The QAPI CoP Series. Session 2 Program Data and Performance Measures

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Gerard Cannon
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1 The QAPI CoP Series Session 2 Program Data and Performance Measures Includes: Seminar slides Common Hospice Measures Performance Measures Data Types QAPI Snapshot Set of Measure Examples For the exclusive use of HEN subscribers

The QAPI CoP: Program Data and Performance Measures 1 The QAPI CoP Series 1. Introduction to QAPI 2. Program Data and Performance Measures 3. Program Activities 4. Performance Improvement 5.

2 The QAPI CoP: Program Data and Performance Measures 1 The QAPI CoP Series 1. Introduction to QAPI 2. Program Data and Performance Measures 3. Program Activities 4. Performance Improvement 5. Patient-level and hospice-level QAPI measures 6. The QAPI Opportunity 2 Download the handouts Makes sure you download a copy of the workshop handouts Click on the links button on the lower left corner of the screen Click on handouts; a pdf file will open Save it and/or print it 3 1

Program Data Part 1 The program must utilize quality indicator data, including patient care, and other relevant data, in the design of its program.

3 Program Data Part 1 The program must utilize quality indicator data, including patient care, and other relevant data, in the design of its program. 4 Program Data - Part 1 What We Need To Know The hospice s QAPI program must be data-driven. Quality indicator data and other data must be included in the QAPI program. Data specifically related to patient care is most essential to the QAPI program. 5 Program Data - Part 1 What We Need To Do Determine what data is relevant and needed Design a QAPI program that includes data collection 6 2

QA DATA QAPI Guy Program Data Part 2 The hospice must use the data collected to: Monitor the effectiveness and safety of services and quality of care; and Identify opportunities for improvement.

The data must be used for surveillance purposes and to drive decisions related to performance improvement opportunities. The governing body must evidence involvement in the QAPI program.

4 QA DATA QAPI Guy Program Data Part 2 The hospice must use the data collected to: Monitor the effectiveness and safety of services and quality of care; and Identify opportunities for improvement. The frequency and detail of the data collection must be specified by the hospice's governing body. 7 Program Data - Part 2 What We Need To Know A hospice will be expected to USE the data it collects. The data must be used for surveillance purposes and to drive decisions related to performance improvement opportunities. The governing body must evidence involvement in the QAPI program. 8 Program Data - Part 2 What We Need To Do Set up systems and processes for regular monitoring and actionable reporting and making performance improvement decisions. Use the data to make decisions. Ensure that governing body minutes indicate their involvement in data collection decisions. 9 3

Learning how to: Objectives Identify useful data elements Learn how to turn data elements into quality indicators Determine what quality information is most valuable for your organization 10 Themes

5 Learning how to: Objectives Identify useful data elements Learn how to turn data elements into quality indicators Determine what quality information is most valuable for your organization 10 Themes Patient Care CoPs QAPI, Comprehensive Assessment and IDT care planning Using DATA to guide decisions and actions and to Assessment must capture data elements for outcome measures Care plans must record expected and actual outcomes Combined data for all patients drive performance improvement Capturing DATA ELEMENTS Documented in a systematic and retrievable way Used for individual patients and in the aggregate 11 What s it all about? Collecting data elements, monitoring indicators of quality and using this information to assess and improve performance, quality and outcomes 12 4

6 Not just Hospice by the numbers Quality assessment (QA) requires quantitative information Numbers OR Uniform variables (e.g. Yes/No; increased/decreased) that you can count Good patient care and PI require qualitative information Narrative data usually non-uniform Provides detail behind quantitative information Some qualitative data can be captured quantitatively 13 Equally Important Work Together Quantitative Data Qualitative Data 14 QAPI vs. Current Quality Program NOT necessarily more data collection More UNIFORM and RETREIVABLE data More USING data: care planning, quality assessment performance improvement 15 5

Data versus Quality Measures You have the data elements in all these places (and more) Patient charts Incident reports Infection reports After hours call logs Satisfaction surveys Complaint logs

The basic unit of identifiable and definable information it occupies the space provided by fields in a record or blocks on a form and has a name and clear values to express a fact.

7 Data versus Quality Measures You have the data elements in all these places (and more) Patient charts Incident reports Infection reports After hours call logs Satisfaction surveys Complaint logs Billing Records HR files Financial Reports Volunteer Records How do you use them to comprise specific quality indicators to be tracked over time? 16 What is a Data Element? The basic unit of identifiable and definable information it occupies the space provided by fields in a record or blocks on a form and has a name and clear values to express a fact. 17 Common Hospice Data Elements Admit date, discharge date Demographic variables Diagnosis code Symptom severity scores Medication name, dose, timing Incident/occurrence type Infection start date/resolution date Patient or family rating/response to a question about care and services Referral source Visit date, time, discipline Billing or other income Cost of medications Names of attendees at a training session 18 6

What is an indicator? A measured value used to monitor the operation or condition of a physical system (including a person) or an organizational system; a gauge of performance or outcome.

Indicator of symptom management performance: Percentage of patients who are uncomfortable on admission because of pain who report being more comfortable after 48 hr Indicator of family

date for each # patients admitted Patient reported comfort on admission and 48 hr later # families answering item of survey # families willing to recommend Employment start and end dates

8 What is an indicator? A measured value used to monitor the operation or condition of a physical system (including a person) or an organizational system; a gauge of performance or outcome. 19 Quality Indicators An indicator that helps to monitor results within a domain of quality; a gauge of performance or outcome in a quality domain. Indicator of symptom management performance: Percentage of patients who are uncomfortable on admission because of pain who report being more comfortable after 48 hr Indicator of family satisfaction: Percentage of families completing survey who are willing to recommend hospice care 20 Data elements Indicators Data Elements # of discharged patients Admit and discharge date for each # patients admitted Patient reported comfort on admission and 48 hr later # families answering item of survey # families willing to recommend Employment start and end dates # of funded/active staff positions Measures/Indicators % patients with short LOS % patients uncomfortable on admission who are comfortable within 48 hr % families who would recommend hospice Turnover and/or vacancy rates 21 7

Information systems reporting functions Tracking processes Chart audits Revise assessment and/or care planning documents

9 Data Types and Sources Handout: Performance Measurement Data Types and Sources 22 Getting to your data elements Are they easily retrievable? Information systems reporting functions Tracking processes Chart audits Revise assessment and/or care planning documents Gather data elements during team meeting Example: NHPCO Core Patient Data Sheet for End-Result Outcome Measures 23 Calculating Indicator Values Information system Excel or another spreadsheet program Written protocol/ formula 24 8

10 A good indicator is. Meaningful address quality in areas that matter to patient, families, staff, or other stakeholders Measurable the data can be easily and accurately collected Manageable the hospice has some control over the factors affecting the indicator 25 Handout: Common indicators/measures ADC; ADC per FTE ALOS, MLOS by diagnosis Referral to admission % conversion % referral sources who get just the right amount of communication % patients with LOS < 7 days Number (%) live discharges due to dissatisfaction Incidence of medical errors and/or falls % patients admitted with severe pain % with pain made comfortable within 48 hr % of charts documenting family education % patients for whom interventions on the plan of care occurred Outcomes of interventions for individual patients Most successful intervention(s) for dyspnea Family ratings of evening/weekend care Costs per patient day by category Employee turnover/ vacancies by discipline 26 Identifying & Selecting Measures Four guiding principles Cover multiple domains or areas of focus Address both patient-level and hospice-level quality Meaningful, quality-based measures Nationally accepted, tested measures 27 9

11 Multiple Areas of Focus NHPCO s 10 Components of Quality Patient and Family Centered Care Ethical Behavior and Consumer Rights Clinical Excellence and Safety Inclusion and Access Organizational Excellence and Accountability Workforce Excellence Standards Compliance with Laws and Regulations Stewardship and Accountability Performance Measurement 28 Selecting measures: Address Patient-level and Hospice-level Patient-level Collect data on individual patients Use data to improve individual care and outcomes Hospice-level Clinical operations Non-clinical operations 29 Selecting measures: Choose meaningful, quality-based measures High risk, high volume, problem-prone Safety Survey deficiencies and/or ADRs Areas of concern (What keeps managers up at night?) Staff suggestions/frustrations Reflect quality of care and/or drive quality outcomes Evidence-based (your evidence or published literature) Example conducting symptom assessment 30 10

12 Selecting Measures: Nationally accepted, tested measures NHPCO National Data Set Family Evaluation of Hospice Care (FEHC) End-result outcome measures (EROM) OASIS selected items Measures utilized by individual hospices and/or vendors (OCS, Deyta, Multiview) NQF endorsed measures for other settings of care CMS/QIO s watch for new measure options 31 Patient and Family-centered Care How often did the hospice team keep you or other family members informed about the patient s condition? % Always (FEHC) How confident were you that you knew what to expect while the patient was dying? % Very confident (FEHC) % of discharged patients who had a stated preference to avoid hospitalization, for whom no hospital admission occurred (EROM) 32 Clinical Excellence and Safety % of patients with pain levels verbalized as uncomfortable on admission, who report a comfortable level was reached within 48 hours (2 days) following admission (EROM) How much help in dealing with his/her breathing did the patient receive while under the care of hospice? % Right amount (FEHC) Incidence (# per 100 patient days) of unscheduled (on-call) visits for symptom management 33 11

Inclusion and Access Percentage of referrals that result in admission (NDS) Average length of stay for patients grouped by diagnosis (NDS) Racial mix of admissions as compared to mix in the community

13 Inclusion and Access Percentage of referrals that result in admission (NDS) Average length of stay for patients grouped by diagnosis (NDS) Racial mix of admissions as compared to mix in the community served (% admits by race) Percentage of admissions by referral sources, including: Community physicians Hospital discharge planners Nursing home physician or DON Other relevant sources for your community 34 Sample set of indicators for today and tomorrow Review Handout This is just one possible set of measures Developed for this workshop Other measures you are using? 35 Thank you

14 Common Hospice Performance Measures Quality Indicator Know it Today Have the data Last quarter Target ADC ADC per FTE ALOS or MLOS by diagnosis % conversion - referral to admission % referral sources who get just the right amount of communication % patients with LOS < 7 days Number (%) live discharges and percent due to dissatisfaction Incidence of medical errors and/or falls % patients admitted with severe pain % patients admitted with pain who are comfortable within 48 hr % charts documenting family education % patients for whom interventions on the care plan occurred Specific outcomes of specific interventions for individual patients Most successful intervention(s) for dyspnea (or another symptom) Family ratings of evening/weekend care Costs per patient day by category Employee turnover and/or vacancies by discipline 2006 Touchstone Consulting. All rights reserved.

15 Performance Measurement Data Types and Sources NHPCO Quality Partners defines ten components of quality, which together encompass the facets of performance that organizations must measure and manage. Defined measures are required for performance assessment, and the first step to defining measures is identifying the data elements from which measures can be created. For each component of quality, the following list identifies valuable types of data and where they can be accessed within hospices. This list includes sources of data for completing the NHPCO National Data Set and other common measures, as well as for tracking success of individual performance improvement projects and unique organizational goals. It is not exhaustive! There is even more available to you. Patient and Family Centered Care (PFC) Documented, quantifiable patient and family goals and preferences in comprehensive assessments and patient chart from clinical systems or patient chart reviews Quantitative evidence for meeting patient goals and preferences from clinical systems, patient chart reviews, records of staff visit timeliness, pharmacy responsiveness, etc. Family satisfaction surveys on patient/family communication, education, and shared decision making Patient satisfaction surveys Data on patient/family complaints Ethical Behavior and Consumer Rights (EBC) Family satisfaction data on respect for patient and patient s rights Patient satisfaction data Complaint and complaint resolution records Administrative records on use of ethics committees Clinical Excellence and Safety (CES) Comfort/ Pain and symptom management Patient reported data on outcomes of pain and/or symptom management from clinical IT systems or patient chart reviews Clinical process data on use of best practices for pain and/or symptom management from clinical systems, patient charts and/or pharmacy records Family satisfaction data about treatment for pain and/or non-pain symptoms Patient satisfaction data about treatment of pain and/or non-pain symptoms Utilization, visit and/or transfer data about hospitalizations or unplanned ER visits for pain and/or non-pain symptom management Safety (Including safe dying and caregiver confidence) Chart audit or clinical systems data on completion of fall risk assessments Family satisfaction survey data about confidence to provide safe care in the home Quantitative data on incidence and prevalence of occurrences (such as falls, infections or medication errors) or adverse events (as defined by the hospice), from information system and/or manual logs Staff responsiveness Family satisfaction data about responsiveness to requests for care Patient satisfaction data Visit data on attendance at death when requested Patient/ family education Family satisfaction data about feeling well-informed about the patient s condition and confident in role as caregiver Patient satisfaction data about understanding the care plan and meeting self-care needs Patient and family assessment data about education needs Copied from the National Hospice and Palliative Care Organization website Do not distribute without attribution.

16 Inclusion and Access (IA) Intake and admission data on source of referrals, conversion rates (referrals that are admitted), and time from referral to admission Data on referral source knowledge and attitudes Data on demographic, diagnosis, and location mix of patients, drawn from comprehensive assessment or intake data Demographic data on community, from state or local government HR records indicating programs offered and individuals receiving staff diversity training Family satisfaction data (usually an after-death questionnaire) about appropriateness of time of referral Length of stay data from information system or patient charts Organizational Excellence and Accountability (OEA) Quantitative evidence of measurable improvement in quality and operating effectiveness from dashboards, external benchmarking, departmental action plans, or internal trends Quantitative evidence of successful performance improvement projects (PIP) from summarized PIP results Records of employee participation in PIPs Data on patient/family complaints and resolution Family satisfaction data about ratings of care and services and willingness to recommend Referral source satisfaction data Ethics committee records showing involvement in executive decision-making Workforce Excellence (WE) Detailed data on training and professional development (including national/state certification), from HR systems, personnel records Staffing mix and utilization data showing adherence to care model Evidence of improved employee performance from HR systems, performance reviews Human resources data on employee turnover and vacancies Employee satisfaction data Family satisfaction data about rating of hospice team members Standards Self-assessment data on compliance with NHPCO standards Accreditation self-assessments and survey results Compliance with Laws and Regulations (CLR) State survey data HR Records showing employee training in laws and regulations Stewardship and Accountability (SA) Profitability data (with and without fundraising), by program, site, etc. Cost management and other resource utilization data, through budget tracking and benchmark analysis Records of family/caregiver demographics and contact information Indicators of effective financial management through direct analysis and ratios from balance sheet, income statement, and statement of cash flows Revenue and cost data on patient mix by diagnosis, location, level of care, and payor Accounts payable and receivable data on timeliness of payments and collections Labor productivity data showing time worked and paid and work (typically visits) accomplished from HR systems, personnel records, clinical and/or financial systems Human Resources data showing employee background checks Community resource utilization data (fundraising and volunteers) Performance Measurement (PM) Results of quality measures for all areas of operation (360 o view) Data on the number of quality assessment measures used quarterly, and new measures added each year Copied from the National Hospice and Palliative Care Organization website Do not distribute without attribution.

18 SAMPLE LIST OF QUALITY MEASURES/INDICATORS NHPCO Component of Quality Patient and Family Centered Care (PFC) Ethical Behavior and Consumer Rights (EBC) Clinical Excellence and Safety (CES) Comfort/ Pain and symptom management Safety (Including safe dying and caregiver confidence) Staff responsiveness Patient/ family education Inclusion and Access (IA) Organizational Excellence and Accountability (OEA) Workforce Excellence (WE) Standards Compliance with Laws and Regulations (CLR) Stewardship and Accountability (SA) Performance Measurement (PM) Examples of Quality Indicators/Measures Percentage of patients discharged for whom documented preferences were met Percentage of families reporting that the hospice team explained the plan of care in a way that they could understand? (FEHC) Incidence of complaints by topic Percentage of families who report that the hospice team ALWAYS treated the patient with respect. (FEHC) Percentage of patients who have weekly symptom screening Percentage of patients who report pain on admission and then report being more comfortable 48 hours later Incidence of occurrences (falls, infections, medication errors) Percentage of patients for whom the comprehensive assessment is completed within 4 days Percentage of families who rate the way the hospice team responded to their needs in the evenings and weekends as EXCELLENT Percentage of families who report they were VERY CONFIDENT that they knew as much as they needed to about the medicines being used to manage the patient s pain, shortness of breath, or other symptoms (FEHC) Conversion rate percentage of referrals admitted within 2 days (48 hr) of referral Use of dashboard or other quality indicator tracking process Documentation of performance improvement as shown in PIP records Percentage of staff demonstrating competence via testing (and/or percentage certified in palliative care) Turnover and/or vacancy rates Results of accreditation, survey or self-assessments Tracking of ADRs by reason Percentage of physician orders lacking signature within the required time period Cost per patient day by diagnosis, level of care, and payor Average days outstanding for receivables Participation in systematic (national) approach to quality assessment and monitoring 2007 Touchstone Consulting and Weatherbee Resources, Inc. All Rights Reserved.

QAPI - What Is It All About? Rebecca McMinn, RN, BSN, MBA New Century Hospice

QAPI - What Is It All About? Rebecca McMinn, RN, BSN, MBA New Century Hospice CMS Quality Initiatives CMS has encouraged Healthcare to monitor itself and gather data Standard measures of quality care are