quality assurance performance improvement (qapi) · pdf fileperformance improvement ......

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Quality Assurance Performance Improvement (QAPI)

Linking Survey and Quality

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What’s New

• New Regulations

• CMS and contractors working on

materials

• New Publication “QAPI at a Glance”

Copyright © Providigm, LLC. 2013

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Sources

• Centers for Medicare and Medicaid Services. S&C: 13-05-NH "Preview of Nursing Home Quality Assurance & Performance Improvement (QAPI) Guide - QAPI at a Glance." , 14 December 2012

• "QAPI at a Glance: A Step by Step Guide to Implementing Quality Assurance and Performance Improvement (QAPI) in Your Nursing Home (DRAFT)." Centers for Medicare and Medicaid Services, University of Minnesota, Stratis Health, December 2012


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4Copyright © Providigm, LLC. 2013

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The New Regulation

• The ACA provision at Section 6102 requires nursing homes to develop a

“compliance and ethics program”

including (at part c) a “Quality Assurance and Performance

Improvement Program [QAPI].”


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The New Regulation

• This provision specifies that the Secretary (delegated to CMS) must “establish standards relating to quality assurance and

performance improvement” and must implement a program that will “provide technical assistance to facilities on the

development of best practices in order to meet such standards.”


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The New Regulation

• This new provision significantly expands the level and scope of facility

activities in order not only to correct

defects but also to constantly monitor all care and services in order to

continually improve performance


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What is Quality Assurance Performance

Improvement (QAPI)

• QAPI is a data-driven and pro-active approach to quality improvement. Activities of this comprehensive approach are

designed to involve all members of an organization to continuously identify opportunities for improvement, address gaps

in systems through planned interventions in order to improve the overall quality of care and services delivered to nursing home

residents.


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Purpose of QAPI

• To greatly enhance each nursing home’s processes of assessing their

quality of care and services

• Continually correcting defects and

improving their performance

outcomes


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CMS Contract

• Evaluate current tools that may be useful for providers

• Develop a web-based resource library for providers and consumers:

� Examples of QAPI frameworks

�Core components and best practices

• Survey procedures and worksheets

• Initiate rollout November 2012


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Current QA Regulation

• Current regulation for Quality Assurance in Nursing Homes requires

only a limited group of staff members

to be involved in a Quality Committee.

�DON

�A physician

� Three members of the staff

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Current Regulation Basis for QAPI

• QAPI uses existing Quality Assessment and Assurance regulation and

guidance as a foundation

• QAPI uses a systems approach to

actively pursue quality not just respond

to external requirements

• May be already using parts of the

process


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Whose Job is Quality?

• Quality is a team sport. All members of an organization must participate in

quality. Everyone has some degree of

responsibility to quality from the top of the organization to bottom. Quality is

not just the responsibility of a

committee or those who attend a meeting.

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Develop a Steering Committee• A team to provide QAPI leadership

• Overall responsibility to develop and modify the plan, review information, set priorities for PIPs

• Charters teams to work on particular

problems

• Reviews results and determines next steps

• Learn and use systems thinking


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Develop a Steering Committee

• Must include top leadership

• Engage medical director in QAPI

• Adapt QA committee to steering

committee

�May need to meet more often

� Include more people

� Establish permanent and time-limited

work groups that report to it


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QUALITY ASSURANCE & PERFORMANCE IMPROVEMENT


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QAPI and National Goals

• Improve Care for Individuals

• Improve Health for Populations

• Reduce per capita Costs in healthcare

delivery system


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Quality Assurance

QA is a process of meeting quality standards and assuring that care reaches an acceptable level. Nursing homes typically set QA thresholds to comply with regulations. They may also create standards that go beyond regulations. QA is a reactive, retrospective effort to examine why a facility failed to meet certain standards. QA activities do improve quality, but efforts frequently end once the standard is met.


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Quality Assurance

• Quality assurance involves measuring

and tracking indicators to find out where the facility is performing well,

and where there are opportunities for

improvement.

Two functions that go hand in hand

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Performance Improvement

PI (also called Quality Improvement - QI) is a pro-active and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems. 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.


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• PI is a proactive and continuous studyof processes with the intent to prevent

or decrease the likelihood of problems

by identifying areas of opportunity and testing new approaches to fix

underlying causes of

persistent/systemic problems.

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• PI in nursing homes aims to improve processes involved in health care

delivery and resident quality of life. PI

can make good quality better.

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• Performance improvement is the reaction and correction to an

opportunity to improve.

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Quality Assurance and Performance Improvement -Comparison


QUALITY ASSURANCE PERFORMANCE IMPROVEMENT

MotivationMeasuring compliance with

standards

Continuously improving systems and

processes

Means Valid measurement PDSA Cycles

Attitude Required, comprehensive Chosen, specific

Focus Outcomes Systems and Processes

Scope Resident Care All Services

Responsibility QA Staff All Staff

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QA+PI=QAPI

• Data driven

• Proactive approach to performance

management and improvement

• Systematic

• Comprehensive

• Improves quality of life, care and

services

• All levels of the organization


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QA+PI=QAPI

• Identify opportunities for improvement

• Address gaps in systems or processes

• Develop and implement an

improvement or correction plan

• Continuously monitor effectiveness of

interventions


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USING THE QIS METHODOLOGY TO IMPLEMENT QAPI

Linking Survey and Quality

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QIS Provides the

Framework for a Quality

Assurance and


System

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What can be done with QIS

• Continuous Survey Readiness

• Continuous Quality Assurance

• Performance Improvement

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Quality Assurance –

Four Fundamental Steps

1. Develop scientifically valid quality

metrics

2. Establish minimum quality standards

3. Systematically evaluate quality using

metrics

4. Verify that quality meets minimum

standards

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Scientifically ValidQIS Metrics – Quality of Care and

Life Indicators (QCLIs)

# Residents in Sample

With Negative Response

= RATE (%)

# Total Residents in Sample

(less relevant exclusions)

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Metrics Validated

Against Regulation§483.15(b) - Self-Determination and Participation The resident has the right to--

(1) Choose activities, schedules, and health care consistent with his or her interests, assessments, and

plans of care;

(2) Interact with members of the community both inside

and outside the facility; and

(3) Make choices about aspects of his or her life in the

facility that are significant to the resident.

Source: State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term

Care Facilities, (Rev. 70, 01-07-11)

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Establish MinimumQuality Standards - Thresholds

• The QCLI rate established to govern the decision of whether to conduct an

in-depth Stage 2 review or

investigation

• Value is absolute, not relative

• Rate is facility-level

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Systematically

Evaluate Quality…

Stage 1Stage 1 Stage 1

Stage 2

Quality Committee

Intervene

Intervene

Intervene

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…Continuously

Assess at a sustainable rate so that continuous use is achieved. This produces

the best results.

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Use Two - Stage Approach

• Stage 1 preliminary investigations

• Mandatory Facility Level Tasks

• Stage 2 in-depth investigations

Copyright © 2011 Providigm, LLC

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The Five Elements of QAPI

1. Design and Scope

2. Governance and Leadership

3. Feedback, Data Systems and

Monitoring

4. Performance Improvement Projects

(PIPs)

5. Systematic Analysis and Systemic Action


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QAPI Strategic Framework


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1. Design and Scope


3. Feedback, Data Systems

and Monitoring

4. Performance Improvement Projects (PIPs)

5. Systematic Analysis and

Systemic Action


1. Design and Scope



and Monitoring



Systemic Action


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1. Design and Scope

• A QAPI program must be ongoing and comprehensive, dealing with the full

range of services offered by the

facility, including the full range of departments

• When fully implemented, the program should address clinical care, quality of

life, resident choice, and care

transitions


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1. Design and Scope

• The Program aims for safety and high quality

with all clinical interventions while

emphasizing autonomy and choice in daily life

for residents (or resident’s agents)

• The Program utilizes the best available

evidence to define and measure goals

• Nursing homes will have in place a written

QAPI plan adhering to these principles.


1. Design and ScopeQAPI

QAPI is Ongoing and Comprehensive

dealing with full range of services

offered by the facility, including the full

range of departments.

When fully implemented the QAPI

program, should address all systems of

care and management practices, and

always include Clinical Care, Quality of

Life, and Resident Choice.

It aims for safety and high quality with all

clinical interventions while emphasizing

autonomy and choice in daily life for

residents (or resident’s agents).

QIS

QIS, covers the whole regulation. Used

routinely, it is ongoing. Covers all

regulatory care areas and services and

departments.

QIS looks at systems of care required by

Federal Regulation including individual

resident care and facility wide care

systems which incorporates Quality of

Life, Quality of Care and Resident Choice.

QIS was designed around resident

centered care. QIS care areas also look at

clinical interventions, choices, resident

rights, accidents, choices, and activities.

1. Design and Scope

QAPI

Utilizes the best available evidence to

define and measure goals.

Nursing homes will have in place a

written QAPI plan.

QIS

In depth investigation in QIS is tied to

CMS QCLI’s and thresholds. If thresholds

are exceeded, there is a high likelihood

of non compliance and quality issues.

QIS can be used in QAPI plan.

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Quality Indicator SurveyFull Range of Services

• Based on the methodology of the Quality Indicator Survey

� Stage 1

� Stage 2

�Designed to cover the entire regulation

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QCLI DictionaryQuality of Life,Care and Resident

Choices


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QCLI Dictionary

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ThresholdsDefine and Measure Goals

1. Design and Scope



and Monitoring



Systemic Action


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• The governing body and/or administration of the nursing home

develops and leads a QAPI program

that involves leadership working with input from facility staff, as well as from

residents and their families and/or

representatives.


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• The governing body assures the QAPI program is

adequately resourced to conduct its work. This

includes:

�designating one or more persons to be accountable for QAPI;

�developing leadership and facility-wide training on QAPI;

�and ensuring staff time, equipment, and

technical training as needed for QAPI.


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• They are responsible for establishing policies to sustain the QAPI program despite changes in personnel and turnover.

• The governing body and executive leadership

are also responsible for setting expectationsaround safety, quality, rights, choice, and respect by balancing both a culture of safety

and a culture of resident-centered rights and choice.


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• 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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2. Governance and LeadershipQAPI

Administration leads QAPI with input from staff,

residents, families.

QAPI program must be adequately resourced,

designating a person accountable for QAPI,

develops facility wide training and provides

training and equipment as needed for QAPI.

Establish policies to sustain the QAPI program

despite changes in personnel and turnover

Set priorities for improvement.

Balance a culture of safety and a culture of

resident-centered rights and choice.

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.

QIS

QIS integrates interviews obtaining input from

residents, family and staff. Use on an ongoing

basis, provides continuous feedback.

As QIS is available as a QA tool, CMS maintains

thresholds and measurement, updates, forms,

resources and materials.

QIS process is sustained despite turnover in staff.

Staff can be educated and with turnover, re-

educated as needed. Multiple staff members can

be trained in the process.

QIS thresholds assist in identifying care areas

where in-depth investigation is needed and

based on investigation, priorities set for

improvement.

QIS assesses resident safety, rights and choice

and in-depth investigation determines if the

facility is meeting the standard.

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Resident Interview and Observation – Multiple Sources

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QIS MatrixCare Areas


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Setting Priorities with Threshold Reporting

1. Design and Scope



and Monitoring



Systemic Action


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and Monitoring• The facility puts in place systems to monitor care and services, drawing

data from multiple sources.

• Feedback systems actively

incorporate input from staff, residents,

families, and others as appropriate.


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and Monitoring• This element includes using Performance Indicators to monitor a wide range of care processes and outcomes, and reviewing findings against benchmarks and/or targets the facility has established for performance.

• This element also includes tracking, investigating, and monitoring Adverse Events that must be investigated every time they occur, and action

plans implemented to prevent recurrences.


3. Feedback, Data Systems, and

MonitoringQAPI

Facility puts into place systems to monitor

care and services, drawing data from multiple

sources.

Feedback systems actively incorporate input

from staff, residents, families, and others as

appropriate.

Performance Indicators monitor a wide range

of care processes and outcomes.

Findings are reviewed against benchmarks

and/or targets the facility has established for

performance.

Includes tracking, investigating, and

monitoring Adverse Events.

QIS

QIS is a systematic process that monitors care

and services through Quality of Care and Life

Indicators (QCLI’s), mandatory tasks and in-

depth investigation.

QIS incorporates resident, family and staff

interviews, resident observations, record

review and MDS. In-depth investigation elicits

additional input.

QCLI’s, which are outcome and process

indicators, monitor numerous care areas,

facility processes and outcomes.

Thresholds are used to determine if findings

indicate a need for further investigation into

performance.

QIS identifies resident and family allegations

of abuse, which is an adverse event.

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Feedback, Data Systems and Monitoring

• How will you know if you are doing well? Without a baseline or point of

comparison, it is hard to judge your

own performance.

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Feedback, Data Systems and Monitoring

• A strong approach to quality management, such as QAPI, uses

performance indicators to monitor a

wide range of care processes and outcomes.

• Then it reviews findings against benchmarks and targets the facility

has established for performance.

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Develop a Strategy for Collecting and Using QAPI Data - Step 7• Your team will decide what data to monitor routinely. Areas to consider may include:

� Clinical care areas e.g., pressure ulcers, falls, infections

� Medications, e.g., those that require close monitoring, antipsychotics, narcotics

� Complaints from residents and families

� Hospitalizations and other service use

� Resident, caregiver, family satisfaction


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Develop a Strategy for Collecting and Using QAPI Data - Step 7

� Resident and caregiver experiences living and working in the setting

� State survey results and deficiencies

� Results from MDS assessments


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Quality Indicator Survey

• QIS process incorporates process and outcome measures, thresholds and in-

depth investigation making an ideal

basis for QAPI


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QP 234 ChoicesResident Interview


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QCLI Dictionary


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QIS Matrix


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Identify Care Areas

• Facility process concerns

(Tasks)

• Resident outcome concerns

(Stage 1):

�Quality of Care

�Quality of Life

� Resident Choice


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Stage 1 Preliminary Investigation

• Census Sample

� Resident Interviews

� Resident Observations

� Family Interviews

� Staff Interviews

� Clinical Record Reviews

• Admission Sample

� Clinical Record Reviews


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Mandatory Facility Tasks

• Liability Notice and Beneficiary Appeal Rights

• Dining Observation

• Infection Control & Immunization

• Kitchen/Food Service Observation

• Medication Administration

• Medication Storage

• Quality Assessment and Assurance (QA&A)

• Resident Council President/Representative Interview


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Triggered Facility Tasks

• Abuse Prohibition

• Admission, Transfer, and Discharge

• Environmental Observations

• Personal Funds

• Sufficient Nursing Staff

• QIS Extended Survey


1. Design and Scope



and Monitoring



Systemic Action


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4. Performance Improvement

Projects (PIPs)• The facility conducts Performance Improvement Projects (PIPs) to

examine and improve care or services

in areas that are identified as needing attention.


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4. Performance Improvement

Projects (PIPs)• A PIP project typically is a concentrated effort on a particular problem in one area of the facility or facility wide; it involves gathering

information systematically to clarify issues or problems, and intervening for improvements.

• PIPs are selected in areas important and meaningful for the specific type and scope of

services unique to each facility.


4. Performance Improvement Projects

(PIPs)QAPI

A PIP project is a concentrated effort

on a particular problem in one area

of the facility or facility wide.

A PIP involves gathering information

systematically to clarify issues or

problems, and intervening for

improvements.

The facility conducts Performance

Improvement Projects (PIPs) to

examine and improve care or

services in areas that are identified

as needing attention.

QIS

Using QIS to assess thresholds and

set targets along with in-depth

investigation assist in determining

the need for a PIP.

QIS QCLI’s can be used as

measurement and re-measurement

for PIPS to determine if goals have

been met.

QIS assists in the assessment to

determine if a PIP should be

chartered.

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Performance Improvement Projects (PIPs)

• Conducting PIPs allows the nursing home to examine performance and

make improvements in any area

identified as needing attention, or that is found to be high priority or high risk

based on the needs of the residents.

What are PIPs?

• A Performance Improvement Project is more than a casual effort - it entails a specific written mission to look into a problem area.

• During a PIP a facility will try out some changes and then see whether or not they made a difference in the area they were trying to improve.

Performance Improvement Charter- PIP

• A charter is typically a documented

plan that identifies the problem, goals

and the team members’ roles and responsibilities.

• The purpose of the charter is to

provide the PIP team with key

information that will allow them to have a clear understanding of what

they are being asked to do.

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Performance Improvement Charter - PIP

• The charter helps a team stay focused

by setting timelines and displaying

milestones.

• The charter does not tell the team how to complete the work but tells them

what they are trying to accomplish.

A typical PIP identifies:

• What the problem is

• A PIP team that will work on it, meet, and report back to the QAPI team in the building

• Do root cause analysis to figure out what the cause of the problem actually is (five whys, fishbone diagrams, etc. )

• What measure they will use to know if they were successful

• What interventions they will do to fix the problem

Create and Name our PIP

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Define our project

Who will be our PIP team?

Analyze: why this is happening?

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1. Design and Scope



and Monitoring



Systemic Action


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Systemic Action• The facility uses a systematic approach to

determine when in-depth analysis is needed to

fully understand the problem, its causes, and implications of a change.

• The facility uses 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 or delivered.


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Systemic Action• Additionally, facilities will be expected to 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.


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Systemic ActionQAPI

The facility uses a systematic approach

to determine when in-depth analysis is

needed to fully understand the

problem, its causes, and implication of a

change.

The facility uses thorough and a highly

organized/ structured approach to

determine whether and how identified

problems may be cause or exacerbated

by the way care and services are

organized or delivered.

Systemic Actions look comprehensively

across all involved systems to prevent

future events and promote sustained

improvement.

Facilities will be expected to develop

policies and procedures and

demonstrate proficiency in the use of

Root Cause Analysis.

QIS

QIS looks at system issues, and has a

process that defines when they need in-

depth analysis.

In-depth investigation tools in QIS Stage

2 assist in the process to identify

causative factors.

Using QIS assists to monitor that

corrective actions are working on a

system level.

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Systematic Analysis and Systemic Action

• To be effective, interventions or corrective actions should target

elimination of root causes, offer long

term solutions to the problem, and be achievable, objective and

measurable.

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Root Cause Analysis

• Root cause analysis (RCA) provides a structure for evaluating events (e.g.,

adverse events, incident, near miss,

unsafe condition, or complaint) The RCA process looks at events and

incidents from a systems perspective.

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Reports help to determine if issue is systemic

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A Model for Performance

Improvement

1. What are we trying to accomplish?

2. How will we know that a change is an

improvement?

3. What change can we make that will result in an improvement?

Source: "The Foundation of Improvement,“ Langley, G.J., Nolan, K.M., and Nolan, T.W., 1994. Quality Progress, ASQC, June 1994, Milwaukee, pp. 81 – 86.

96Copyright © Providigm, LLC. 2013

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Plan-Do-Study-Act

• Try some changes and see whether they made a difference in the area

you are trying to improve


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Plan

• Plans for how the improvement will be measured

• Plans for any changes that might be implemented

• Team learns more about the problem


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Do

• Plan is carried out

• Includes measures selected


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Study

• Team summarizes what it learned


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Act

• Team and leadership determine what should be done next

• The change can be adapted (and re-studied)

• Adopted (perhaps expanded to other areas)

• Abandoned

• This decision determines next step in the cycle


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For information regarding QIS Education Contact:

Cindy Mason,

VP Provider Services, Providigm

7500 E. Arapahoe Rd, Suite 101

Centennial, CO 80112

727-403-7423

[email protected]


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For information regarding abaqis Contact:

Ellen Sandler,

VP Sales and Marketing, Providigm

7500 E. Arapahoe Rd, Suite 101

Centennial, CO 80112

720-240-9920

[email protected]


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