quality assessment & performance improvement, root cause analysis and the model for improvement...
TRANSCRIPT
Quality Assessment & Performance Improvement,
Root Cause Analysis and the Model for Improvement
Melody Malone, PT, CPHQTMF Health Quality Institute
ObjectivesThe learner will be able to: Describe quality assessment & performance
improvement (QAPI) Define the three categories of human factor
performance gaps Explain root causes Understand rapid cycle quality improvement
methodology2
About TMF
TMF Health Quality Institute focuses on improving lives by improving the quality of health care through contracts with federal, state and local governments, as well as private organizations. For more than 40 years, TMF has helped health care providers and practitioners in a variety of settings improve care for their patients.
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About the QIO Program
Leading rapid, large-scale change in health quality:
Goals are bolder. The patient is at the center. All improvers are welcome. Everyone teaches and learns. Greater value is fostered.
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About the QIO Program
Leading rapid, large-scale change in health quality:
Goals are bolder. The patient is at the center. All improvers are welcome. Everyone teaches and learns. Greater value is fostered.
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Have You Ever Said “HUMMMM”
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10152025
QM
Sco
re
Quality Measure
Facility
Top 10% of TX
How come I CAN’T:
Get my calls returned on time? Why can’t I document in OmbudsManager? Stay within budget? Get my facilities where I want? Sustain improvements?
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How do I get here??
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Through Quality Improvement
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“Quality is not an act, it’s a habit.”- Aristotle
Current State of Affairs
“How do YOU do
Quality Improvement Now?”
{in your office}
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Current State of Affairs
“We have our QAA meeting every
month… isn’t that QI?”
{Nursing Home}
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Comparison of QA and QI
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Quality Assurance (QA) Quality Improvement (QI)
Focus: Catch “bad apples” or detect serious problems
Improve processes—not fault finding
Goal: Meet minimal standards Ongoing process improvement
Who’s Involved:
Usually 1-2 individuals Teams
Driven By: Regulation/accreditation
Organizations
Occurs: Monthly or quarterly Continuously
QA & A F520 A facility must maintain a quality assessment and
assurance committee consisting of:• The director of nursing services • A physician designated by the facility• At least three other members of the facility’s staff
The quality assessment and assurance (QA & A) committee:• Meets at least quarterly to identify issues with respect to
which QA & A activities are necessary• Develops and implements appropriate plans of action to
correct identified quality deficiencies 14
QA & A F520, cont.
The 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.
Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions .
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Quality Assurance and Performance Improvement
(QAPI)
QAPI Background
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Mandated in the Affordable Care Act, enacted March 2010
Legislation requires the Centers for Medicare & Medicaid Services (CMS) to establish QAPI program standards and provide technical assistance to nursing home providers.
CMS identified training needs for long-term care surveyors.
Demonstration projects are ongoing now and tools are coming.
5 Elements of QAPI
• Element 1 – Design and scope Element 2 – Governance and leadership Element 3 – Feedback, data systems and
monitoring Element 4 – Performance improvement projects Element 5 – Systematic analysis and systemic
action
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Element #1: Design and Scope A QAPI program must be:
• Ongoing and comprehensive • Dealing with the full range of
services offered by the facility • Including ALL departments
It utilizes the best available evidence to define and measure goals.
A written QAPI plan
Address:• Clinical care• Quality of life• Resident choice• Care transitions Aims for safety and high
quality with all clinical interventions
Emphasizes autonomy and choice in daily life for residents
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Element #2: Governance and LeadershipThe governing body and/or
administration: Develops and leads a QAPI
program Involves leadership Uses input from facility staff,
residents and their families and/or representatives
Assures the QAPI program is adequately resourced
Designates one or more persons to be accountable for QAPI
Develops leadership and facility-wide training on QAPI
Ensures staff time, equipment and technical training as needed for QAPI
Responsible for establishing policies to sustain the QAPI program despite changes in personnel and turnover
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Element #2: Governance and Leadership, cont.Also responsible for: Setting priorities for the QAPI
program Building on the principles identified
in design and scope Setting expectations around:
• Safety• Quality• Rights• Choice• Respect• Balancing both a culture of
safety and a culture of resident-centered rights and choice
The governing body ensures that while staff are held accountable, there exists an atmosphere in which staff are not punished for errors and do not fear retaliation for reporting quality concerns.
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Element #3: Feedback, Data Systems and Monitoring Use systems to monitor care and services, drawing data from
multiple sources. Feedback systems actively incorporate input from staff,
residents, families and others as appropriate. Use performance indicators to monitor a wide range of care
processes and outcomes, and review findings against benchmarks and/or targets the facility has established for performance.
Use tracking, investigating and monitoring adverse events that must be investigated every time they occur, and action plans implemented to prevent recurrences.
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Element #4: Performance Improvement Projects (PIPs) Conduct PIPs to examine and improve care or
services in areas identified as needing attention. A PIP is:
• A concentrated effort• On a particular problem in one area of the facility or
facility-wide• Involves gathering information systematically to clarify
issues or problems• Intervening for improvements• Selected in areas important and meaningful for the
specific type and scope of services unique to each facility23
Element #5: Systematic Analysis and Systemic Action
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Use a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes and implications of a change (a.k.a. root cause analysis).
Use a thorough and highly organized/structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized/delivered.
Develop policies and procedures and demonstrate proficiency in the use of root cause analysis.
Systemic actions look comprehensively across all involved systems to prevent future events and promote sustained improvement.
This element includes a focus on continual learning and continuous improvement.
CMS QAPI Efforts Nursing home quality improvement
questionnaire Development of QAPI tools and resources Development of QAPI website QAPI demonstration project:
• Test tools/resources• Conduct learning collaboratives• Online resource center for demo participants
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National Rollout Plans Initial release of QAPI materials on CMS website (late
summer, 2012) Continued identification of resources and case examples Engagement of state and national stakeholders Encouragement of learning collaboratives with partner
organizations Development of regulation Development of surveyor training materials and survey
worksheet
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LET’S WATCH A MOVIE!
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Human Errors in Medicine
“… and the adverse events that may follow, are problems of psychology and engineering, not of medicine.”
- J.W. Senders, PhD, Medical Researcher
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Human Error – The Old View
The bad apple theory:
Complex systems would be fine if it weren’t for some unreliable people.
Human errors cause accidents.
Failures are surprises.
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What’s wrong with the old view?
Focusing on individuals does not solve underlying problems.
Errors are not intrinsically bad.
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Human Error
Human error is not the cause of accidents, it is a symptom of deeper trouble.
Human error is not random.
Human error is not the conclusion of an investigation, it is the beginning.
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What is “Human Factors”?
“Human Factors” is about how features of our tools, tasks and work environments continually influence what we do and how we do it.
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In Other Words
Human Factors is about how the design of things impacts how well we do any task.
• Design of our workplace • Design of the tools we use• Design of processes (how we do our work)
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What’s wrong with this picture???
Human Factors
How could this happen?
• Distracted sign maker
What could happen as a result?
• What were conditions and situation like when driving?
• What are characteristics of the task?
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Combating Human Error with Better Designs
Where do we start?• Assume that people do reasonable things. • Look at why there is a performance gap.
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3 Categories of Performance Gaps
The plan itself was inadequate to achieve desired outcome (planning error).
The plan is not executed properly (execution error).
There was a deliberate departure from “safe” practice (violation).
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Planning Errors
Driving to favorite gas station—run out of gas
Giving antibiotics to a patient with a viral infection
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When is it a planning error?
Don’t know what to do
Don’t know how to do it
Don’t know who is supposed to do it
“I couldn't do it”
“I used to do it differently”
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Planning Errors
Table Talk…
• What sort of planning errors have you experienced lately?
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Planning Errors
What may not work:1. Punishment2. Rewards3. Reminders
Why? They believe they are acting correctlyor following the set process.
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Planning Errors
What may work:1. Memory aids2. Training or education3. Creating/redesigning process
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Execution Errors
Turning left instead of right!
Giving the wrong medicine when distracted
Forgetting to assess a patient’s pain due to interruptions
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When is it an execution error?
Forgot
Distracted or interrupted
Steps look alike
“It slipped my mind”
Just “messed up”
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Execution Errors
Table Talk…
• What sort of execution errors have you experienced lately?
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Execution Errors
What may not work:1. Punishment2. Rewards3. Training or education of skilled
operators/expertsWhy? They intended to correctly complete the task.
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Execution Errors
What may work:1. Prompts2. Reminders3. Memory aids
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Violations
Act itself is deliberate
Negative consequences are not intended
Certain conditions more likely to produce violations
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When is it a violation?
Don’t have to do it
Frustration
Cumbersome rules, policies
Perception of being above the rules
“Saving time if I do it my way”
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Violations
Table Talk…
• What sort of violations have you experienced lately?
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Violations
What may not work:1. Training and education2. Reminders3. Prompts4. Memory aids5. Punishment
Why? Violations are a product of consequences,and positive consequences are strongest.
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Violations
What may work:1. Redesign work to eliminate frustrations.2. Use policies and rules only when
necessary.3. Give positive feedback for desired
behavior.4. Simplify processes.
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Possible Solutions in Summary Planning errors
• Memory aids• Training/education• Process changes
Execution errors• Prompts• Reminders• Memory aids
Violations• Redesign work• Use policies only
when necessary• Positive feedback
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Human Factors vs. Disciplinary Action
Human error (a.k.a. human factors):• Planning errors• Execution errors• Violation (intentional and/or recklessness)
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Just Culture vs. Disciplinary Action
Just culture (safety thinking):• Promotes a questioning attitude• Resistant to complacency• Committed to excellence• Fosters both personal accountability and
corporate self-regulation in safety matters• Atmosphere of trust
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Goals of Quality Improvement Identify problem areas Identify sources of variation Simplification Eliminate duplication, rework, extra steps Improve fragmentation Remove waits, delays Eliminate errors
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And Most Importantly, QI…
Is a process to build a culture of safety and move beyond the culture of blame.
Remember :Human Factors and a Just
Culture!
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Quality PrinciplesSystems Thinking Cyclical─not linear (cause/effect) System is dynamic in achieving goals Looks at a system in total, as sum of its
parts, all working together Encourages communication and
speaking up to break down silos Depends on feedback to maintain
stability System at fault versus individual
employee Promotes understanding of the patterns
of behaviors that lead to outcomes, positive and negative
Principles of QAPI Just culture Ongoing, continuous 5 elements that are interrelated Learning organization; sustaining
improvements Culture where staff do not fear
reporting quality concerns Feedback, data systems and
monitoring An approach to QI where the
culture is to make continuous improvement. “It’s just what we do.”
Feedback, data systems and monitoring 59
Where do we begin?
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The most fundamental reason a problem has occurred.
When performance does not meet expectations
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Search for the Root Cause
Root Cause Analysis
Inter-disciplinary Involving experts from
the frontline services Continually digging
deeper by asking why, why, why at each level of cause and effect
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The Goal of a Root Cause Analysis is to Find Out:
What happened? Why did it happen? What to do to
prevent it from happening again
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Root Cause Analysis Identifies needs for systems changes Is a process that is as impartial as possible As well as a tool for
identifying prevention strategies
There are various tools to use.
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5 WHYs Tool
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Brainstorming
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Brainstorming Rules
Postpone and withhold your judgment of ideas.
Encourage wild and exaggerated ideas. Quantity counts at this stage, not quality. Build on the ideas put forward by others. Every person and every idea has equal
worth.
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Brainstorming
Why can't we keep sufficient staff?
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Silent Brainstorming
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Silent Brainstorming
What do you want to change about the Ombudsman program?
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Silent Brainstorming
What should not be changed about the Ombudsman program?
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Problem Statement
StaffMaterials
EducationEquipment
Fishbone Diagram
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We Have the Root Cause
Now what?
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What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Act Plan
Study Do
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Act• What changes are to be made?• AdApt? AdOpt? or Abandon?• Next cycle?
Plan• Objective• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)
Study• Complete the analysis of the data
•Compare data to predictions
•Summarize what was learned
Do
• Carry out the plan• Document problems and unexpected observations• Begin analysis of the data
The PDSA Cycle for Learning and Improvement
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What are we trying toaccomplish?
How will we know that a change is an improvement?We are going to measure!
Set a goal: 50% imp. Q1 to Q2
What change can we make that will result in improvement?
Follow up daily on fall risk assessments from day before.
Model for Improvement
Decreasing falls
Act
• What changes are to be made?• AdApt? AdOpt? or Abandon?• Next cycle?
Plan• Verify one of prior day’s fall risk assessments • Validate 1• Observe 1• By unit manager• Track results
Study• Complete the analysis of the data
•Compare data to predictions
•Summarize what was learned
Do
• Carry out the plan• Document problems and unexpected observations• Begin analysis of the data
The PDSA Cycle for Learning and Improvement
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Repeated Use of the Cycle
A P
S D
APS
D
A P
S DD SP A
DATA
Very Small-scale Test
Follow-up Tests
Wide-scale Tests of Change
Spread
Hunches Theories
Ideas
Changes That Result in
Improvement
Implementation of Change
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Act
• What changes are to be made?• AdApt? AdOpt? or Abandon?• Next cycle?
Plan• Verify prior day’s fall risk assessments Done, daily • Validate 10% of each• Observe 10% of each• By unit manager• Track results
Study• Complete the analysis of the data
•Compare data to predictions
•Summarize what was learned
Do
• Carry out the plan• Document problems and unexpected observations• Begin analysis of the data
The PDSA Cycle for Learning and Improvement
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Overall Goal: Implement the Model for Improvement
A P
S D
AP
SD
A P
S D
D S
P A
A P
S D
A PS D
A P
S D
D S
P A
A P
S D
AP
S D
A P
S D
D S
P A
Concept C Concept D
Develop strategies for each component of the model.
A P
S D
AP
S D
A P
S D
D S
P A
Concept B Concept EConcept A
A P
S D
AP
S D
A P
S D
D S
P A
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GOAL – Improve Outcomes
Change concepts, theories, ideas
Concept B
Concept CConcept D
Concept A
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Start Small
What can you do by Tuesday?
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QI Resources: http://TexasQIO.tmf.org
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Questions?
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Contact
Melody Malone, PT, CPHQQuality Improvement Consultant
TMF Health Quality Institute214-632-2238
[email protected]://TexasQIO.tmf.org
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This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-TX-C7-12-174