindnesses that often go unnoticed in the business of providing service and the significant difference they have made in individual lives. It has given reason to pause and reflect how important these basic principles of Christian service are and that is what gives us reason for being.