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Quality Award Program
Quality First Initiative
Nurse Assistant Training

Frequently Asked Questions 

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What is Quality First? Three of the nation’s largest long term care organizations—together representing the overwhelming majority of the 17,000 nursing facilities—as well as several thousand housing, assisted living, MR/DD, and community services providers joined together to launch a quality initiative called “Quality First: A Covenant for Healthy, Affordable, and Ethical Long Term Care” that calls on all long term care providers to make a voluntary, organization-wide commitment to performance excellence.

Providers who pledge to participate in Quality First agree to adopt the 7 Core Principles and to target the 6 Expected Outcomes as goals to demonstrate performance excellence and to increase public trust in the long term care community’s commitment to excellence. However, note that not every Expected Outcome applies equally to different long term care settings.

Quality First is a commitment by the long term care community of nursing facilities, assisted living residences, homes for persons with mental retardation or developmental disabilities and other service providers to attain a high level of quality of care and quality of life. Quality First is a first-ever nationwide, publicly articulated pledge on the part of the long term care profession to establish and meet quality improvement targets.

Why Quality First? In 2002 the federal government launched the Nursing Home Quality Initiative (NHQI) to publicize care outcome data regarding eight conditions found in nursing facilities. Quality First is the long term care community’s commitment to build on that effort and heighten quality and accountability. With today’s data gathering and analysis capabilities, there is a greater ability to measure performance on patient/resident outcomes. This allows for the creation of quality improvement goals that was not previously possible.

The Quality First initiative promotes a uniform and publicly articulated position regarding quality across the entire long term care community; the initial focus will be on nursing facilities. Even so, other providers, such as MR/DD, are integral to the Quality First initiative and should pledge and adopt the Core Principles of Quality First and target the Expected Outcomes that are appropriate for their setting.

What is the goal of Quality First? A key part of Quality First is the development of measurable goals that will be understandable and useful to consumers, providers, regulators, and legislators alike. The goals of Quality First are twofold:

  1. Achieve excellence in the quality of care and services and quality of life for older persons and persons with disabilities; and
  2. Publicly report quality results to strengthen the confidence and trust of the public and other key groups.

How will Quality First goals be achieved? Signing the Quality First pledge is voluntary. However, providers who sign it will be publicly announcing their agreement to a set of 7 Core Principles that encompass the Quality First Covenant. The over-arching theme of the Core Principles is that the facility adopt a people-centered approach to its daily routines and activities and put people first whether they be residents/patients, families, staff, volunteers, vendors, the general public, or the greater community around the facility. The following definition of “quality” from “Total Quality: Management, Organization and Strategy” may be helpful when implementing the Core Principles of Quality First:

Keep the over-arching, people-centered approach and the definition of “quality” in mind as you read the following 7 Core Principles.

7 Core Principles

  1. Ethical Practices
  2. Financial Stewardship
  3. Patient, Resident and Family Rights
  4. Continuous Quality Assurance and Quality Improvement
  5. Workforce Excellence
  6. Public Input and Community Involvemen
  7. Public Disclosure and Accountability

Those who pledge to support Quality First will be guided by the 6 Expected Outcomes for assessing quality in the profession as enumerated in the Covenant, which are:

6 Expected Outcomes for 2006

  1. Continued improvement in compliance with federal regulations
  2. Demonstrable progress in promoting financial integrity and preventing occurrences of fraud
  3. Demonstrable progress in the quality of care outcomes and prevention of confirmed abuse and neglect
  4. Measurable improvements in all Centers for Medicare and Medicaid Services Continuous Quality Improvement measures
  5. Higher rates on consumer satisfaction surveys will indicate improved consumer satisfaction with services
  6. Demonstrable improvement in employee retention and turnover rates
What are the benefits of participating?

For providers and caregivers, the benefits are to:
  • Champion the quality services you provide
  • Focus attention on standards and recommended practices
  • Demonstrate your commitment to those served
  • Enhance the pride of the profession of long term care;
  • Recognize and uphold the critical importance of long term care
  • Validate the commitment and dedication of staff
  • Acknowledge the expectations of those in your care and
  • Strengthen the public’s trust through accountability.

For the profession, the benefits are to:

  • Leverage the collaborative QIO models
  • Align the profession with the plans to publicize quality indicators
  • Pave the way for systematic and evidenced-based quality
  • Create a new perspective for the professio and
  • Foster a profession-wide commitment to responsibility.

Who is sponsoring Quality First? In July 2002, three national membership organizations, which represent the majority of long term care facilities, joined together to sign an historic Covenant to work to improve the quality of care delivered within the nation’s long term care facilities. The organizations are: The American Health Care Association (AHCA) which represents a diverse membership that includes providers in various long term care settings from individual owner/operators to multifacility organizations of both for profit and not-for-profit sponsorship; The American Association of Homes and Services for the Aging (AAHSA), which represents not-for-profit nursing homes, continuing care retirement communities, assisted living, senior housing, and community service organizations; and The Alliance for Quality Nursing Home Care (“The Alliance”), which represents 14 national nursing home multifacility organizations.

Is the National Center For Assisted Living (NCAL) a sponsoring organization? Since the principles of Quality First are beneficial to all long term care providers and those they serve, the National Center For Assisted Living supports the program even though the initial thrust of Quality First is on nursing facilities. NCAL is committed to the 7 Core Principles of Quality First.  

However, the outcomes and timeframes to implement Quality First for assisted living will not be the same as those for the nursing facility profession; a reflection of the systems under which each profession operates and the differences in the individuals served. In addition, as a result of the Assisted Living Workgroup (ALW), an organizing committee has formed to create a Center for Excellence in Assisted Living (CEAL). The ALW was created in 2001 at the request of the Senate Special Committee on Aging to develop recommendations related to assisted living quality. The ALW’s recommendations were presented to the Committee in 2003 and included a recommendation calling for the creation of CEAL. CEAL eventually will have many similar responsibilities to those of the National Commission (see below) but will focus solely on assisted living. It is envisioned that CEAL will be the primary entity responsible for assisted living quality information and resources. It is not the intent of the National Commission to duplicate the work of CEAL. In the event that duplication of efforts occurs, the National Commission will defer to CEAL.

How does Quality First apply to MR/DD residential care facilities? Even though Quality First will initially focus on the nursing facility profession, MR/DD providers should commit to the 7 Core Principles of Quality First as they apply equally to all long term care settings. The Expected Outcomes may vary in how they apply since each setting has unique operating systems and serves distinct populations. By taking the pledge now MR/DD providers can begin the process of implementing integral parts of Quality First, such as a quality management system and quality leadership competencies (to be discussed later in this document).

What will be the role of the sponsoring organizations? The sponsoring organizations have joined together to establish the framework for a National Commission, which will oversee the Quality First program. The sponsors will provide seed funds through targeted grants for the operations of a National Commission and also serve as the liaison between the long term care profession and the National Commission. 

Why is a National Commission needed? In order for Quality First to be credible and effective, it will operate independent of the long term care provider community. The implementation and monitoring of Quality First will be the role of an autonomous National Commission composed of respected individuals with expertise in various disciplines (business, government, consumer advocacy, quality improvement etc.).

What will be the National Commission’s role? The National Commission will formulate measures and outcomes through which a facility’s quality performance can be assessed and develop ways to communicate these outcomes to the public and other groups. A key task for the National Commission will be to identify factors that allow facilities to continuously improve quality. Specific responsibilities of the National Commission will be to:

  • Evaluate the quality of care in nursing homes, SNFs, assisted living residences, elderly housing, continuing care retirement centers (CCRCs), and home and community-based services
  • Recommend national quality improvement aims and goals
  • Identify specific objectives and targets for quality improvement;
  • Report on quality indicators and performance measures to determine progress in achieving improvement aims and goals
  • Report on the success of improvement efforts
  • Assess adherence with Quality First
  • Recommend changes to and improvements in Quality First
  • Provide a public forum for dialogue on quality and quality improvement
  • Review quality-related policy proposals and
  • Recommend a national policy agenda for quality improvement.

How will the National Commission be funded and managed? Funding will initially be provided by targeted grants from the three sponsoring organizations with an expectation that in the future the Commission will acquire funding grants on its own. The three national associations will designate an independent third party organization to manage the Commission.

What will this other organization do? The National Commission will be supported by an independent third-party administrative organization that will provide support services to the Commission as well as:

  • Identify and appoint National Commission participants during the last half of 2003
  • Secure technical assistance for data analysis and interpretation
  • Retain subject matter experts as appropriate
  • Administer and facilitate the Commission’s activities and
  • Issue reports annually and additional communications materials as needed.

How will Quality First be implemented by each of the sponsoring organizations? While AHCA, AAHSA, and The Alliance jointly signed the Covenant and agreed to the 7 Core Principles and 6 Expected Outcomes, each group has a unique structure that necessitates different strategies to implement Quality First. Implementation plans will be tailored to meet the needs of each organization’s members, yet the plans will be identical in the outcomes they support.

If a facility is a member of multiple organizations, it should use the tools that best fit its particular situation since each Quality First implementation plan ultimately has the same goals.

What will be the role of state affiliates? State affiliates will provide leadership and a vision for Quality First and thus exercise a pivotal role in shaping the way providers prioritize this initiative. Their role will be to:

  • Facilitating knowledge transfer from the QIOs and others
  • Collaborate with all strategic organizations
  • Leverage the strength of existing programs and initiatives
  • Reduce duplication
  • Deliver essential tools, resources and programs
  • Communicate successful clinical and other practices
  • Promote activities that enhance and increase performance excellence and
  • Focus on opportunities for benchmarking and measurement.

What direction does AHCA/NCAL provide? AHCA/NCAL’s Foundations for Quality is based upon the AHCA/NCAL Quality Award program. This program, which began in 1996, utilizes the constructs of the Malcolm Baldrige National Quality Award in their entirety.

Using this foundation, AHCA’s Quality Improvement Subcommittee has developed two sets of guidelines to support providers: Developing a Quality Management System and Developing Quality Leadership.

A typical baseline for providers to operationalize Quality First is to focus on building and fully integrating Quality Management System (QMS) criteria to align continuous quality improvement activities with Quality First to ensure performance excellence facility-wide. The following are 6 Criteria for a QMS system:

Developing a Quality Management System: 6 Criteria

  1. Create a healthcare culture of safety and security by developing and communicating a quality-focused mission statement
  2. Develop facility performance indicators and continuously monitor and adapt to optimize performance excellence
  3. Conduct family and resident satisfaction surveys
  4. Conduct staff satisfaction surveys
  5. Develop a system for handling customer and staff concerns and
  6. Monitor and adapt quality processes for performance excellence.

What are the characteristics of quality leadership? Quality leadership and management are requisite to improving and sustaining systemic performance excellence. Therefore, facility staff must cultivate and model the core values and concepts for quality leadership in themselves and their co-workers. The AHCA/NCAL core values and concepts for quality leadership are:

  • Visionary leadership
  • Resident-focused excellence
  • Organizational and personal learning
  • Valuing staff and partners
  • Management flexibility
  • Focus on the future
  • Managing for innovation
  • Management by fact
  • Social responsibility and community health
  • Focus on results/creating value and
  • Systems perspective.

Is there a web address? Members should visit http://www.ahca.org and or http://www.ncal.org click on “Quality.”

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© 2010 American Health Care Association