Go for the BRONZE! Bronze application tip #8 of 8

By Shauna Kapsner  |  December 1, 2023  |  All providers

Welcome back to our last tip sheet! If you missed any of the previous tips, please see the prior ACTION articles here. We are moving on to the last three questions of the Bronze application below. These are questions that are related to your Performance Improvement System and are labeled P.2.c.#. 

Criteria/Question #17 = P.2.c.1
c. PERFORMANCE IMPROVEMENT SYSTEM
SNF & ID/DD & AL
 
GLOSSARY DEFINITIONS
  • KEY: Major or most important; critical to achieving your intended outcome.
  • PERFORMANCE: Outputs and their outcomes obtained from health care services, processes, patients, and other customers that permit you to evaluate and compare your organization’s results to performance projections, standards, past results, goals, and other organizations’ results.
  • PROCESS: Linked activities with the purpose of producing a product or service for a customer (user) within or outside your organization.

Shauna’s 411 for P.2.c.1
 What is your improvement system? What processes (which includes specific steps) do you take, to make improvements in your building? QAPI? Six Sigma? PDSA/PDCA? (These are popular examples, and none are better than another.) What are the steps your center uses? Describe them using terminology like: first, second, next, and last.

Skilled centers have a QAPI requirement, however steps can vary a bit. Describe the steps your center takes. Assisted living sites in Minnesota are required to have a quality management plan and the site can choose its format. Either case—state what your site does and the steps it takes. That’s it! 

Criteria/Question #18 = P.2.c.2
SNF, ID/DD

ASSISTED LIVING (AL)

GLOSSARY DEFINITIONS
  • HEALTH CARE RESULT: A health care result is a measure of a specific clinical factor, either negative or positive, which is typically measured and expressed in terms of frequency of occurrence or prevalence of a condition within a population.
  • KEY: Major or most important; critical to achieving your intended outcome.
  • PERFORMANCE: Outputs and their outcomes obtained from health care services, processes, patients, and other customers that permit you to evaluate and compare your organization’s results to performance projections, standards, past results, goals, and other organizations’ results.
  • RESULT: Outputs and outcomes achieved by your organization.
  • PROCESS: Linked activities with the purpose of producing a product or service for a customer (user) within or outside your organization.
  • PATIENT/RESIDENT: The person receiving health care, including long-term care, preventive, promotional, acute, chronic, rehabilitative, and all other services in the continuum of care. Other terms used for patient include resident, client, member, consumer, and customer.
  • DATA: Numerical representation of an organizational performance. See also MEASURES AND INDICATORS.
  • MEASURES AND INDICATORS: Numerical information that quantifies the input, output, and performance dimensions of processes, programs, projects, services, and the overall organization (outcomes).

Shauna’s 411 for P.2.c.2
 What measure or result have you improved using your improvement system described in the last question (P.2.c.1)? Please note, SNF applicants must discuss a CLINICAL measure, ID/DD and AL providers can choose any type of measure. For SNFs, please make sure the clinical measure chosen is an indicator of resident’s physical well-being and that correlation is obvious. An error can be submitting the application to AHCA with a measure that is not truly clinical in nature. For example, while there may be links to meal tray delivery time and weight loss, tray delivery time would not be considered a clinical measure. Some examples of clinical measures include, but are not limited to: falls, medication errors, site acquired wounds or infections, weight loss, UTIs, and falls with injury.

Ensure the steps described in the last question directly correlate to your response here when describing the process for change. Please be precise so the examiner can see the steps are the same.

Describe your intervention that prompted your center’s change. A meeting, discussion, or using your improvement system is not it. 

Data is required. For the best response, please give three data points. Let’s say you tracked falls and have monthly data points. In September your center had 20 falls, October there were 15 and November there were 8. Thus, falls improved by 60%. A chart can be submitted but is not required.

Please present data and an example here of a POSITIVE change to show the great things your center is doing.

Requirements for this response:
  1. A measure or result is identified 
  2. The process described here corresponds to the exact same process described in the last question (P.2.c.1)
  3. At least one change is described
  4. Data is provided
  5. The data given shows a positive change

If you are an SNF, you are DONE and can disregard P.2.c.3! PLEASE skip down to the 100% graphic for next steps and closing tips.
Criteria/Question #19 = P.2.c.3
ID/DD ONLY

ASSISTED LIVING (AL) ONLY

GLOSSARY DEFINITIONS
  • HEALTH CARE RESULT: A health care result is a measure of a specific clinical factor, either negative or positive, which is typically measured and expressed in terms of frequency of occurrence or prevalence of a condition within a population.
  • KEY: Major or most important; critical to achieving your intended outcome.
  • PERFORMANCE: Outputs and their outcomes obtained from health care services, processes, patients, and other customers that permit you to evaluate and compare your organization’s results to performance projections, standards, past results, goals, and other organizations’ results.
  • RESULT: Outputs and outcomes achieved by your organization.
  • PROCESS: Linked activities with the purpose of producing a product or service for a customer (user) within or outside your organization.
  • PATIENT/RESIDENT: The person receiving health care, including long-term care, preventive, promotional, acute, chronic, rehabilitative, and all other services in the continuum of care. Other terms used for patient include resident, client, member, consumer, and customer.
  • DATA: Numerical representation of an organizational performance. See also MEASURES AND INDICATORS.
  • MEASURES AND INDICATORS: Numerical information that quantifies the input, output, and performance dimensions of processes, programs, projects, services, and the overall organization (outcomes).

Shauna’s 411 for P.2.c.3
 If you are an SNF provider, you are DONE, and a response is not required for this question! Skip to the 100% graphic below.

ID/DD and AL providers must present a second data item with all the descriptions and explanations—the exact same guidance for the last question applies from P.2.c.2 to this one P.2.c.3.

YEAH! You’re DONE!

Congratulations! 

Tips and items to do to wrap this up and submit your application are next.

Week #1 back in the October 6 edition of ACTION, I did reference AHCA/NCAL Quality Award Application Policies that go from pages 8-12 for the SNF & ID/DD packet, or pages 8-10 for the AL packet. Please ensure you still meet the requirements for the following:
  • Membership & organizational requirements
  • Survey requirements (SNF & ID/DD)—You can check for yourself here if you’re not certain of your survey status. If you’ve had a recent survey that isn’t accounted for (dates are in the referenced website header), you will need to email the Quality Award program directly to ask about the specific circumstance of your center: qualityaward@ahca.org. 
  • Originality: Do not plagiarize. Seriously. If you are part of a larger organization with multiple applications, please take care of your wording used.
  • Technical requirements
    • Character count matters! The maximum is 17,000. In the Quality Award Portal, there is a “Validate Characters Typed” button at the bottom on your screen. Check and re-check. The maximum is strictly followed, and no minimum limit exists.
    • Sentence/prose format matters! Lists are only accepted for two questions which are: P.1.a.4 and P.1.b.1. 
  • Confidentiality. Whether your center applies or not is confidential. Care Providers of Minnesota does not have access to that information. If you’d like to share that information, that is the decision of your center alone. However—all award recipients are announced publicly.
  • The Quality Award Renewal Policy along with some Q&A is found here

Please take time to tweak and ensure that you’ve used complete sentences for your responses. Also ensure that each and every question is answered, and your character count is within the limit. Remember, nothing can be left blank. All questions MUST be answered. If you did not enter your responses directly into the Quality Award Portal, please make time to navigate that system AND ensure you have clicked the “Save Draft” button on the bottom of the screen to ensure that your submission will be smooth and successful.

If you have a Federal Provider Number (six-digits), it must be provided. If not, this is the ONE time you CAN enter “N/A.”

There is an “Authorizations” tab that you will need to review and confirm content and contact information for your center’s application. This is for the center’s obvious award recipient status that will be forthcoming.

The “Convert to PDF” button allows you to see your center’s application in PDF format. This is your Organizational Profile. You’ve now defined who you are and what you do and provided either one or two examples of data proving that you are, indeed, awesome. Your center can use this as an operations and management tool.

DON’T FORGET TO HIT “SUBMIT.” If you submit early, and need to make any revisions, you CAN! Just remember to hit “Submit” again after those revisions are completed. Please ensure your center does click “Submit” PRIOR to January 25, 2024, at 8:00 PM EST. You can submit today if you so choose!

The application deadline is Thursday, January 25, 2024, at 8:00 PM ET sharp (7:00 PM Minnesota time). 8:01 PM ET/7:01 PM CT is late, and your submission will not be accepted. This is not a joking matter, nor an exaggeration. Please submit early to ensure timing is not a concern for your center. I do suggest submitting the day before at the latest—so Wednesday, January 24. 

The Bronze award notification emails are sent in June. I am SO excited and looking forward to celebrating with you! The AHCA/NCAL Quality Award celebration and ceremony for the Bronze, Silver, and Gold awards will be held at the AHCA/NCAL convention in Orlando, Florida, held October 7-9, 2024. Save the date now!

Welcome to your Quality journey where you’ll experience the fact that it really is not about the plaque on the wall or crystal trophy the shelf. It is about what and how you do what you do AND leading your center to excellence.

Virtual office hours for Q&A are coming in January on Tuesday afternoons and Thursday mornings (and a last-minute Wednesday one thrown in for good measure) using Microsoft Teams:

Any step along the way please ask questions. You can contact me at the Association office. I am here to help! Want to go to the source? You can also email the AHCA/NCAL Quality Award staff directly at: qualityaward@ahca.org. 

Going for the Bronze ~ where legends begin! 


Shauna Kapsner
Shauna Kapsner  |  Director of Education & Events  |   skapsner@careproviders.org  |  952-851-2490