Joel Elsenbroek
Christ ina Matzke
LeadingAge MI
Annual Conference
2014
TRANSFORMING QUALITY IMPROVEMENT
Section 6102(c) of the Affordable Care Act requires CMS to establish regulations in Quality Assurance and Performance Improvement (QAPI) and provide technical assistance to nursing homes to help them develop best practices to comply with the forthcoming regulations
QAPI is the coordinated application of two mutually -reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, comprehensive, and data -driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving.
QAPI
CMS – QAPI at a Glance
QA is the specification of standards for quality of service and outcomes, and a process throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards. QA is on-going, both anticipatory and retrospective in its efforts to identify how the organization is performing, including where and why facility performance is at risk or has failed to meet standards.
PI (also called Quality Improvement - QI) is the continuous study
and improvement of processes with the intent to better services or outcomes, and prevent or decrease the likelihood of problems, by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems or barriers to improvement. PI in nursing homes aims to improve processes involved in health care delivery and resident quality of life. PI can make good quality even better.
QAPI
CMS – QAPI at a Glance
As a result, QAPI amounts to much more than a provision in Federal statute or regulation; it represents an ongoing, organized method of doing business to achieve optimum results, involving all
levels of an organization.
QAPI
CMS – QAPI at a Glance
HHS/CMS RIN: 0938-AR61 Publication ID: Fall 2013
Title: Reform of Requirements for Long-Term Care Facilities and Quality Assurance and Performance Improvement (QAPI) Program (CMS-3260-P)
Abstract: This proposed rule would reform the Medicare conditions of participation for long-term care facilities to reflect significant changes in the industry and remove obsolete or unnecessary provisions. In addition, under the Affordable Care Act, this rule would propose to expand the level and scope of required QAPI activities to ensure that facilities continuously identify and correct quality deficiencies as well as promote and sustain performance improvement.
Agency: Department of Health and Human Services(HHS)
Priority: Other Significant
RIN Status: Previously published in the Unified Agenda
Agenda Stage of Rulemaking: Proposed Rule Stage
Major: Undetermined Unfunded Mandates: Undetermined
CFR Citation: 42 CFR 483
Legal Authority: PL 111-148, sec 6102; secs 1102, 11281 and 1871 Social Security Act
Legal Deadline: None
Timetable:
Action Date FR Cite
NPRM 03/00/2014
Additional Information: Includes Retrospective Review under E.O. 13563.
Regulatory Flexibility Analysis Required: Undetermined
Government Levels Affected: State
Small Entities Affected: Businesses
Federalism: No
Included in the Regulatory Plan: No
PROPOSED RULE - CMS
www.reginfo.gov
Why change if you don’t have to?
(1) A facility must maintain a quality assessment and assurance committee consisting of--
(i) The director of nursing services;
(ii) A physician designated by the facility; and
(ii) At least 3 other members of the facility’s staff.
Intent §483.75(o)
The intent of this regulation is to ensure the facility has an established quality assurance
committee in the facility which identifies and addresses quality issues, and implements
corrective action plans as necessary.
F520 §483.75(O) QUALITY ASSESSMENT AND ASSURANCE
(2) The quality assessment and assurance committee -- (i) Meets at least quarterly to identify issues with respect to which
quality assessment and assurance activities are necessary; and
(ii) Develops and implements appropriate plans of action to correct identified quality deficiencies.
(3) A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section.
(4) Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.
F521
Members were leadership only Met monthly, but physician and
pharmacy couldn’t meet monthly
Set additional quarterly QA meeting to satisfy the regulation of participation. And another quarterly corporate QA meeting to f inish the circle to executive leadership and the Board of Directors – l imited feedback
Long meeting – reporting on everything. Litt le to no collaboration
Data was reported, but questionable if processes were actually addressed
Majority didn’t know why we were reporting on what we were reporting on
No one outside of the meeting knew what QA was
No root cause analysis Redundant Nothing really ever came off
the l ist Each staff member made up
their own tools and data collection
Lots of paper to be f i led Many, many sub committee’s
that were QA related, but not contributing to the reports made at QA
TRADITIONAL QA SHORT COMINGS
Felt like we were meeting a regulated standard – but not accomplishing anything.
T
IME
& E
NE
RG
Y
DR
AIN
ED
Recognize this traditional QA format isn’t functional, or meaningful to the organization
Started talking about QAPI concepts at leadership meetings; sparking interest in change, allowed people to start thinking about the what if ’s…
what if we had less to audit but more useful results?
what if the staff on the floor had a way to contribute?
what if we could combine some of our meetings for one purpose?
PATHWAY TO CHANGE
http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey -and-Cert-Letter-13-05.pdf
Determine do we want to do/need to do/should do from this.
Like everything else, weed out the unnecessary parts.
Don’t overwhelm your team with things they don’t necessarily need to know.
Complete self assessment tool as a team.
Gather input to priorities
QAPI AT A GLANCE
Be sure your measurements are justified:
Do you have to track this?
Do you want to track this?
Should you track this?
What are you going to do with this information?
Not all things tracked need to be discussed…
DEVELOPMENT OF TOOLS
Tracking Tool – data driven, uniformed, accessible, easy to use
Reporting Tool – basic trends & accountability
Use the data reported in the QAPI meetings to identify Problems or Opportunities that require a PIP.
Assemble your PIP team
Format & track your progress
PIP Meeting protocols
Trouble Shooting
Case Studies
PERFORMANCE IMPROVEMENT PROJECT
Players Faci l itator Owner(s) Front l ine staff (HR/Leadership support)
Who picks the team? Direct Supervisor Faci l itator DON/Administrator
Who do you need on your team? Good ones Bad ones Team Players
PIP TEAM
Team Charter Ensure Compliance
Get Buy-in
Set Structure
FORMAT AND TRACK PIP PROGRESS
QAPI Performance Improvement Project
This charter team has been specifically selected to address an opportunity for improvement.
Being on this team is an important part of your job and requires that you actively engage and
contribute to the discussion. This team is required to provide written reports to the QAPI
steering committee detailing the following agenda:
Agenda Based on the Scientific Method
PDCA
Culture of Continuous Improvement
PLAN
Define the Problem (what, where, when, magnitude, trend)
SMART Goal (specific, measurable, assigned, realistic, time-bound)
Determine Measures/Data
Root Cause Analysis
Brainstorm Solutions/Experiments
FORMAT & TRACK PIP PROGRESS
Agenda
DO
Construct Hypothesis
Implement Solutions/Experiments
Gather Data
CHECK
Compare Data to Starting Condition/SMART Goal
Successful Yes or No?
Brainstorm Solutions/Experiments
Determine Measures/Data
FORMAT & TRACK PIP PROGRESS
Agenda
ACT
Continue. Spread, or Start Over
Standardize Work
Policies & Procedures
Control/Continuous Improvement
FORMAT & TRACK PIP PROGRESS
FORMAT & TRACK PIP PROGRESS
PIP Status Report Reported at monthly QAPI meetings
PIP Status Report
Subject/Date Problem Goal Report Status
Pre-Selct Menus
1/22
70% compliance on turning
in menus by 11 am Increase compliance to 95%
Everyone feels that fi l l ing
out menus with residents
has become standard
work.
Monthly Avg. 95.5% Next
meeting 2/13
Med Errors 1/30Reduce med errors on routine
passes
lower transcriptional errors to no more than 3 per
month
PCC upgrade coming in
FEB; reducing interuptions
6 transcriptional errors in
JAN; next meeting 2/19
Falls 1/21
Too many falls throughout
the facility on 2nd shift that
have the potential to harm
residents.
root cause analysis;
revising fall report form
still need to establish a goal;
next meeting 2/5
FORMAT & TRACK PIP PROGRESS
Performance Improvement Project
Project: Start Date:
Team Members:
Assess Problem:
SMART Goal:
Measurement: Baseline: Target:
Date Current Date Current Date Current
PIP Tracking Report (page 1) Used for notes in PIP meetings
FORMAT & TRACK PIP PROGRESS
Root Cause Analysis Findings:
Brainstorming Solutions/Experiments:
Experiment Results/Analysis:
Hypothesis:
Performance Improvement Project
Project: Start Date:
PIP Tracking Report (page 2) Used for notes in PIP meetings
PIP MEETING PROTOCOLS
Timing
Hold meetings between shifts
1 hour max
Frequency
Ideally every week
Realistically every two weeks
Atmosphere Closed Door Meeting
Confidential & Safe
Provide Snacks
Follow the Agenda! Facilitator should be a PDCA Purist
Don’t let your Team Rush the Process Let QAPI be the bad guy!
When the Pathway is Unclear When is doubt, use the QAPI forms http://cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/ProcessToolFramework.pdf
Lack of Commitment (I’m too busy!) Look for Champions
Team Dynamics (personalities clash) Must have a Facilitator
Loss of Momentum (we’re stuck!) Learn to be Comfortable with Discomfort
PIP TROUBLE SHOOTING
PIP TROUBLE SHOOTING
PIP TROUBLE SHOOTING
Pre-Select Menus
Problem:
Pre-select menus on all halls are not ready for pick up by 11 am. Lately, approximately 30% of them have not been ready, which results in loss time for dietary having to track them down, food-prep time is delayed, and food shortages occur during the next day’s lunch and supper.
(What, Where, When, Magnitude, Trend)
PIP CASE STUDIES
Pre-Select Menus
SMART Goal:
Achieve 95% compliance on having CNAs turn in pre-select menus by 11 am on all halls for 3 consecutive months.
(Specific, Measurable, Assigned, Realistic, Time -bound)
PIP CASE STUDIES
Pre-Select Menus
Determine Measurement/Data:
Dietary will track % turned in on-time daily, and compile monthly averages, reporting results at PIP meetings.
PIP CASE STUDIES
PIP CASE STUDIES
Pre-Select Menus
Root Cause Analysis:
CNA’s don’t have time to help residents fill them out because they are busy toileting, dressing, feeding
Call lights are top priority so menus get forgotten
Each hall is a little bit different so they require different solutions
Lakeshore has two breakfast times, 7:30 & 9 am, and all of the residents at 9 am require assistance
Not enough volunteers to chart/help out at mealtime
PIP CASE STUDIES
Pre-Select Menus
Brainstorm Solutions:
Put the menus on the breakfast trays when they are delivered
Assign the task to one volunteer
Have volunteers who chart/help out at breakfast do it
Involve family and have them help resident fil l them out a week in advance
Write “Refused” on the menu if the resident is unavailable (sleeping, not responding, doesn’t care)
Fill them out two days in advance (Ex: fi l l out Wed menu on Mon)
Have restorative aids assist residents in fil l ing out menus (Lakeshore)
Pass out menus first, and then pass out breakfast trays
PIP CASE STUDIES
Feb-14 97%
Jan-14 95%
Dec-13 97%
Nov-13 92%
Oct-13 94%
Sep-13 81%
Aug-13 86%
Measurement: track % turned in on-time daily,
and compile monthly averages
Baseline: 70% Target: 95%
Date Current Date Current Date Current
Performance Improvement Project
Project: Pre-Select Menus Start Date: 8/22/13
Team Members: Julie Schmuker, Amanda Krulek, Joel Elsenbroek, Kristen Contreras, Jessica VanBelkum, Amanda Walsh,
Bobbie J. Marzean, Chris TereloAssess Problem: Pre-select menus on all halls are not ready for pick up by 11 am. Lately, approximately 30% of them have not
been ready, which results in loss time for dietary having to track them down, food-prep time is delayed, and food shortages
occur during the next day’s lunch and supper.
SMART Goal: Achieve 95% compliance on having CNAs turn in pre-select menus by 11 am on all halls for 3 consecutive
months.
PIP CASE STUDIES
Experiment Results: Created standard work: 1. Grab the menu when you bring the tray 2. Fill out menu while feeding resident.
3. If the menu is still there when you go to pick up the tray, help them fill it out. 4. put menu back in clearly marked folder on
top of cart.
Analysis: daily compliance fluctuates but overall is up; staff awareness increased; pizza party planned for day when we first hit
95% compliance. Continue monitoring, Change dietary policy regarding pre-select menu choices and add standard work to
competencies.
Performance Improvement Project
Project: Pre-Select Menus Start Date: 8/22/13
Root Cause Analysis Findings: CNA’s don’t have time to help residents fill them out because they are busy toileting, dressing,
feeding
Call lights are top priority so menus get forgotten
Each hall is a little bit different so they require different solutions
Lakeshore has two breakfast times, 7:30 & 9 am, and all of the residents at 9 am require assistance
Not enough volunteers to chart/help out at mealtime
Brainstorming Solutions/Experiments: Put the menus on the breakfast trays when they are delivered
Assign the task to one volunteer
Have volunteers who chart/help out at breakfast do it
Involve family and have them help resident fill them out a week in advance
Write “Refused” on the menu if the resident is unavailable (sleeping, not responding, doesn’t care)
Fill them out two days in advance (Ex: fill out Wed menu on Mon)
Have restorative aids assist residents in filling out menus (Lakeshore)
Pass out menus first, and then pass out breakfast trays
Hypothesis: Compliance will improve if we can get everyone to do it the same way and it becomes a habit.
PIP CASE STUDIES
Pre-Select Menus
70%
75%
80%
85%
90%
95%
100%
Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14
% Compliance
Month
Pre-Select Menus Turned In
Goal: 95% Compliance
Fall Prevention
Problem:
Too many falls throughout the facility on 2nd shift with no or minimum injury, but could have the potential to harm residents.
(What, Where, When, Magnitude, Trend)
PIP CASE STUDIES
Fall Prevention
SMART Goal:
The Falls PIP team will create an effective falls investigation process (including standardized written form, online documentation, and staff training)by the end of May to capture 100% complete & accurate information on all investigations.
(Specific, Measurable, Assigned, Realistic, Time -bound)
PIP CASE STUDIES
Fall Prevention Determine Measurement/Data: Continue to track falls by: Number of Falls Frequent Fallers Shift Unit Classification (witnessed, un-witnessed, lowered to the
floor) Level of injury
PIP CASE STUDIES
PIP CASE STUDIES
Fall Prevention Root Cause Analysis: Toileting demands Resident anxiety/confusion Staff confusion on difference between witnessed and
lowered to the floor (inconsistent language in EMR and written reports)
Medication changes/side effects Infections (UTI & other) Lack of sleep cycle information (gathering & sharing) Changes in assistance level Inconsistent shift reports Incomplete incident report forms
PIP CASE STUDIES
Fall Prevention
Brainstorm Solutions:
Create shift hand-off report for high risk residents
Add hand-off report to daily team meetings
Standardize language in EMR and written report (Fall Witnessed, Fall Un-witnessed, Lowered to Floor)
Revise Falls Incident Reporting Form
Consultants
Physician
Exec’s
Board
Team Pip’s
Communication board
Non-pip sub-committee meetings; roaming
GET EVERYONE ON BOARD
Policy
Edit as you go
Create a culture of change – it’s okay to start and make adjustments as needed.
May need to help individuals with their tracking tool’s depending on their level of comfort with technology
Don’t need to spend any money to start
GIVE IT A WHIRL
QUESTIONS