Quality Credentialing
 

 

 
 
 

Introduction
A primary benefit of facility members of Florida Health Care Association is access to the Quality Credentialing Program which provides telephone and onsite regulatory compliance and care practices guidance upon request. We encourage nursing home providers to enroll in the Advancing Excellence campaign, a two-year voluntary effort to improve quality for residents and the work setting for employees. The American Health Care Association is leading this campaign, in part, to gain public recognition for providers' efforts to improve quality. Advancing Excellence is a coalition effort-comprised of providers, caregivers, researchers, government agencies, workers and consumers. The campaign builds on the success of previous initiatives of Quality First and our Quality Credentialing work and focuses on specific, measurable quality improvement goals supported by evidence-based information and a national infrastructure. The campaign is designed to foster greater partnership both nationally and at the state level, which is ameliorating the sometimes adversarial atmosphere among these groups.

We know that long term care providers care about quality. There is an important link between reimbursement and quality of care outcomes with good staff. CMS recognizes that link, too; in recommending that SNFs receive a 3.3% market basket update for FY2008, CMS Acting Administrator Norwalk noted, "These new payment rates reflect our commitment to improving the quality of care in the long-term care setting while maintaining predictability and stability in payments for the nursing home industry...." Advancing Excellence in America's Nursing Homes is helping us to demonstrate that critical link.

The Advancing Excellence campaign is complementary of the FHCA Quality Credentialing Program's Internal Review Process and an External Review Process in demonstrating a provider's accountability and commitment to quality. [Return to index]

 

Internal Review
Internal review includes the expectation that each member will utilize a program of continuous quality improvement. In order to operationalize the Qualify First Credentialing Program, administrators, regional representatives, and owners will focus on building a quality management system and developing quality leadership. Such a quality management system includes key criteria that the American Health Care Association's Quality Improvement Subcommittee has identified as critical for success, and our Self Assessment Checklist explores:

  • Gathering & Analyzing Performance Data and Information
  • Recording & Responding to Client (Resident) Concerns
  • Continuously Improving the Processes and Outcomes
  • Employee Satisfaction Surveys
  • Integrating an meaningful Mission Statement
  • Client Satisfaction Surveys
  • Developing Quality Leadership
An explanation of each of these key criteria is available in the Quality First manual Guidelines for Developing a Quality Management System for Long Term Care Providers (see References). The Self Assessment Checklist provides you with a coordinated tool to assist you in evaluating the facility's progress in each of these areas (see References).

Developing quality leadership is the other building block for meeting the Quality Credentialing Program outcomes. The core values and concepts that build Quality Leadership can be explored in detail at the Quality First website (see References).

Your facility's Risk Management and Quality Assurance Committee will be an integral part of conducting and directing these activities. Additionally, each participating facility will be expected to conduct a quarterly monitoring of key quality processes, hopefully averting negative outcomes. If, however, the facility begins to experience difficulties, FHCA is prepared to assist by a series of actions that are designed to support the facility in improving care and services. [Return to index]

 

External Review
External Review is triggered by facility requests by FHCA members for assistance. It may also be triggered by quarterly FHCA Quality Unit staff review of performance survey outcomes, including:

  • Agency for Health Care Administration's Nursing Home Guide ranking,
  • Agency for Health Care Administration's Watch List
  • CMS Quality Measures
  • Survey history
An External Review may consist of consultative and mentoring services with the CMS Quality Improvement Organizations (QIO) or specially trained Quality Foundation Board members and will address:
  • Selected MDS Quality Indicators - i.e. pressure ulcers, falls, continence care, malnutrition and dehydration, restraints and sentinel events;
  • Significant risk factors associated with a decline in quality of care
(e.g. history of Substandard Quality of Care citations, Administrator/DON turnover/performance issues; pool utilization, increase in state complaint visits (e.g. 2 in 1 month, 3 in 2 months), and staffing levels).

Activities conducted through both the Internal and External Reviews are part of the records and meetings of your facility's Risk Management and Quality Assurance Committee and thereby have certain protections and confidentiality. The Florida Statutes address this:
 

400.119 Confidentiality of records and meetings of risk management and quality assurance committees.--

(1) Records of meetings of the risk management and quality assurance committee of a long-term care facility licensed under this part or part III of this chapter, as well as incident reports filed with the facility's risk manager and administrator, notifications of the occurrence of an adverse incident, and adverse incident reports from the facility are confidential and exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution. However, if the Agency for Health Care Administration has a reasonable belief that conduct by a staff member or employee of a facility is criminal activity or grounds for disciplinary action by a regulatory board, the agency may disclose such records to the appropriate law enforcement agency or regulatory board.
(2) Records that are confidential and exempt under subsection (1) and that are obtained by a regulatory board are not available to the public as part of the record of investigation and prosecution in a disciplinary proceeding made available to the public by the agency or the appropriate regulatory board. However, the agency or the appropriate regulatory board shall make available, upon request by a health care professional against whom probable cause has been found, any such records that form the basis of the determination of probable cause.
(3) Records disclosed to a law enforcement agency pursuant to subsection (1) remain confidential and exempt until criminal charges are filed.
(4) The meetings of an internal risk management and quality assurance committee of a long-term care facility licensed under this part or part III of this chapter are exempt from s. 286.011 and s. 24(b), Art. I of the State Constitution and are not open to the public.
(5) This section is subject to the Open Government Sunset Review Act of 1995 in accordance with s. 119.15, and shall stand repealed on October 2, 2006, unless reviewed and saved from repeal through reenactment by the Legislature. [Return to index]

 

In Support of Quality Improvement
Other components important to the success of quality improvement are recognition, quality-focused education, and access to best practices.

Recognition programs play a vital role in the support of continuous quality improvement by recognizing individual contributions and outstanding corporate responsibility. Our recognition programs include:

  • FHCA Excellence in Nursing Awards
  • American Health Care Association's Quality Awards
  • Annual CNA Essay Contest

Quality-focused education is vital to any commitment to improve quality in long term care. Two premiere specialty training programs focusing on quality improvement are:

  • Quality Improvement Certification Program
  • Radiating Excellence

Participants of the Quality Credentialing Program tap into other resources as well as part of their membership. In addition to the Self Assessment Checklist, the Florida Health Care Association's Quality Credentialing Foundation has compiled resources to guide you as your work through the Quality Credentialing Program. [Return to index]

 

Credentialing
The Self Assessment Checklist will help you understand how the credentialing levels are being developed and where your facility might place. The credentialing component of Florida's Quality Credentialing Program, when finalized, will offer avenues for peer recognition as a quality leader, public recognition for efforts and achievements, and increased client loyalty from your demonstrated commitment to quality. [Return to index]

 

How to Get Involved
As a member of Florida Health Care Association, your facility is automatically a part of the Quality Credentialing Program family.

Further, as you work through the Self Assessment Checklist, identify areas of weakness with which FHCA may assist you, and then contact us to find out how we can help. [Return to index]

 

Governance
The Quality Foundation, established in 2001, develops policy and provides direction for the Quality Credentialing Program. The 15-member Foundation operates under Foundation Bylaws and is comprised of:

  • 1 member of the Florida Health Care Association Management Committee.
  • 4 licensed nursing home administrators; 2 of which are employed as administrators of facilities that are considered multi-facility pursuant to the FHCA bylaws and 2 who are employed by independent and/or non-profit members as so defined. This ration shall be reviewed every 4 years and, if necessary altered to reflect the constituency of FHCA. However, under no circumstances shall the number representing either group be less than 1.
  • 4 nurses currently employed in long term care, at least one of which is employed as a director of nursing.
  • 1 medical doctor or doctor of osteopathy who is currently practicing in the long term care setting in an FHCA member facility.
  • 2 corporate representatives, at least one of which is a representative of a multi-facility organization.
  • 1 social worker representative of the Florida Health Care Association of Social Worker.
  • 1 medical director representative of the Florida Medical Directors Association
  • 1 nurse representative of the Florida Association of Directors of Nursing Administration Association.
Foundation board members serve as consultants, mentors, and are role models for sharing lessons learned and best practices.

Quality Credentialing Foundation
November 2008

 
Chair
David Sylvester
Health Central
10000 West Colonial Drive
Ocoee, FL 34761
Phone: (407) 296-1835
Fax: (407) 253-1675
Email: david.sylvester@healthcentral.org

Vice Chair
Nina Willingham
Life Care Center of Sarasota
8104 Tuttle Avenue
Sarasota, FL 34243-2885
Phone: (941) 360-6411
Fax: (941) 360-6499
Email: nina_willingham@lcca.com

Tom Kelly
Village on the Isle - Luke Haven
910 Tamiami Trail South
Venice, FL 34285-3652
Phone: (941) 486-5420
Fax: (941) 486-5480
Email: tkelly@villageontheisle.com

Connie O'Donnell
All Saints Catholic Nursing Home
5888 Blanding Boulevard
Jacksonville, FL 32244-1927
Phone: (904) 772-1220
Fax: (904) 772-6334
Email: codonnell@allsaintsnursing.org

Scott Allen
Palm Garden of Tampa
3612 East 138th Ave.
Tampa, FL 33613-4703
Phone: (813) 972-8775
Fax: (941) 978-0680
Email: sallen@gramercyhealth.com

Bruce Robinson, MD
Sarasota Memorial Hospital TCU
10 East Tower Rehab
Sarasota, FL 34239-3509
Phone: (941) 917-6579
Fax: (941) 917-4278
Email: bruce-robinson@smh.com

Patches Bryan, RN
Chief Executive Clinical Officer
Greystone Health Management, Inc.
3922 Coconut Palm Dr., Suite 102
Tampa, Fl. 33619
Phone: (813) 635-9500
Fax: (813) 635-0008
Email: Pbryan@greystonehcm.com

Ex-Officio
Deborah Franklin
Florida Living Options
2806 Fritzke Road
Dover, FL 33527
Phone: (813) 679-7533
Fax: (813) 986-4291
Email: dkfranklin@rfmsinc.com

Advisory Group
Cynthia Mason
Social Work Consultants of Florida
PO Box 457
Palm Harbor, FL 34682
Phone: (727) 403-7423
Fax: (727) 942-4802
Email: cindy.mason@nursinghomequality.com

Howard Tuch, MD
3324 Westmoreland Drive
Tampa, FL 33618
Phone: (813) 963-6280
Fax: (813) 963-6280
Email: hstuch@msn.com

Bonnie Cruz
Florida Association Directors of Nursing Administration
1500 N White Point Road
Niceville, FL 32578
Phone: (850) 897-5592
Fax: (850) 897-0501
Email: cruzbdon@aol.com

Ann DaSilva
3548 98th Terrace
Pinellas Park, FL 33782
Phone: (727) 415-6097
Fax: (727) 299-9816
Email: samann1@verizon.net

E. Max Hauth, Hauth Health Care Consultants, Inc.
2516 Jonila Avenue
Lakeland, FL 33803
Phone: (863) 688-0863
Fax: (863) 688-5127
Email: emhauth@aol.com

Robin Bleier
RB Health Partners, Inc.
210 South Pinellas Avenue, Ste 176
Tarpon Springs, FL 34689
Phone: (727) 786-3032
Fax: (727) 942-4802
Email: robinbleier@yahoo.com

[Return to index]
 

Mission
The mission of the FHCA Quality Foundation is to promote mentoring and collaboration between FHCA staff, providers, and long term care stakeholders through a shared commitment to communication, and the creation and dissemination of best practices, information and resources, education, and advocacy. [Return to index]

 

Staff
Florida Health Care Association Quality Unit staff oversees and administers the Quality Credentialing Program. If you have any questions, we invite you to contact us.

LuMarie Polivka-West
Sr. Vice President, Chief of Clinical Services
lpwest@fhca.org

Debbie Afasano
Director of Clinical Service
dafasano@fhca.org

Lee Ann Griffin
Director of Quality and Regulatory Services
lgriffin@fhca.org

Koko Okano
Health Services Research Analyst
kokano@fhca.org [Return to index]

 

References
In addition to Florida Health Care Association's Quality online resources, these other valuable tools are available to members of FHCA and AHCA:

American Health Care Association, Resources for Quality First
www.ahca.org/quality/qf_tools.htm
www.ahca.org/quality/qf_resources.htm

American Health Care Association, Guidelines for Developing a Quality Management System for Long Term Care Providers
www.ahca.org/quality/qf_qms_guidelines.pdf

American Health Care Association, Core Values and Concepts for Quality Leadership
www.ahca.org/quality/qf_corevalues.htm

American Health Care Association, Quality First Pledge - See Who's Pledged
www.e-noah.net/AHCA/vb/QFirst/map.aspx [Return to index]

 

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