>>> quality assurance and performance improvement

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1 >>> quality assurance and performance improvement QAPI: Preparing for the evolution of nursing home quality Abstract...2 What is QAPI and Why is It Important?...3 Preparing for QAPI: An Interview with Dr. Nicholas Castle, PhD, MHA, AGSF...4 Five Elements of QAPI and How ehds Helps...6 But is It Really that New? The Evolution of Quality Improvement Regulations in Nursing Homes...7 Early Quality Regulations...7 OBRA Other Quality Initiatives...7 Resources to Prepare for QAPI...9 Glossary of Quality Improvement Terms...10 Works Cited... 12

2 2 Quality Assurance and Performance Improvement ABSTRACT In accordance with an Affordable Care Act mandate, the Centers for Medicare & Medicaid Services (CMS) is in the process of establishing regulations, standards, and resources for nursing facilities to improve care through quality improvement techniques. Quality Assurance and Performance Improvement (QAPI) represents the next step in the evolution of nursing home quality regulation. As outlined by CMS, the five elements of QAPI include: 1) Design and Scope 2) Governance and Leadership 3) Feedback, Data Systems and Monitoring 4) Performance Improvement Projects, and 5) Systematic Analysis and Systematic Action. 1 Facilities can begin to prepare for QAPI by learning about performance improvement and assessing current QA activities. ehealth Data Solutions provides data collection systems and analytics to help you identify and monitor quality improvement in all five areas of the QAPI process. Acknowledgment The content of this paper was developed by the ehealth Data Solutions team with primary authors Theresa Schmidt, MA, RAC-CT, and Joyce Rutherford-Donner, MBA, BSN, LNHA, RN, CCEP, CRM, RAC-CT, with thanks to Julie Standerfer for her work researching the document. ehealth Data Solutions ehealth Data Solutions is committed to providing innovative web-based tools for information and data management that improve the quality of long-term care. Our solutions CareWatch, RiskWatch, and UBWatch support evidence-based decision processes that increase productivity, reduce risk, and improve quality through cost effective, resident-centered care and services. Our solutions provide leaders with the ability to convert data into informed action, and informed action produces better results. 1 (Centers for Medicare & Medicaid Services, Five Elements of QAPI).

3 Education White Paper 3 What is QAPI and Why is It Important? The 2010 Affordable Care Act includes section Accountability Requirements for Skilled Nursing Facilities and Nursing Facilities. This section mandates that the Secretary of Health and Human Services establish and implement a quality assurance and performance improvement program for facilities, including multi unit chains of facilities and establish standards relating to quality assurance and performance improvement with respect to facilities and provide technical assistance to facilities on the development of best practices in order to meet such standards. Section 6102 of ACA further directs that the Secretary will use regulations to achieve this mandate and that facilities will be required to submit a plan to meet Quality Assurance and Performance Improvement (QAPI) standards and implement QAPI best practices within a year of the release of the new regulations. 2 This plan must reveal how the facility intends to coordinate the implementation of a QAPI plan with QAA activities conducted under existing regulations. 3 The Secretary has delegated this project to the Centers for Medicare & Medicaid Services (CMS) 4, who worked with contractors during 2011 to collect information and create prototype tools and resources to assist nursing facilities in QAPI implementation. CMS evaluated these tools through expert review 5 and is now testing the tools, resources and level of technical assistance needed to implement QAPI in a two year demonstration project that includes seventeen facilities in California, Florida, Massachusetts, and Minnesota. 6 Over the summer of 2012, CMS distributed a questionnaire to 4,200 randomly selected nursing facilities to identify challenges and barriers to effective QAPI program implementation. 7 CMS plans to use the results of the questionnaire to further assist in the direction and content of QAPI tools and resources. 8 Additionally, CMS is developing training materials and worksheets to assist surveyors as they observe for QAPI concerns in the future. The demonstration program is scheduled to continue until August However, Dr. Rosalie Kane, professor at the University of Minnesota and Director of CMS QAPI Demonstration Project states, I am confident that CMS is not, and has not, been waiting for the conclusion of this demonstration period to develop a draft rule or to release information nationally. 9 Initial CMS QAPI tools and resources are expected to be released for public use and comment in the near future. 10 A second wave of data collection is slated to occur in 2013 and This data will be used to evaluate development of QAPI systems and refine the technical assistance offered to nursing facilities in the future (H.R th Congress: Patient Protection and Affordable Care Act.) 3 (Centers for Medicare & Medicaid Services, Nursing Home Quality Assurance & Program Improvement) 4 (Centers for Medicare & Medicaid Services, Nursing Home Quality Assurance & Program Improvement) 5 (Centers for Medicaid & Medicare Services, Nursing Home Quality Assurance & Program Improvement) 6 (Upstairs Solutions 6) 7 (McKnight s Staff) 8 (Centers for Medicaid & Medicare Services, Nursing Home Quality Assurance & Program Improvement) 9 (Kane) 10 (Centers for Medicaid & Medicare Services, Nursing Home Quality Assurance & Program Improvement) 11 (Palmer)

4 4 Quality Assurance and Performance Improvement Preparing for QAPI An Interview with Dr. Nicholas Castle, PhD, MHA, AGSF To learn more about the intent and potential impact of QAPI, ehds interviewed Dr. Nicholas Castle, professor at the Department of Health Policy & Management, Graduate School of Public Health at the University of Pittsburgh and a member of the CMS Quality Assurance Performance Improvement technical expert panel. During this conversation, Dr. Castle shared his insights on QAPI, what facilities can do now to prepare for implementation, and the potential impact on survey. QAPI represents an innovative approach to improving nursing home quality. In the past, surveyors used a stick and carrot approach that was heavy on the stick; if a facility did not meet standards, citations followed. The QAPI approach still has a stick, but perhaps one wielded with a lighter touch. According to Dr. Castle, This is a brave move for CMS to make this (process) less confrontational. The QAPI approach is more collaborative and fosters the idea that quality is the prime objective. Recognizing that CMS has not yet released regulations, Dr. Castle summarized the aim of QAPI as encouraging facility and enterprise administration to incorporate quality improvement processes into organizational culture. In the move from Quality Assurance to QAPI, it is performance improvement that will be stressed. Consequently, QAPI meetings may be quite different from the quality assurance and improvement meetings held in many facilities today. To meet the desired standards, QAPI committees will include representation from a wide variety of disciplines that engage in investigation and root cause analysis. Each discipline will examine a problem from its own point of view and contribute to the development of an interdisciplinary approach to resolution. In addition, rather than delegating QAPI leadership to the DON or other staff members, the administrator of the facility will be expected to lead, attend, and actively participate in QAPI activities. Dr. Castle asserted that although bottom up initiative has traditionally been integral to total quality improvement, without top down buy-in, support, and involvement, the culture of a facility will not change. To prepare for their expanded roles leading the QAPI process, facility administrators may consider the following steps: Seek education on quality assurance and performance improvement processes and select one that works best in the facility. For example, pursue course work on a topic such as Rapid Cycle Quality Improvement. When CMS releases QAPI resources and tools, become an expert in the use of those tools in order to provide the leadership expected. However, Dr. Castle noted, I m sure there is not a mandate (that the tools) be picked from the CMS list. Critically examine the analytic tools and products already available to long term care (LTC). If the facility already uses such a tool, take full advantage of the information provided to identify quality issues and judge the effectiveness of performance improvement projects (PIP). Because CMS will probably not mandate the exact QAPI tools a facility employs, root cause analysis (RCA), statistical process control (SPC), Six Sigma or other methods of analysis may be allowed. Consider the composition of the QAPI committee and prepare staff for possible change(s) to the present system. The role of surveyors will also be affected by QAPI, and there will probably be a learning curve for surveyors, as for facilities. Although no defined survey guidelines have been released by CMS, a focus on QAPI may direct surveyors to evaluate the processes that were used to address quality issues rather than relying entirely on outcomes to determine substandard care. This approach to survey is much different than traditional methods. Dr. Castle noted,

5 Education White Paper 5 The challenge for CMS is getting away from the check-box mentality and focusing on the art of QI Is it becoming part of the culture of the nursing home? [The question] is it done? is less important than is it filtered throughout the organization? Are the committee members representative of the facility? Do all levels of staff know what PIP (performance improvement program) is being worked on? What tools and resources were used? From what I can see, surveyors will be looking at proof of process, proof of tools The tools themselves will be less important than the use of tools. For example, if a facility discovered through the use of analytics that the rate of falls among their residents was higher than national or state average, facility leadership would engage a multidisciplinary team in a thorough investigation including processes such as root cause analysis (RCA) to identify causes. With these causes identified, a performance improvement program (PIP) would be developed and implemented to correct the faulty system or process and reduce falls. Data would be gathered over time and analyzed to determine if the program was successful, and further action would be taken as needed to continue to correct the problem. In this example, surveyors might recognize that there was a problem with resident falls, but would observe that a thorough investigation and RCA were conducted and a monitored program was put in place. Because the PIP demonstrated that administration had addressed the situation, it may be that no citation would be given. QAPI is going to cause many facilities and organizations to change the way quality improvement is addressed. Many will balk at the change, insisting that it will not improve care. But we need only look back to CMS initiatives to reduce restraints and how providers fought that change to realize that sometimes we are unable to see significant opportunities for improving resident care and quality of life. Dr. Castle noted that improving care can also lead to an increase in the bottom line due to decreased staff turnover and related costs. [QAPI] could potentially result in a different relationship with CMS The potential benefits are huge if this works as well in the facilities as it does in theory. But just like restraint reduction, we may not see all the benefits in the first six months. This may take a few years to have an impact; surveyors and administrations have to get used to it. It will probably take years to see the results. For right now, the important action is to start preparing yourself and your staff to embrace this new approach.

6 6 Quality Assurance and Performance Improvement five elements of qapi and how ehds helps CMS identified five elements that are shared among many quality improvement systems and are, therefore, key to successful implementation of QAPI. 12 Data management tools, like CareWatch, RiskWatch, and UBWatch can help support each of these elements: 1. Design and Scope Definition The written QAPI plan is ongoing, comprehensive, and includes all departments. Goals are defined and measured by evidence based data. Emphasis is put on the balance between safety/high quality care and resident autonomy. The plan addresses: clinical care, quality of life, resident choice, and care transitions. 2. Governance and Leadership Using input from staff, residents, and families/representatives, nursing home leadership and governing body develops, leads, and supports the QAPI project by: establishing accountability for QAPI and policies to sustain the program setting expectations and priorities (building on the principles from Design and Scope section) providing training and resources to staff encouraging a non-punitive atmosphere for reporting quality concerns 3. Feedback, Data Systems, and Monitoring The facility implements systems that draw data from multiple sources to monitor care and services and compare performance indicators to benchmarks and targets. This also includes tracking, investigating, and monitoring Adverse Events that must be investigated every time they occur, and action plans implemented to prevent recurrences Performance Improvement Projects (PIPs) Facility conducts PIP projects systematically: gathering information to identify or clarify problems specific to the facility intervening to improve care or services 5. Systematic Analysis and Systemic Action This element includes a focus on continual learning and continuous improvement. 14 Facilities should use a systematic approach to: identify facility systems that may cause problems or make them worse develop policies and procedures demonstrate proficiency in the use of root cause analysis (RCA) review all involved facility systems and take action to prevent future events and promote sustained improvement How ehds Helps Better data support better decisions. CareWatch, RiskWatch, and UBWatch provide the data, or evidence, to help facilities define and measure goals. CareWatch uses MDS data to measure clinical care and quality of life outcomes, along with the rate of readmissions. RiskWatch incident/occurrence reporting, follow-up, and analysis help administrators identify quality and safety opportunities for improvement as well as providing statistical evidence of progress toward goals. ehds products are good examples of resources that may be provided to support QAPI. The delegation of responsibilities sometimes leads to dilution of efficacy. ehds helps address this by allowing leadership to monitor outcomes progress on an ongoing basis. Use analysis features in all products help leaders at the facility and organizational level promote accountability. ehds offers onsite and web-based training to help staff use products for quality improvement. CareWatch, RiskWatch and UBWatch are feedback systems that provide data that help facilities monitor care and services. MDS data is an important source of information for performance improvement, but loses its utility if it is not accurate. CareWatch logic flags help improve accuracy of the MDS and the quality of the data used for QAPI. CareWatch benchmarks QMs against state, national, and organizational norms. By including these norms in QM statistical process control (SPC) charts, CareWatch allows facilities to compare facility performance to these benchmarks over time. UBWatch helps facilities improve the accuracy of UB-04 claims and facilitates a triple-check process. RiskWatch facilitates reporting of adverse events and guides facilities through investigation of occurrences, including root cause analysis and recording recommendations for improved care. RiskWatch analytics assist in pinpointing specific areas, procedures, and systems in need of improvement as well as documenting progress toward goals. ehds users monitor performance over time to identify adverse trends and special cause alerts. CareWatch Quality Measure pages and clinical Watch pages help users drill down into facility data to identify specifics such as residents, units, and (by extension) caregivers that may contribute to clarifying the problem and developing solutions. Quality measure statistical process control (SPC) charts graphically demonstrate the success, or failure, of a program and allow for early adjustments to the improvement plan. RiskWatch also facilitates the collection of data to assist in root cause analysis (RCA) of situations that adversely affect residents, breaking down the data in a multitude of ways to determine such minutiae as number of falls per shift, per unit, and per caregiver. SPC charts of occurrences allow facilities to monitor trends over time and assess the effectiveness of interventions. Because CareWatch and RiskWatch can be made available to all disciplines in the facility, departments can readily identify problems that are best resolved interdepartmentally. ehds products support continuous quality improvement. RiskWatch supports and records RCA for adverse events. Through detailed analytics of facility data, RiskWatch and CareWatch help identify facility systems that may be the root cause of repeated adverse outcomes. Facility leadership can use this information to modify policy and procedure. Tables and graphical displays of data, including SPC charts, help all staff visualize both problems identified and the effects of an implemented program. Because CareWatch, RiskWatch and UBWatch can be made accessible to a variety of users within a facility, all disciplines are able to monitor departmental performance as well as the impact of each department on other departments. 12. (Palmer) 13. (Centers for Medicare & Medicaid Services, Five Elements of QAPI) 14. (Centers for Medicare & Medicaid Services, Five Elements of QAPI)

7 But is It Really that New? The Evolution of Quality Improvement Regulations in Nursing Homes Education White Paper 7 Early Quality Regulations The role of governance in quality assurance is long standing and significant. According to Castle and Ferguson, 15 a history of nursing home quality is intertwined with developments in federal and state entities. In 1961, after reports of problems by the Commission on Chronic Illness and a number of states, the Public Health Service released the Nursing Home Standards guide that recommended minimum standards for nursing home quality. 16 In 1965, Medicare and Medicaid were enacted. 17 As these programs developed, certification was dependent on surveyor inspection of quality of care and other variables, and additional standards were created saw the establishment of the Health Care Financing Administration (HCFA, which changed its name to CMS in ) to coordinate Medicare and Medicaid. Over the next ten years, HCFA continued to develop standards and established the deficiency citation process for use when nursing home standards are not met. However, these standards largely focused on the structure of nursing homes, rather than the process of providing care or quality care outcomes. 20 OBRA-87 Increasing complexity of resident care needs and widespread reports of the unacceptable practices of some providers including poor care, fraud, abuse, and neglect, led to investigation by the Institute of Medicine (IOM) and validation by the General Accounting Office (GMO). 21 In 1986, the IOM issued the report, Improving the Quality of Care in Nursing Homes, which contained many detailed recommendations that were built into Subtitle C of the Omnibus Budget Reconciliation Act of 1987 (OBRA-87). 22 OBRA-87 was a game-changing event for nursing home quality, and included a more stringent survey process, revised care standards, sanctions and remedies, training of nurse aides, and use of the Resident Assessment Instrument (of which the Minimum Data Set (MDS) is a major component). 23 The MDS has provided a wealth of resident data and has been a source for developing quality indicators and quality measures. However, serious concerns have been raised about the accuracy of this data. 24 OBRA-87 also defined and mandated quality assurance. QAA sought to provide a framework for evaluating a facility s systems in order to prevent deviation in and correct inappropriate care processes. 25 F520, in the Guidance to Surveyors for Long Term Care Facilities, requires that facilities establish a quality assessment and assurance committee that meets at least quarterly to identify issues and develop and implement corrective action plans. Revisions of F520 also defined quality assessment, quality assurance, quality deficiencies, and quality improvement. These definitions are included in the glossary of this white paper. 26 In 2007, RTI International researchers Wiener, Freiman, and Brown, evaluated the impact of OBRA 87 on the industry after twenty years in place. Although there was an initial upgrading of the quality of care as a result of OBRA 87, improvements appear to have reached a plateau. Substantial proportions of nursing homes are still cited for inadequate care. 27 This, coupled with continuing findings of poor quality and enforcement challenges, has led researchers and stakeholders to call for higher standards. 28 Other Quality Initiatives The Agency for Healthcare Research and Quality (AHRQ) was created in 1989 to support research to improve the quality, safety, efficiency, and effectiveness of healthcare for the nation. 29 In 1991, the Institute for Healthcare Improvement (IHI) was founded, created by Dr. Don Berwick to campaign for healthcare improvement around the world, and 1996 saw the establishment of the National Patient Safety Foundation. 30 To further encourage quality improvement in nursing homes, CMS began operating the Nursing Home Compare website in The intention of this site is to publicize information about nursing homes, thus providing a market incentive for improving quality. 31

8 8 Quality Assurance and Performance Improvement The website now features the fivestar quality rating system to make the process of comparing nursing homes easier. 32 Another way that governance has attempted to impact quality is through pay for performance initiatives, which have been enacted by some states to encourage improved quality by linking it to Medicaid reimbursement. Scrutiny from surveyors, media, and consumers continued, and quality initiatives have arisen from governmental and LTC industry associations. In 2006, Advancing Excellence in America s Nursing Homes began with the mission to help nursing homes achieve excellence in the quality of care and quality of life for the more than 1.5 million residents of America s nursing homes by: Establishing and supporting an infrastructure of Local Area Networks for Excellence (LANEs), Strengthening the workforce, and Improving clinical and organizational outcomes. 34 Now in Phase 2, Advancing Excellence provides resources that focus on eight goals for nursing home quality improvement. National quality initiatives such as Quality First [LeadingAge], the Nursing Home Quality Initiative [AHCA], the Culture Change movement, the Quality Improvement Organization (QIO) 9th Scope of Work complement one another. Working with one initiative will usually strengthen results and outcomes of the other. 35 What these programs share with QAPI is the desire to impact nursing facility quality. However, while many pre-existing initiatives focus on specific goals or outcomes, QAPI has made the process of performance improvement of paramount importance. The methods of QAPI can, therefore, be used to enhance other quality initiatives. For example, a facility might use the QAPI process to assist with Advancing Excellence goals. 36 Thus, QAPI represents the next step in the evolution of nursing facility quality regulation. 15. (Castle and Ferguson 427) 16. (Castle and Ferguson 427) 17. (Centers for Medicare & Medicaid Services, Key Milestones in CMS Programs 1) 18. (Castle and Ferguson 428) 19. (Castle and Ferguson 434) 20. (Wiener, Freiman and Brown 3) 21. (Castle and Ferguson 428) 22. (Wiener, Freiman and Brown 5), (Castle and Ferguson 428) 23. (Castle and Ferguson 428) 24. (Wiener, Freiman and Brown 14) 25. (Upstairs Solutions 1) 26. (Centers for Medicare & Medicaid Services, State Operations Manual Appendix PP) 27. (Wiener, Freiman and Brown 6) 28. (Wiener, Freiman and Brown 35) 29. (Department of Community and Family Medicine, Duke University Medical Center) 30. (Department of Community and Family Medicine, Duke University Medical Center) 31. (Wiener, Freiman and Brown 28) 32. (Centers for Medicare & Medicaid Services, Five-Star Quality Rating System) 33. (Castle and Ferguson 435)

9 Education White Paper 9 Resources to Prepare for QAPI In addition to the tools CMS will be releasing Medicare/Provider-Enrollment-and- Certification/SurveyCertification- GenInfo/QAPI.html, there are several resources leaders can begin to review to prepare for QAPI. American Health Care Association (AHCA) believes two types of tools will be useful for preparing for QAPI, QAPI process tools available to help NHs manage their QAPI program [such as] examples, checklists, templates, flow-sheets, [and] QAPI topic tools for processes and outcomes related to monitoring or PIPs. The organization is building an online resource library that can be found at org/advocacy/healthcarereform/ Pages/QAPI.aspx. One of these resources is the Stratis Health (QIO) Document, Tips for Preparing for QAPI, which lists six steps to preparing for QAPI: Know the facts about QAPI for nursing homes. 2. Help key stakeholders such as your board of directors, leadership team, and staff learn more about QAPI. 3. Meet with other leaders about QAPI. 4. Think about how you might (re) structure your QAPI program. 5. Consider your current culture and how it will promote performance improvement. 6. Think about a potential project that can get you an early success. LeadingAge has also published a QAPI update and linked to the Upstairs Solutions white paper, Developing an Effective Quality Assurance Program. This paper provides a description of QAPI and the quality assurance committee, and goes on to discuss discovery and waiver of privileges, root cause analysis, and the role of effective training. This paper can be downloaded at: org/learn_about_cms_new_ Quality_Assurance_Performance_ Improvement_Guidelines.aspx. The Institute of Health Improvement (IHI) website also houses an extensive library of tools and educational materials that nursing facilities and other healthcare entities can use for quality improvement projects at knowledge/pages/default.aspx. The How to Improve article, for example, teaches the fundamentals of the Model for Improvement and testing changes on a small scale using Plan-Do-Study-Act (PDSA) cycles. 39 In our 2009 white paper, Converting Data To Action, ehds suggested six steps to process improvement which follow the PDCA (PDSA) process and support continuous quality improvement: 1. Ensure data is complete and accurate 2. Identify opportunities for improvement 3. Look for root cause of the current state (and determine if the process is stable) 4. Set measurable goals 5. Develop an action plan 6. Follow up to evaluate the effectiveness of your action plan This paper can be found at biz/index.php/resources and also offers tips to integrating one possible PI tool, statistical process control, into your facility processes using CareWatch, RiskWatch, and UBWatch. 34. (NH Quality Campaign, Purpose and Description) 35. (NH Quality Campaign, Purpose and Description) 36. (Bridwell 2) 37. (O Neill) 38. (Care2Learn/Upstairs Solutions) 39. (Institute for Healthcare Improvement)

10 10 Quality Assurance and Performance Improvement Glossary of Quality Improvement Terms As nursing homes begin to explore QAPI tools and evaluate current processes, staff may encounter some common quality improvement terms. Becoming familiar with these terms will help facility leadership evaluate tools and choose which will be most useful for their teams. Quality Health Care the Institute of Medicine defines quality health care as, The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. 40 Evidence-based Medicine or Evidence-based Practice aims to apply the best available evidence gained from the scientific method to clinical decision making. 41 Using data for decisions is a critical component and also in line with the IOM definition of quality care listed previously. Quality Improvement (QI) F520 defines QI as an ongoing interdisciplinary process that is designed to improve the delivery of services and resident outcomes. 42 CQI: Continuous Quality Improvement a structured organizational process for involving personnel in planning and executing a continuous flow of improvements to provide quality health care that meets or exceeds expectations. 43 LeadingAge s Quality First website advocates using CQI methods to enhance existing programs, improve effectiveness and foster a collaborative work environment (LeadingAge). Quality Assessment an evaluation of a process and/or outcomes of a process to determine if a defined standard of quality is being achieved. 44 Quality Assurance the organizational structure, processes, and procedures designed to ensure that care practices are consistently applied and the facility meets or exceeds an expected standard of quality. Quality assurance includes the implementation of principles of continuous quality improvement. 45 Quality Deficiencies potential markers of quality that the facility considers to be in need of investigating and which, after investigation, may or may not represent a deviation from quality that results in a potential or actual undesirable outcome. The term quality deficiency in this regulation is meant to describe a deficit or an area for improvement. This term is not synonymous with a deficiency cited by surveyors. 46 Performance Improvement QAPI demonstration project director, Dr. Rosalie Kane, has noted, PI is a proactive effort to use data to understand and improve your own problems. It includes formal Performance Improvement Projects, root cause analysis and above all, systems thinking. 47 Performance Improvement Program (PIP) 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. 48

11 Education White Paper 11 Root Cause Analysis (RCA) a process that uses five steps to ask why and examine a system to uncover underlying causes of a problem. 49 A root cause is an initiating cause of a causal chain which leads to an outcome or effect of interest. Commonly, root cause is used to describe the depth in the causal chain where an intervention could reasonably be implemented to change performance and prevent an undesirable outcome (Wikipedia contributors). PDCA: Plan Do Check Act (or Plan Do Study Act) Defined by Deming as a method for continuous performance improvement. 50 Plan: Study existing processes to identify where improvement is needed. Do: Choose a goal and identify the best way to measure success. Implement interventions to achieve the goal. Check (Study): carefully measure the actual results of the process improvement and compare those to the desired results. 51 Statistical Process Control a method for quality control which uses statistical methods. 52 SPC charts represent data as a process that changes over time. 53 SPC charts display measures of performance over time and calculate averages and control limits that expose changes in process and significant events. Although the Joint Commission on Health Accreditation does not accredit many nursing homes, the JC has been using SPC charts in accreditation surveys since Six Sigma a management technique that seeks to improve the quality of process outputs by identifying and removing the causes of defects (errors) and minimizing variability processes following a series of steps and using statistical and other qualitymanagement tools. Six sigma has also professionalized quality improvement, and multiple levels of certification are available. 55 Pay for Performance a payment mechanism combining prospective payment with incentive payments that vary according to measures of the quality of the care provided. 56 Some states have already incorporated pay for performance initiatives into their Medicaid reimbursement systems. 57 Quality Improvement Organizations (QIO) Quality Improvement Organizations (QIOs) assist beneficiaries with nursing home quality. A QIO is a group of practicing doctors and other health care experts paid by the federal government to check and improve the care given to people with Medicare (Lohr 21) 41. (Wikipedia Contributors, Evidence-based medicine) 42. (Centers for Medicare & Medicaid Services, State Operations Manual Appendix PP 652) 43. (Kaluzny and McLaughlin 3) 44. (Centers for Medicare & Medicaid Services, State Operations Manual Appendix PP 651) 45. (Centers for Medicare & Medicaid Services, State Operations Manual Appendix PP 651) 46. (Centers for Medicare & Medicaid Services, State Operations Manual Appendix PP ) 47. (Upstairs Solutions 2) 48. (Centers for Medicare & Medicaid Services, Five Elements of QAPI) 49. (Upstairs Solutions 11) 50. (Wikipedia Contributors, PDCA) 51. (Schmidt, Jeffers LaRochelle and Sheridan 5) 52. (Wikipedia Contributors, Statistical Process Control) 53. (Schmidt, Jeffers LaRochelle and Sheridan 8) 54. (Carey xix) 55. (Wikipedia Contributors, Six Sigma) 56. (Wiener, Freiman and Brown 25) 57. (Wiener, Freiman and Brown 25), (Castle and Ferguson 435) 58. (Centers for Medicare & Medicaid Services, Medicare Nursing Home Compare: Note to Nursing Homes)

12 12 Quality Assurance and Performance Improvement works cited Department of Community and Family Medicine, Duke University Medical Center. Timeline August 2012 < duhs.duke.edu/module_d/timeline.html>. Bridwell, Lisa. Advancing Excellence in America s Nursing Homes and Collaborative Updates. PowerPoint Presentation Care2Learn/Upstairs Solutions. What You Need to Know About the CMS Quality Assurance Performance Improvement Guidelines. 24 June August 2012 < CMS_New_Quality_Assurance_Performance_ Improvement_Guidelines.aspx>. Carey, Raymond G. Improving Healthcare with Control Charts: Basic and Advanced SPC Methods and Case Studies. Milwaukee: American Society for Quality, Castle, Nicholas G. and Jamie C. Ferguson. What Is Nursing Home Quality and How Is It Measured? The Gerontologist (2010): Centers for Medicaid & Medicare Services. Nursing Home Quality Assurance & Performance Improvement. 23 August August 2012 < Provider-Enrollment-and-Certification/ SurveyCertificationGenInfo/QAPI.html>. Centers for Medicare & Medicaid Services. Five Elements of QAPI. 8 September CMS.gov. 31 August 2012 < gov/medicare/provider-enrollment-and- Certification/SurveyCertificationGenInfo/ Downloads/fiveelementsqapi.pdf>.. Five-Star Quality Rating System. 16 August August 2012 < cms.gov/medicare/provider-enrollment-and- Certification/CertificationandComplianc/ FSQRS.html>.. Key Milestones in CMS Programs. 22 August cms.gov. 31 August 2012 < Agency-Information/History/Downloads/ KeyMilestonesinCMSPrograms.zip>.. Medicare Nursing Home Compare: Note to Nursing Homes. 22 August August 2012 < NursingHomeCompare/Resources/Note-to- Nursing-Homes.aspx>.. Nursing Home Quality Assurance & Program Improvement. April cms.gov. 19 August 2012 < gov/medicare/provider-enrollment-and- Certification/SurveyCertificationGenInfo/ Downloads/nhqapibackground.pdf>.. State Operations Manual Appendix PP: Interpretive Guidelines for Long-Term Care Facilities. 7 January Centers for Medicare & Medicaid Services. 3 September 2012 < som107ap_pp_guidelines_ltcf.pdf>. H.R th Congress: Patient Protection and Affordable Care Act. SEC ACCOUNTABILITY REQUIREMENTS FOR SKILLED NURSING FACILITIES AND NURS- ING FACILITIES. 12 April cms.gov. 20 August 2012 < Provider-Enrollment-and-Certification/ SurveyCertificationGenInfo/Downloads/ qapisection6102ac.pdf>. Institute for Healthcare Improvement. How to Improve. 28 August September 2012 < HowtoImprove/default.aspx>. Kaluzny, Arnold D. and Curtis P. McLaughlin. Continuous Quality Improvement in Health Care. Sudbury: Jones and Bartlett, Kane, Rosalie. Personal Communication 29 August Lohr, Katherine N, ED. Medicare: a strategy for quality assurance. Washington: National Academy Press, McKnight s Staff. CMS to survey nursing homes about quality assurance best practices. 28 June August 2012 < mcknights.com/cms-to-survey-nursing-homesabout-quality-assurance-best-practices/ article/247740/>. NH Quality Campaign. Advancing Excellence in America s Nursing Homes. 31 August 2012 < Purpose and Description. 31 August 2012 < index.aspx?controls=mission>. O Neill, Kelly. Tips for Preparing for Quality Assurance Performance Improvement (QAPI): Suggestions for Senior Leaders. 17 October ahcancal.org. 3 September 2012 < survey_certification/documents/tips%20 for%20preparing%20for%20qapi.pdf>. Palmer, Laura. Nursing Home Providers Given Opportunity to Participate in CMS Landmark Quality Improvement Initiative. 7 June amda.com. 26 August 2012 < amda.com/advocacy/cmsqapi.pdf>. Schmidt, Theresa, Candace Jeffers LaRochelle and John Sheridan. Converting Data to Action with CareWatch, RiskWatch, and UBWatch. White Paper. Cleveland, OH: ehealth Data Solutions, Upstairs Solutions. Developing an Effective Quality Assurance Program: Turning minimum requirements into a comprehensive strategy. February UpstairsSolutions.com. 20 August Wiener, Joshua M., Marc P. Freiman and David Brown. Nursing Home Care Quality: Twenty Years After the Omnibus Budget Reconciliation Act of Menlo Park, CA: The Henry J. Kaiser Family Foundation, Wikipedia Contributors. Evidence-based medicine. 3 September September 2012 < PDCA. 12 August August 2012 < Root cause. 28 July November 2009 < php?title=root_cause&oldid= >.. Six Sigma. 2 September September 2012 < Six_Sigma>.. Statistical Process Control. 30 August August 2012 < org/wiki/statistical_process_control>.. W. Edwards Deming. 18 November December 2009 < en.wikipedia.org/w/index.php?title=w._ Edwards_Deming&oldid= > fax info@ehds.biz