The Role of the Medical Director in Quality Assurance Performance Improvement

Transcription

1 The Role of the Medical Director in Quality Assurance Performance Improvement Verna Sellers, MD, MPH, CMD, AGSF Medical Director Centra PACE Lynchburg, Virginia 1

2 Speaker Disclosures: Dr. Sellers has disclosed that she has no relevant financial relationship(s).

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4 Role Definition: The set of behaviors an organizational member is expected to perform and that he/she feels obligated to perform. 4

5 Objectives 1.Know the PACE regulations related to Quality Assurance Performance Improvement (QAPI) 2.Describe the role of the medical director in the design, implementation and the monitoring of QAPI. 3.Discuss the Basic Principles of Quality 5

6 PACE Medical Director 42 CFR Part 460 states: The Organization must employ or contract with in accordance with a medical director who is responsible for the delivery of participant care, clinical outcomes and the implementation as well as oversight of the quality assurance and performance improvement program. 6

7 PACE QAPI Coordinator The QAPI coordinator would be responsible for day-to-day quality issues, collecting data, analyzing data, detecting trends, coordinating IDT members, PACE staff, and contract providers in planning QAPI activities, disseminating reports on activities to them, and compiling comments related to participant/caregiver satisfaction and concerns. 7

8 Programs of All-Inclusive Care for the Elderly (PACE) Chapter 10 Quality Assessment and Performance Improvement (Rev. 2, Issued: ) 20 - QAPI Program (Rev. 2, Issued: ; Effective: ; Implementation: ) The PACE organization must develop, implement, maintain, and evaluate an effective data-driven QAPI program. 8

9 Definitions Quality Assurance addresses primarily negative outcomes Performance Improvement seek opportunities to improve care by improving upon satisfactory outcomes Continuous Quality Improvement builds on previous improvements and uses a systematic process including data analysis to enhance performance American Board of Quality Assurance and Utilization Review Physicians, Inc. 9

10 Quality Management: Definition Organizational activities designed to: Continually improve performance and productivity levels. Improve the efficiency and predictability of the care process. Reduce unnecessary care and waste. Contain costs. Improve patient outcomes and quality of life. --Dimant 10

11 The Big Picture Group of related interdependent processes working together to achieve a common goal System Made up of a culture, structure and boundary Process Sequence of tasks aimed at accomplishing a goal Produce data which can be analyzed People Have beliefs, values, interests, needs Have roles which are made up of functions and tasks 11

12 Internal QAPI Activities PACE organizations must use a set of outcome measures to identify areas of good or problematic performance and take actions targeted at maintaining or improving care based on these outcome measures. CMS expects PACE organizations to use the most current clinical practice guidelines and professional standards in the development of outcome measures applicable to the care of PACE participants. (Rev. 2, Issued: ; Effective: ; Implementation: ) 12

13 First Step: Select performance goals Census Growth End of life care Grievances Appeals Participant satisfaction Effectiveness of contract services Promptness of service delivery 13

14 Second Step: define success Routine Immunizations Grievances and Appeals; Enrollments; Dis-enrollments; Prospective Enrollees; Readmissions; Emergency (Unscheduled) Care; Unusual Incidents; and, Deaths. 14

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16 Spark Lines Infection Control Target Dec'14 YTD Infection Rate Jan'12 to Dec'14 UTI Infections per 1000 participant days

17 Seven Basis Principles of Quality Focus on Mission Continuous Improvement Focus on Processes & Systems Empower Front-Line Maintain Strong Partnerships Leadership Commitment Focus on Data Schamp, R: NPA Medical Director s Handbook 17

18 Continuous Improvement Step 1 Understand the Process Step 2 Identify the Problem Step 3 Attend to the Problem Step 4 Course of Action Step 5 Monitoring & Feedback 18

19 The Model for Continuous Improvement - PDCA Plan START Act Do Check 19

20 Quality Improvement Beyond projects to an integrated strategy. Quality and continual improvement need to be a formal part of every PACE organization Executive commitment to quality. Can not overlook the cultural/psychological issues of quality improvement. Medical Director can not do this alone. 20

21 Empowering Front Line Staff

22 Participant Assessments Physiological and clinical well-being Functional status Cognitive functioning Emotional/mental health status Effectiveness and safety of staff-provided and contractprovided services Centra PACE QAPI Plan

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25 Root Cause Analysis Fishbone Diagrams Show the causes of a certain event. A Fishbone or Ishikawa diagram can be useful to break down (in successive layers of detail) root causes that potentially contribute to a particular effect

26 Plan Mission Statement: Reduce the percertange of participants, who acquire any pressure ulcer after enrollment into the PACE program or a pressure ulcer that is present upon enrollment worsens. This rate includes all pressure ulcers regardless of the location or stage when it is initially identified. Goals: 2015 Goal is to reduce the Centra rate to 1.5% of PACE participants will acquire a pressure ulcer in any given month or have a pressure ulcer present on admission worsen. This is a stretch goal FMV Rate: 2.6% per month 2014 LYN Rate: 2.1% per month Team Members Dawn Stanley, FMV Int Ctr Mgr Kendra Kerr, Int LYN Ctr Mgr Renee Gilliam, FMV Clinic Coord Jenny Link, LYN Clinic Coord, Cassandra Hurt, FMV HCC Carol Arthur,LYN HCC Meagan Waller, FMV Dietician Brenda Meredith, LYN Dietician Verna Sellers, MD Kimberly Woodley, Facilitator Chrissette Brooks, Outcomes Specialist Do Revise nutrition criteria for Risk Assessment Tool: Brenda/Meagan Update Risk Assessment Tool and distribute: Kimbelry Trial Tool in January for all semi-annual & annual assessmetns at both sites: Renee & Jenny Analyze results: Kimberly Pressure Ulcer Reduction Check Current Metrics December, 2014 Site SENSORY PERCEPTION ability to respond meaningfully to pressure- related discomfort COGNITIVE IMPAIRMENT MOISTURE degree to which skin is exposed to moisture (include feet) ACTIVITY degree of physical activity MOBILITY ability to change and control body position Percentage of Participants w/ Acquired Pressure Ulcers during month. 1.Completely Limited Unresponsive (does not moan flinch or grasp to painful stimuli due to diminished level of consciousness or sedation OR Limited ability to feel pain over most of body 1.La te, S e ve re Impa irme nt Nearly unintelligible verbal output Remote memory gone Unable to copy or write No longer grooming or dressing Motor or verbal agitation MMSE 0 to Inc ontine nt of Bla dde r a nd/or Bowe l R equires changing every two hours. 1. Be dfa st Confined to bed. 1. Immobile Does not make purposeful movement OR Inability to change position without assistance. Centra PACE Pressure Ulcer Risk Assessment 2. Very Limited Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR Has a sensory impairment which limits the ability to feel pain or discomfort. 2. Middle, Mode ra te Cognitive Impa irme nt Disoriented to date, place Comprehension difficulties (aphasia) Impaired new learning Getting lost in familiar places Delusions, agitation, aggression MMSE 11 to Very Moist Skin is often moist. Incontinent at times Requires assistance changing BMI 40 w/ multiple skin folds 2. Cha irfa st Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair. 2. Very Limited Makes occasional changes in body or extremity position but unable to make consistent or frequent or significant changes independently. Prevelence of Participants w/ Acquired Pressure Ulcers. FMV 0.0% 0.0% LYN 2.0% 6.0% Centra PACE 1.9% 3.9% 3. Slightly Limited Responds to verbal commands but cannot always communicate discomfort or the need to be turned. OR Has some sensory impairment which limits the ability to feel pain or discomfort in 1 or 2 extremities. 3. Early, Mild Cognitive Impairment Disoriented to date Naming difficulties (anomia) Recent recall problems Mild difficulty copying figures Decreased insight Problems managing finances MMSE 21 to Oc c a siona lly moist. Skin is occasionally moist. Some skin folds Moisture between toes 3. Walks Occasionally Walks occasionally during day but for very short distances with or without assistance. Spends majority of time in bed or in chair. 3. Slightly Limited Makes frequent though slight changes in body or extremity position indecently. 4. No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. 4. Mild Cognitive Impairment Report by patient or caregiver of memory loss Objective signs of memory impairment. Mild construction, language, or executive dysfunction. MMSE 26 to Continent of bladder and bowel Toilet self OR Able to change self w/o assistance 4. Walks Frequently Walks at least once every two hours during waking hours. 4. No Limitation Makes major and frequent changes in position without assistance. NUTRITION 1. Ne e ds proba bly not be ing me t (two or more of the following Nutrition risk assessment w ill be fa c tors) assessed by RD in semiannual/ annual Weight loss or BMI 23 assessment. Rated on a scale of 1-4 Poor/ fair intake in Center as a skin core under "other" in skin No appetite; poor intake part of nutritional assessment. Interventions in place to meet nutritional needs, but status remains compromised Totally dependent for feeding /hydrating FRICTION & SHEER 1. Maximum Assistance Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed requiring frequent repositioning with maximum assistance. Scoring: TBD 2. High Risk (two or more of the following factors) Weight loss due to insufficient calories Dependent and/or refuses supplements/food Intake is primarily "empty calorie food" BMI 23 Takes > 40 minutes to eat Upper GI or mouth issue effecting PO 2. Needs Assistance Maintains relatively good position in chair or bed most of the time but occasionally slides down, and needs some assistance for repositioning. ACT: Determine if Risk Assessment tool is Adequate. Needs revision? Second trial to confirm usefulness? Determine scoring Deveiop interventions for each risk level 3. Mode ra te Risk (one or more of the following factors) Weight stable but questionable protein intake. Dependent on supplements Intake is primarily "empty calorie food" BMI 23 Upper GI or mouth issue effecting PO Weight Loss Pattern 3. Some Assistance Maintains relatively good position in chair or bed most of the time seldom slides down, and needs little assistance for repositioning. 4.Low Risk Weight stable indicative of calories to spare protein. Intake is primarily balanced diet from "My Plate" Adequate food resources Able to feed self without problems 4. No Assistance Maintains relatively good position in chair or bed most of the time. Needs no assistance in repositioning. 26

27 Effective QAPI Programs Assess current performance. Ensure that improvement gains are held. Focus on Process Establish a baseline for improvement efforts. Predict future performance. Assess improvement efforts

28 PACE Audit Agenda Administrative Clinical Chart Review Home visit Bus Rides Interviews DMAS and CMS representatives 28

29 Quality Management vs Risk Management An essential component of an effective quality improvement program is risk assessment and management Ideally-proactive Reality-reactive 29

30 Overview Risk Management Define Analyze Reduce Risk 30

31 Risk Management Includes An integrated process of defining and monitoring specific areas of risk and Developing and implementing a comprehensive plan to PREVENT, MITIGATE and/or RESPOND TO RISK 31

32 Centra PACE Quality Program Compliance Committee (Includes Director of Corporate Compliance) Centra Board of Directors Pace Reports Quarterly Bioethics Committee (Includes Medical Director MD) Southside Community Board of Directors (A Division of Centra Board) Pace Reports Quarterly Centra Council (A Division of Centra Board) Pace Reports Quarterly Southside Professional & Patient Care Committee (A Division of Centra Board) Pace Reports Quarterly Centra PACE Quality Team (Medical Director( Program Director, Site Managers, Finance Manager & Quality Coordinator) Rehabilitation and Geriatric Specialists Committee (Verna Sellers, MD) Site Specific Participant Advisory Committee (Staff, Participants, Family Members, Community Leaders) Site Sepecific Quality Team (Medical Director, Specific Site Manager, Transportation, SW, Activities, HCC, & Quality Coordinator) Site Specific Performance Improvement Teams (Falls Team, Hospitalization Team) Site Specific Participant Council (Participants, Activities, Quality Coordinator) Individual PACE Employees Waste, Fraud, and Abuse and Pharmacy Review Committee (Corporate Compliane, Medical Director, Program Director, Site Directors,Finance Manager, Transportation Coordinator, Pharmacy Reprentatives, PACE Pharmacy, HCC, Quality Coordinator) 32

33 References o Plans/pace/downloads/finalreg.pdf o 33

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35 Thank you 35

36 The Right Tool for the Right Job! 36

37 Flowcharting To allow a team to identify the flow or sequence of events in a process; helps picture the process. Shows where simplification / standardization possible. Compares / contrasts actual vs. ideal flow, thus identifying improvement opportunities. Facilitates agreement on the steps of a process & examines impact of activities of process performance. Identifies areas for data collection and analysis. 37

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39 Facility Stay Flow Chart Participant Sick Can't go home Prt./Family Agrees to go to a Facility MD/RN talk with Prt/Family Prt in Hospital HCC/Navigator Talk w/prt Family Prt in ED Available RN Coordinate DR. SELLERS NEED TO EDUCATE Prt in PACE Clinic Hospital Case Management and PACE SW Coordinate Going to Facility RN/MD contacts SW to Coordinate MD Determine Level of Care based on input from Therapy, RN, Hospital Notes, etc. SW Coordinates with Clinic, Therapy, & Transport MD determines level of care with input from SW/Therapy/RN Woodlands SW in conjunction w/ Dept. Asst. create authorization form and obtain sign. GG or MB MD determines number of days (Woodland 7 days) SW/Therapy/RN Other Facilities Fax basic info to other facilities Dawn/SW/HHC Dawn/HHC/SW FAX infor to Woodland to determine bed availability Send Authorization Number Bed is Obtained 39 39

40 Describing the Process Include all members of the team They can tell you what is stopping them from doing their job. Also gives you an opportunity to see if they: Know what should be done. Know how to do it. Understand why it is important. Think their way is better than the required way

41 SIPOC Diagram The SIPOC tool is particularly useful when it is not clear: Who supplies inputs to the process? What specifications are placed on the inputs? Who are the true customers of the process? What are the requirements of the customers? 41

42 SIPOC Diagram identify all relevant elements of a process improvement project before work begins defines a complex project that may not be well scoped similar and related to process mapping or flowcharting but provides additional detail. 42

43 SIPOC Diagram Suppliers Input Process Outcome Customer 43

44 SIPOC Participant Attending Center on an Unscheduled Day S Suppliers I Inputs P Process O Output C Customer Participant Needs to Attend Day Center on Unscheduled day due to Clinic Appointment, DME Need, or Transport to Outside Provider Clinic (On Call Nurse) Therapy Transportation Clinic Nurse/Tech (or On Call Nurse) OR Therapist (LPTA or CODA) Initates Telephone List Clinic Schedule Adjusted (if Initiated) DME Coordination (if Initiated) Assign Pick Up/Drop Off Times Satisfied Participant with Immediate Future Needs being Met. Home Care Coordinator Adjust PCA hours with Agency Meals Establish Pick Up/ Take Home Times with Transport Coordinator Meal: Current Diet/ Take Home/ "box lunch" Staffing Maintain 6:1 Ratio Participant Notification Participant Notified of Plan Family Notification (if applicable) Complete Remainder of Notifications Family Notified of Plan Social Work If Clinic initated: respite maybe required. Pharmacy Medication Delivery Coordination Hospital Resources Send out Follow Up when Complete Schedule Resource & Transport to CSCH Outside Providers Outside Providers Appointment 44

45 Pareto Chart How do I do it? Decide on problem to be analyzed. Brainstorm or collect data to select problems or causes to be analyzed. Choose unit of measurement and timeframe for the study. Collect data (real time or historical). Compare relative frequency of each problem or cause. Graph the frequencies with a cumulative % line to interpret the results. 45

46 Number of Falls Cumulative Percentage of Falls Participant Falls at Lynchburg Site January 1, 2014 to December 31,2014 n= % % % % 60% 50% 40% 30% 40 20% 20 10% 0 Home Nursing Facility Assisted Living Community PACE Center PACE Bus Dialysis Hospital 0% Location Number of Falls Percentage 46

47 Data Analysis - Control Charts Graphical representation of data over time. Time ordered plot of a set of data in it s naturally occurring order with the median of the data drawn in as a reference line. Ignoring the time element implicit in every data set can lead to incorrect statistical conclusions. 47

48 Quality Improvement: Control Chart Falls with Average and Control Limits Falls Average Upper Control Limit Lower Control Limit Jan-00 Mar-00 May-00 Jul-00 Sep-00 Nov-00 Jan-01 Mar-01 May-01 Jul-01 Sep-01 Nov-01 48

49 Root Cause Analysis Fishbone Diagrams Show the causes of a certain event. A Fishbone or Ishikawa diagram can be useful to break down (in successive layers of detail) root causes that potentially contribute to a particular effect

50 Fishbone Diagram Weight Loss 50 50

51 Fishbone Diagram CNA assistance with meals Type of Patient Weight Loss Dietary Staffing Food Not Appetizing 51 51

52 Fishbone Diagram CNA assistance with meals Type of Patient Ortho Rehab Hospice Obese patient on diet Inadequate training Lack of interest Don t understand importance Short staffed High toileting needs Holiday call-offs Wages not competitive Weight Loss New Dietician Dietary Staffing Wages not competitive Holiday call-offs Poor presentation Wrong Temperature Monotonous Menu Food Not Appetizing 52 52