Implementing QAPI: Translating Data into Action. Objectives

Transcription

1 Implementing QAPI: Translating Data into Action Jane C Pederson, MD, MS April 16, 2013 Objectives Prioritize improvement opportunities based on data Identify a baseline measure for an improvement project Monitor progress of an improvement project What is QAPI? Quality Assurance and Performance Improvement (QAPI) is a data-driven and proactive 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 the care and services delivered to nursing home residents. 3

2 The Big Picture the Basics The ultimate goal QAPI is to provide person-centered care to focus on the person living in the nursing home QAPI is not a program; rather, this is the way we do our work The ability to think, make decisions, and take action at the system level is a prerequisite for QAPI success 4 Context QAPI is required in other federally certified health care programs hospitals, transplant programs, dialysis centers, ambulatory care, hospice NH QAPI is to be consistent with other settings at a high level, but also take into account issues unique to NH setting Background QAPI program in Nursing Homes was required in Affordable Care Act, enacted March 2010 Legislation requires CMS to establish QAPI program standards and provide technical assistance to nursing homes Opportunity for CMS to develop and test QAPI technical assistance tools and resources program before rule promulgation

3 Complementary Quality Approaches: QA merged with PI Five Elements of QAPI Design & Scope Governance & Leadership Feedback, Data Systems & Monitoring Performance Improvement Projects (PIPs) Systematic Analysis & Systemic Action In God we trust. All others bring data W.E Deming

4 Data Collections of facts, such as numerical values or measurements. It can be collected, tracked, reviewed, and used as a basis for reasoning, discussion or calculation. Value of Data Information is data that has been processed in order to answer the who? what? where? when? Knowledge is being able to apply data and information to answer, how? Understanding is when we can appreciate "why" Wisdom is evaluation of our understanding Goal of Feedback, Data Systems and Monitoring The goal is to create a system that allows your nursing home to effectively examine its performance and make data-driven decisions about which improvement efforts to undertake and then to take the next step to evaluate how effective these improvement efforts are.

5 Data Guides Performance Improvement Feedback Data systems Monitoring Sources of Data Publicly reported quality measures MDS data/measures Clinical data Resident, family, and staff satisfaction surveys Other data measured at fixed intervals (for example data collected via the AE tracking tools) Sources of Data Incidents/adverse events/near misses Survey & Certification findings Spontaneous feedback from residents, families, or staff Other data measured at variable intervals

6 Data Collection Select a range of data that reflects your organizations unique characteristics and services Mix and match data in order to categorize (e.g. human resources, financial, clinical, resident quality of life) Data Collection Some data is easier than others to put a system in place for collection. Quality measures vs. spontaneous comments from residents or families For all data sources, create a process to collect and document Everyone can identify data for QAPI Don t Just Watch Data Identify a baseline Set a goal or aim Set a threshold Benchmark

7 Monitor and Feedback Assign responsibilities for data collection and monitoring ownership Everyone has a role Use tools such as dashboards Determine appropriate frequency based on the type of data Do Not Forget Data Display How data is presented can make a big difference in how it is received Data Integrity Accurate/Valid Reliability Without bias Putting data to work for Performance Improvement

8 The Performance Improvement Process Prioritize opportunities Charter Performance Improvement projects (PIPs) Test Measure Process Outcome Indicators or Measures? PIP Measurement Measure of process and outcome Measures effectiveness of action, not the completion of the action Defined numerator/denominator Defined sampling plan and time frame Realistic performance threshold Plan for when initial measure did not meet threshold

9 Data Sources Tally sheets Checklists Questionnaires Feedback interviews Observation Daily reviews Chart audit Data obtained from existing databases and systems Outcome Measures A measure which evaluates the result of an intervention For example, the impact on the condition or well-being of residents. Assesses whether the change you have put in place had the desired effect. Outcome Measure Examples The number of falls that occurred during a lift transfer. The number of residents identified as high risk that developed a facility acquired pressure ulcer. Number of incidents when a resident received the wrong medication. Number of missed therapy appointments per month 100

10 Process Measures A measure which evaluates whether something is happening as expected Did the change in process actually occur? Necessary in order to determine if a change in outcome was linked to an actual change in process Sustainability Process Measure Examples The number of residents that had a fall risk assessment tool completed in the expected timeframe. The number of residents with a Braden score of 12 or lower that received a WOC nurse consult. Structural Measures A measure that evaluates whether needed structure is in place and working well. Examples All mattresses replaced New workstations installed All audible alarms removed from inventory

11 Measurement Sample Size Varies with size of population Frequency Goes hand-in-hand with the sample size Goal is to catch an error Measurement Duration Generally longer than you would like Need to make sure process change and outcome are sustained Typically > 6 months Remember Quality improvement measurement is for learning, not research All measures have limitations Watch for measurement fatigue Try to add to existing measurement Not all change is a real change be thoughtful on how you track and display data

12 Feedback To everyone who cares about the results To organizational performance monitoring Receive from staff, residents, families Questions? Jane Pederson, MD, MS Director of Medical Affairs or Stratis Health is a nonprofit organization that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities. This material was prepared by Stratis Health, the Minnesota Medicare Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 10SOW-MN-C