Operational Success Through Partnership with Acute Care Providers: A Guide for Initiating Joint Quality Committees

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Kindred Healthcare Executive Director Shelly Szarek-Skodny, Director of Clinical Operations Leslie Vajner and local Medical Director Dr. Michael Felver from Cleveland will be giving an exciting …

Kindred Healthcare Executive Director Shelly Szarek-Skodny, Director of Clinical Operations Leslie Vajner and local Medical Director Dr. Michael Felver from Cleveland will be giving an exciting presentation at American Medical Directors Association or AMDA this year on the nuts and bolts of how to set up a Joint Quality Committee and improve communication between local SNFs and acute care hospitals. Entitled “Operational Success Through Partnership with Acute Care Providers: A Guide for Initiating Joint Quality Committees,” the presentation is on Saturday, March 10th at 4pm (schedule of events here: http://ltcmedicine.com/saturday/ ), 2012

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  • This is a complicated system with communication breakdown. CMS is recognizing the inefficiencies and ineffective care offered on Medicare patients with chronic conditions that “ping-pong” in/out of the hospital and ERs. Thus the opportunity is to come together and create local market communication channels and processes that solve the problems of “silo” care. Although we do not fully understand how healthcare reform will impact us as physicians and clinicians, one thing is for certain: To be included in future demonstrations and ACOs , we need to demonstrate we have contributed to the solutions. Many of these solutions will focus on providing better chronic care in lower acuity care sites.
  • Felver…only 6% of this groups volume is outside of the Main campus (CC regional facilities) Subacute LOS variance…. 2010 ALOS - 23.2------Referral volume - 548 2011 ALOS – 25.1-----Referral volume - 561
  • MedPAC and CMS will be measuring post-acute facilities on their ability to reduce unnecessary re-admissions. Although many factors can contribute to these re-hospitalizations, we ask for you to notify our Dir of Nsg Services or Exec Director (Note: say Executive Director” and do not use acronym) if you see any of these barriers we can improve upon. We are looking for your expertise to help us.
  • Relationship spans almost 2 years. 955 patients cared for under this model through May 2011
  • Relationship spans almost 2 years. 955 patients cared for under this model through May 2011

Transcript

  • 1. Success Through Relationshipswith Acute Care Providers:A Guide to Initiating Joint Quality Committees 1
  • 2. Speakers & PanelSpeakers Panel• Michael Felver MD • Shelly Szarek-Skodny LNHA• Seth Vilensky MBA • David Johnson, MBA• Leslie Vajner RN MHA • Dan Blechschmid, LNHA Disclosures • All Speakers & Panel Members have no Financial Disclosures to Reveal/Present • Cleveland Clinic and Kindred have no financial relationship. • Both Cleveland Clinic & Kindred have developed these types of relationships with other providers. This presentation highlights one example of an integrated care model. 2
  • 3. Learning Objectives• Review the healthcare reform and the impact on traditional organization and level of care relationships• Describe a model for partnering between the hospital and SNF focusing on quality outcomes, transparency and successful transition of clinical care.• Provide the guide to create your own Joint Quality Committee.• Share the “foundational” components that will generate meaningful dialog between the partnering organizations. 3
  • 4. Discussion Agenda Driving Forces & Market Overview Joint Quality Committee…Getting Started Monitoring Quality and Performance Indicators  Collaborative Process Improvement  Return to Acute Care Timeline & Accomplishments- Key Lessons Learned Joint Quality Committees in Multiple Settings 5 Steps to Starting Your Own Joint Quality Committee Panel Discussion 4
  • 5. Tremendous Opportunities Exist to Better Manage Patient Care for Patients Discharged to Post-Acute Medicare Patients’ Use of Post-Acute Services Throughout an “Episode of Care” (1)Higher Intensity of Service Lower SHORT-TERM LONG-TERM SKILLED HOME INPATIENT OUTPATIENT ACUTE CARE ACUTE CARE NURSING HEALTH REHAB REHAB HOSPITALS HOSPITALS FACILITIES CAREPatients’ first site ofdischarge after acute 2% 10% 41% 9% 37% care hospital stay Patients’ use of siteduring a 90 day episode 2% 11% 52% 21% 61% 35% of Medicare beneficiaries are discharged from acute hospitals to post-acute care (1) Source: RTI, 2009: Examining Post Acute Care Relationships in an Integrated Hospital System 5
  • 6. The Cleveland Clinic & Kindred Healthcarein Northeast Ohio Cleveland Clinic Foundation Kindred Hospital Fairhill and Co-Located Hospital-Based SNF 1,300 beds located at the Cleveland  Located approximately one mile from the Cleveland Clinic Main campus Clinic Regarded as one of the top 4 hospitals  68 Bed LTACH with 6 Special Care Beds in the United States  40 co-located Sub Acute SNF Beds System comprised of its main campus  Over 85% of Fairhill’s nearly 1,000 annual admissions and eight regional hospitals in come from 5 nearby hospitals, with 65% from the Northeast Ohio (4,400 total beds) Cleveland Clinic Employs more than 2,700 salaried  Kindred also has the Gateway Long-term Acute care physicians and scientists Hospital, 3 Transitional Care Nursing Centers, and 2 Owns home health service line and IRF Assisted Living Facility in the Cleveland Market Highest acuity hospital in the country 6
  • 7. The Cleveland Market:Kindred & Cleveland Clinic 7
  • 8. Driving Forces: SNF Concentration - CC + Regional HospitalsCleveland Clinic Sentn= 22,735 placements in 2010 in 2010 Patients providersSNFs 860 unique >800 100% 860 Facilities in Total 90% 150 Facilities makeCumulative % of SNF Placement Volume up 90%of activity 80% 80 Facilities make 70% up 80%of activity 60% 40 Facilities make up 60%of activity 50% 40% 30% 20% CCHS SNFs make up ~10% of activity 10% 0% 6 6 6 6 1 1 1 6 1 1 6 1 6 1 1 6 1 1 6 1 6 1 1 6 1 6 1 6 6 1 6 1 51 26 76 10 12 15 17 20 25 27 32 42 45 52 57 60 67 70 72 75 77 82 85 22 30 35 37 40 47 50 55 62 65 80 SNF Facilities (1) Source: Cleveland Clinic Health System internal data 8
  • 9. Nursing Home Reimbursement Outlook for 2012 Medicaid: The outlook for 2012 is extremely bleak. According to Kaiser Survey, Combined Medicare/Medicaid Shortfall for 2012 42 states face budget deficits, Payer 2012 Days in Margin/ Net margin/ collectively totaling 103 billion at Avg. million Shortfall % Shortfall the start of 2012. rate s revenue in billions Medicare $457.59 67.4 18.10% $5.58 Medicare: Medicaid $176.49 322.9 -14.00% ($7.96) A combined shortfall for 2012 Net shortfall ($2.38) taking into account Oct. 1, 2011 reduction in Part A to SNF’s of 3.87 billion or 11.1%.Sources: MedPAC report to congress Medicare Payment Policy, AHCA Reimbursement and Research Department SNF PPS Modelbased upon FY 2012 Medicare Rates and SNF claim data, A Report on Shortfall in Medicaid Funding for Nursing Home Care,ELJAY, LLC December 2011. 9
  • 10. Driving Forces Value Based Purchasing Episode-based / Bundled payment Readmission Penalties pilots Look back period began October,  Released on August 23, 2011 2011  Four Models to Propose Initial focus on CHF, AMI,  Eligible Awardees: Hospitals, Pneumonia Physician Groups, Post-Acute Targeted DRG reduced by Providers adjustment factor based on  Applicants have significant latitude readmissions deemed “excessive” to propose: or above the national average  Length of Episode Will allow for a 1%- 2% reduction in  Clinical conditions targeted and total Medicare Payments to services included Hospitals– 2013 – 2017  Expected discount provided to  Projected $7.1B in reduced Medicare payments (2013 – 2019)  Quality metrics will be developed to track results 10
  • 11. Driving Forces:The Affordable Care Act - Implementation Timeline 2012 2013 2014• Hospital Value-Based • Improving Preventive Health • No Discrimination Due to Pre-Existing Purchasing program (VBP). Coverage to expand the Conditions or Gender. Financial incentives to number of Americans • Eliminating Annual Limits on hospitals to improve the receiving preventive care. Insurance Coverage. quality of care. • Expanded Authority to • Ensuring Coverage for Individuals Bundle Payments; a national Participating in Clinical Trials.• Encouraging Integrated pilot program to encourage Health Systems. Incentives • Improving Quality and Lowering hospitals, doctors, and other Costs: tax credits to make it easier for for physicians to form providers to work together the middle class to afford insurance. "Accountable Care to improve the coordination and quality of patient care. • Establishing Health Insurance Organizations”. • Increasing Medicaid Exchanges to easily shop for more• Reducing Paperwork and affordable private insurance. Administrative Costs Payments for Primary Care Doctors. • Small Business Tax Credit. through Electronic Health • Increasing Access to Medicaid. Records. • Additional Funding for the Childrens Health Insurance • Promoting Individual Responsibility;• Understanding and Fighting Program individuals who can afford it will be Health Disparities. required to obtain basic health• Providing New, Voluntary insurance coverage Options for Long-Term Care Insurance. Source: http://www.whitehouse.gov/healthreform/timeline 11
  • 12. Why Are These Relationships So Important? Complicated Healthcare Environment Lack of Continuity between Care Site & Provider Office Lack of Clinician Communication CMS Payment Penalties for Re-Hospitalization Pending Healthcare Reform – “What will really happen?” Changing Environment Changing Strategy• Health Reform, PPACA • Hospitals reducing SNF capacity• Episode-based Bundled Payments • Emerging pilots of Post-Acute partnership across the country in many structural• Readmission Penalties variations• Continuing Care Hospital demonstration • IT as “enabler”• Public Quality Metrics 12
  • 13. Discussion Agenda Driving Forces & Market Overview Joint Quality Committee…Getting Started Monitoring Quality and Performance Indicators  Collaborative Process Improvement  Return to Acute Care Timeline & Accomplishments- Key Lessons Learned Joint Quality Committees in Multiple Settings 5 Steps to Starting Your Own Joint Quality Committee Panel Discussion 13
  • 14. You Can Develop These Relationships in Your Market Disclaimer…The Cleveland Clinic & Kindred are:• Large Organizations• With Corporate Resources and• Focus on information technology infrastructure These Relationships DON’T Need ANY of the Above!What you do need:• The willingness to take on this type of partnership• A commitment to patient outcomes and care across the continuum• Short term commitment (time, resources) for a long term benefit 14
  • 15. Establishing a Joint Quality Committee Leadership Physician Complementary Tracked & Robust Engagement & Engagement & Clinical Transparent Communication Commitment Alignment Capabilities Outcomes Protocols Establish mutual  Educate key  Identify key needs of  Establish shared  IT Linkages objectives physicians and hospital quality and  Education of all key Articulate Goals & obtain buy-in  Focus on clinical operating measures constituents on Objectives in  Invest in physicians outcome and quality  Build dashboard collaborative charter with leadership roles indicators  Establish baseline  Formation of Joint Identify and  Establish mutual  Identify parallel performance Quality Committee with empower key privileges and competencies to measures monthly meetings leaders on both education on post- establish in post-  Set targets  Review dashboard of sides acute setting (billing, acute partner  Track and trend clinical and operating Initial focus on utilization, etc.)  Implement post- data metrics high impact  Engage physicians in acute staff training  Celebrate  Establish change of outcomes (e.g., re- post-acute staff and competency milestones condition hospitalizations) training and validation protocols communication Longer term goals establishing  Avoid temptation to protocols (eg, participate in communication discuss referral  Establish patient CMS ACO demos) protocols patterns and volume transitions protocols Review  Foster integration of that does not have a related to quality/safety relationship/ physicians across quality component affiliations  Transparency is KEY charter with your legal counsel Source: Advisory Board interviews and analysis. 15
  • 16. Getting Started: Aligned and Clearly Articulated Goals• Develop and enforce processes, procedures, and workflow that contributes to high-quality and efficiency• Provide a forum for sharing clinical quality data and improvement plans• Address day-to-day issues including: admissions, nursing, therapy, IT, physician relations, ancillary services, etc.• Discuss medical staff privileges/faculty and training of physicians (fellows and residents)• Communicate other corporate-level initiatives and changes that may impact the project 16
  • 17. Getting Started: Administrative Processing• Business Associates Agreements• Executive Leadership Sponsors• Credentialing• Membership: Key Players & Stakeholders Cleveland Clinic Kindred Healthcare • Executive Leadership • Executive Leadership • Clinical Leadership • Local/Facility Specific Leadership • Quality • Clinical Leadership • Case Management • Quality • Special Project Program Leadership • Case Management • Physicians • Rehabilitation 17
  • 18. Getting Started: Meeting Structure• Meeting Times & Locations • Standing monthly meetings • Ad-hoc meetings / conference calls can be called by chairs at any time to solve immediate issues Proposed Standing Agenda• Facilitator, Agenda, Minutes • Successes –milestones achieved, things that went well• Assigned Deliverables • Monthly Quality Scorecard Review • Review list of key challenges • Special Projects • Action Items – team to identify specific actions that need to happen and who is responsible 18
  • 19. Getting Started Understand & Align Culture Troubleshooting• Understand Current Clinical Candidly Discuss Competency Issues & Concerns ASAP!• Optimize patient transfers between • Attendance and Participant levels of care Engagement• Share of Drug Formularies & • Quality & Customer Service Pharmacy contacts Performance• Use of Referral Source for • Pertinent Data/Outcome Review Continued Care (appointments & • Incomplete Data urgent care) • Need for Deeper Analysis• Collaborate on Special Patient • All members need to avoid Population defensiveness or excuses when issues arise- focus on the patient & outcomes 19
  • 20. Discussion Agenda Driving Forces & Market Overview Joint Quality Committee…Getting Started Monitoring Quality and Performance Indicators  Collaborative Process Improvement  Return to Acute Care Timeline & Accomplishments- Key Lessons Learned Joint Quality Committees in Multiple Settings 5 Steps to Starting Your Own Joint Quality Committee Panel Discussion 20
  • 21. Getting Started:Jointly Established Quality Goals & Benchmarks Long-Term Nursing & Sub-Acute Care Hospitals Rehabilitation CentersAdmissions * * *Discharges * * *Length of Stay * * *Return to STAC (short term acute care) * * *Restraints * * *Falls Rate * * *Aquired Pressure Ulcer Rate * * *Nocomial Infection Rate BSI * * * VAP * N/A N/A UTI * * * C-Diff * * *Ventilator Wean Rates * N/A N/ARetun to Prior Level of Functioning (PT& OT) N/A * *Patient Satisfaction "Would Recommend" * * *Home Health: 30 day disposition * * 21
  • 22. Getting Started:Jointly Established Quality Goals & Benchmarks Nosocomial Pressure Wounds Definitions in Acute Care Match Definitions in Post Acute Care Inclusion Process Completed for All • Numerator: • New nosocomial (developed after Day 3 of admission) Reported Data • Stage II or higher Pressure wound(s). Pressure wounds with eschar will be considered Stage II or higher for these purposes. • Follow guidelines for identifying and documenting “unstageable” wounds such as Deep Tissue Injuries (DTI). • Include applicable DTIs once the wound becomes stageable. If a Stage I advances to Stage II or higher, count as a new pressure wound. • Numerator EXCLUDES: Wounds that develop within the first 3 days after admission, skin tears, surgical wounds, rashes, or any non-pressure related wounds. •Denominator • Every patient contributes every day of stay to the denominator. Jointly Determined Quality Exclusions Performance Target No exclusion for hospice, pre-death condition, non-compliance, etc. Rate of 3.0/1,000 patient days 22
  • 23. Getting Started:Jointly Established Quality Goals & Benchmarks Partner Specific Data• Breaking out data can be cumbersome!• Must understand current information systems• Have dedicated resource/time to parse information Suggested Partner Specific Data • Administrative •Admission/Discharges •Length of Stay • Outcomes •Discharge Disposition •Return to Acute Care 23
  • 24. Year Over Year Statistics Cleveland Clinic Physician Group Admissions for Kindred Facilities# of Patient Admits 1,000 957 900 800 700 675 527 LTAC 600 262 500 400 300 383 SAU 200 413 100 63 63 47 Greens TCU 0 2009 2010 2011 24
  • 25. Collaborative Process Improvement: Case Study Kindred LTAC Patient Satisfaction Would You Recommend Kindred to a Friend or Family Member? 10.0 9.5 9.0 8.5 8.0 7.5 7.0 6.5 6.0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Cleveland Clinic 2010 2011 Kindred Health Care • High expectations & monitoring • Historical monitoring without large of patient experience change in performance • Feedback of Patient Experience • Use of Cleveland Clinic best practice resulted in increased scrutiny due from Office of Patient Experience to Kindred relationship * Process Improvement Includes:  Collaborative process improvement initiatives  Use of Administrative Rounding Program; daily visit by leadership team  Implementation of Hourly Rounding, flexible visitation policy Efforts to understand patient/family needs prior to Kindred Admission  Streamlined communication of issue or concern with swift resolution 25
  • 26. Getting Started: Collaborative Process Improvement Kindred Subacute Unit Nosocomial C-Diff 21.61.20.80.4 0 1stQ 2010 2ndQ 3rdQ 4thQ 2010 1stQ 2011 2ndQ 3rdQ 4thQ 2011 2010 2010 2011 2011 Kindred Subacute Unit Nosocomial Pressure Wounds 8 7 6 5 4 3 2 1 0 1stQ 2010 2ndQ 3rdQ 2010 4thQ 2010 1stQ 2011 2ndQ 3rdQ 2011 4thQ 2011 2010 2011 26
  • 27. Getting Started: Collaborative Process Improvement Kindred Subacute Unit: Return to Acute Care 40.0% 30.0% 20.0% 10.0% 0.0% 27
  • 28. Return to Acute Care: Contributing Factors Complex Discussion in the Post-Acute Care Setting• Physician involvement and availability• Diagnostic testing availability• Nursing assessment skills• Clinical competencies of staff• Nurse / physician communication and understanding• Advance Directives, Surrogate Decision making, End-of-Life planning• Family expectations• Transition issues – accurate transfer data and medical info, continuity of care 28
  • 29. Detailed Review of Each Return to Hospital Case Length of Stay Time of Discharge (day of week, time of day) Attending physician Physician ordering transfer Findings and intervention at facility Findings and interventions at acute care hospital* Evaluate if re-admission is Appropriate, Potentially Avoidable, Avoidable Extenuating circumstances or other pressures impacting decision to transfer  Availability/timeliness of services, clinical assessment/intervention, psycho-social or family pressures, etc. 29
  • 30. Data Management & Analysis Deeper Understanding of Performance • Volume of patients • Length of Stay • Indicator of acuity Physician • Discharge Disposition Performance • Patients to lower level of care • Return to Acute Care • Mortality • Medical Records compliance Monthly • Highlight areas of pride & areas where process improvement initiatives are required Scorecards • Monitor consistency of performance over time Control Charts • Track impact of process improvement initiatives 30
  • 31. Discussion Agenda Driving Forces & Market Overview Joint Quality Committee…Getting Started Monitoring Quality and Performance Indicators  Collaborative Process Improvement  Return to Acute Care Timeline & Accomplishments- Key Lessons Learned Joint Quality Committees in Multiple Settings 5 Steps to Starting Your Own Joint Quality Committee Panel Discussion 31
  • 32. Kindred - Cleveland Clinic RelationshipTimeline & Accomplishments 2009 2010 2011 • Monthly Joint Quality Committee • Collaborative process • Initiation of the Cleveland Clinic –Information • Full-time Dedicated project management improvement initiatives resulting in better Kindred “Futures” Committee • Interface for physician notes from Sharing • Information technology infrastructure in place performance EPIC to ProTouch goes live which insures truly integrated care • Relationship expands to “The Greens” • Developed methodology to • 675 patients cared for under free-standing Transitional Care Center Care determine examine and act this model of care. on avoidable return to • Kindred Fairhill SAU & The GreensTransitions acute care admit first patients to the “Heart Care to Home” program • Cleveland Clinic physician • Kindred Fairhill begins as an • Dr. Michael Felver Medical Dir. of Physician coverage for both LTAC & SubAcute level of care academic site for Cleveland Clinic residents & medical Transitional Care Unit • Caregiver group expands 100% toEngagement • Cleveland Clinic physician offices at Kindred Fairhill LTAC students include more internists, specialists & mid-level providers • Review of quality indicators, • Patient outcomes managed • Continued improvement in quality andQuality & definitions and calculations by the Cleveland Clinic performance indicators physician group reviewed • Collaborative, inter-organizationalOutcomes separately process improvement Kindred Fairhill + Kindred’s The Greens 32
  • 33. Key Lessons Learned “Focus Locally, Succeed Locally”  Merge culture through candid conversations and operational/clinical subgroupsInformation  Information Technology projects require aligned priorities Sharing  Enhanced information sharing requires understanding/comfort of compliance and legal  Understand current clinical competency and manage gaps Care  Utilize experts to enhance knowledge and skill for highly acute/specialty patient populationsTransitions  Access to patient historic information is a key enabler for smooth transitions of care, though more exchange of information is needed to improve patient outcomes  Dedicated and engaged physician leadership is cornerstone to relationship success Physician  Physician engagement and communication strengthened with use of EPIC/physicians on-siteEngagement  Lack of key specialists directly impacts readmission rates  Quality & outcome measures, including definitions, must be measured consistentlyQuality &  Strong working relationships & the ability to communicate candidly can overcome barriers and speed issue resolutionOutcomes  Focus on key quality outcomes can help contribute to success Italicized font depicts areas of continued focus 33
  • 34. Highlighted Benefits Increased rigor around quality data collection and reporting Relationship may open up opportunities for your staff:  Participate in hospital training  Hospital sponsored community outreach events, task forces, or process improvement committees Facility name recognition among hospital staff without added marketing expense Immediate feedback on complaints that otherwise facility would be unaware Insight into strategic plans, initiatives and programs of the hospital/referral source; ability to better facilitate collaborative growth 34
  • 35. Discussion Agenda Driving Forces & Market Overview Joint Quality Committee…Getting Started Monitoring Quality and Performance Indicators  Collaborative Process Improvement  Return to Acute Care Timeline & Accomplishments- Key Lessons Learned Joint Quality Committees in Multiple Settings 5 Steps to Starting Your Own Joint Quality Committee Panel Discussion 35
  • 36. Joint Quality Committees in Multiple Settings Variations on a Theme• Post Acute LTACH - Post Acute SNF• Post Acute (SNF/LTACH) - Home Care• Payors - Facilities• Physician Practices - Facilities 36
  • 37. Variations on a Theme: Expanding the Relationship Kindred The Greens & Expanding the Relationship Hillcrest Hospital with Specialty Services• Top referring hospital within 2 miles • International Services• 32% of patients admitted to Green’s from Hillcrest • Home Care- enhanced post• Initiating JQC in 2012 acute linkages• Specialty Programs: Orthopedic, Cardiac and Pulmonary patients• Physician Overlap: Pulmonologist and • Research Initiatives Orthopedic surgeon from Hillcrest round on patients. • Clinical Programs• Hillcrest’s Lab, Infusion Therapy and Emergency Services support care at the Greens 37
  • 38. Discussion Agenda Driving Forces & Market Overview Joint Quality Committee…Getting Started Monitoring Quality and Performance Indicators  Collaborative Process Improvement  Return to Acute Care Timeline & Accomplishments- Key Lessons Learned Joint Quality Committees in Multiple Settings 5 Steps to Starting Your Own Joint Quality Committee Panel Discussion 38
  • 39. 5 Steps to Starting Your Own Joint Quality Committee1. Make Phone Calls: Physician to Physician Relationship will Facilitate the Start Up2. Focus on QUALITY3. Commit to monitoring partner specific data4. Initial Meetings MUST be VALUABLE • Monthly (to develop the relationship) • Use participants time wisely • Delver on ALL promises/To-Do items5. Address Concerns, Issues and Cultural Differences ASAP! • Be Open, Candid & Transparent 39
  • 40. Talking Points for First Meeting Highlight the Benefit of Partnering  Reduced length of stay  Ability to monitor shared patients outcomes  Venue to impact hand-off and other quality indicators Commit resources to relationship development Jointly identified indicators to measure and monitor Ability to report statistics specific to Partner Organization Transparency, Transparency, Transparency Collaborative Process Improvement One point of contact for questions, ideas and issue resolution • Specialty Programs Highlight • Location & Highlights of Physical Plant Your • Physician credentialing overlap • 5-Star Rating & Survey Results Facility • Leadership & Staff Consistency 40
  • 41. Discussion Agenda Driving Forces & Market Overview Joint Quality Committee…Getting Started Monitoring Quality and Performance Indicators  Collaborative Process Improvement  Return to Acute Care Timeline & Accomplishments- Key Lessons Learned Joint Quality Committees in Multiple Settings 5 Steps to Starting Your Own Joint Quality Committee Panel Discussion 41
  • 42. Thank You 42