Take Your CoPs to the Next Level. Part 2 QAPI, Infection Control, Services and Administration

Transcription

1 Take Your CoPs to the Next Level Part 2 QAPI, Infection Control, Services and Administration

2 J non Griffin, RN MHA, WCC, HCS D, COS C Principle and Sr. Consultant

3 QAPI And Infection Prevention and Control

4 Infection Prevention and Control The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. An infectious disease is a disease caused by a microorganism and therefore potentially infinitely transferable to new individuals. It may or may not be communicable. An example of a non communicable disease is disease caused by toxins from food poisoning or infection caused by toxins in the environment, such as tetanus. A communicable disease on the other hand is an infectious disease that is contagious and which can be transmitted from one source to another by infectious bacteria or viral organisms.

5 Infection Prevention and Control The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. An infectious disease is a disease caused by a microorganism and therefore potentially infinitely transferable to new individuals. It may or may not be communicable. An example of a non communicable disease is disease caused by toxins from food poisoning or infection caused by toxins in the environment, such as tetanus. A communicable disease on the other hand is an infectious disease that is contagious and which can be transmitted from one source to another by infectious bacteria or viral organisms.

6 Standard (a) Prevention

7 Hand Hygiene Perform hand hygiene by means of hand rubbing or hand washing Perform hand washing with soap and water if hands are visibly soiled, or exposure to spore forming organisms is proven or strongly suspected, or after using the restroom. Otherwise, if resources permit, perform hand rubbing with an alcoholbased preparation. Ensure availability of hand washing facilities with clean running water. Ensure availability of hand hygiene products (clean water, soap, single use clean towels, alcohol based hand rub). Alcohol based hand rubs should ideally be available at the point of care.

8 Waste Disposal Ensure safe waste management. Treat waste contaminated with blood, body fluids, secretions and excretions as clinical waste, in accordance with local regulations. Human tissues and laboratory waste that is directly associated with specimen processing should also be treated as clinical waste. Discard single use items properly. Sharp items should be placed in containers that are puncture resistant, leak proof, closable and labeled biohazard. Non sharp disposable items saturated with blood or body fluids (i.e., fluid can be poured or squeezed from the item or fluid is flaking or dripping from the item) should be discarded into biohazard bags that are puncture resistant, leak proof, and labeled with a biohazard symbol or red in color. Such items may include used PPE and disposable rags or cloths.

9 Patient Care Equipment Handle equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of pathogens to other patients or the environment. Clean, disinfect, and reprocess reusable equipment appropriately before use with another patient.

10 Challenges in the home setting Environmental contamination Pets and pests Lack of control of caregiver

11 Policies Should have policies for TB skin test/equivalent prehire and then ongoing monitoring Policies should address Hep B vaccine

12 Standard (b) Control

13 Control The HHA must maintain a coordinated agency wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention.

14 Infection Prevention and Control Program Authority and responsibility for the infection prevention and control program Responsibilities Governing Body Administrator Clinical Manager Staff

15 Monitoring At least quarterly, the Clinical Manager and infection control and QAPI committees will review and assess the infection control logs. Data will be aggregated and analyzed on as part of the PI program. Problems and/or undesirable trends in infections will be identified, including potential significant Agency acquired and/or community acquired infections. If such problems or undesirable trends are identified, the infection control and PI committees will identify any common factors that could have led to the transmission of the infection(s).

16 Professional Standards of Practice

17 Standard (c) Education

18 Education standard (C) The HHA must provide infection control education to staff, patients, and caregiver(s).

19 Hang posters in common staff areas Wear hand washing buttons Give stickers Education for Staff and participation

20 Education to staff Agency should have a new hire orientation that covers infection control, handwashing, bag technique, and ways to minimize bloodborne pathogen exposure Monitors staff adherence to recommended policies, procedures and protective measures. When monitoring reveals a failure to follow recommended precautions: Counseling, education and/or retraining will be provided. If necessary, appropriate disciplinary action will be taken.

21 Management responsibilities Screens staff as required by law and regulation for exposure and/or immunity to infectious diseases that staff may come in contact with. Refers staff who are exposed to or who potentially have an infectious disease to physicians for assessment, testing, prophylaxis treatment, counseling and/or immunization.

22 Available for download at

23 Education references for patients Cover your Coughhttps:// Flu vaccine for patients over 65 factsheet.pdf Hand washing

24 Goals of successful program To reduce the risk of acquisition and transmission of infections by addressing prioritized risks. To limit unprotected exposure to pathogens throughout the organization by implementing current CDC and OSHA guidelines To improve hand hygiene compliance. To minimize the risk of transmitting infections associated with the use of procedures, medical equipment and medical devices. To improve influenza vaccination rates.

25 What should your program include? Method for identifying infectious and communicable disease problems Consider reviewing Centers for Disease Control and Prevention (CDC) material Assess types of soap and hand sanitizers provided to clinicians Consider an assessment form for at risk patients. Actions to result in improvement and disease prevention Identify at risk patients and provide education Track all infections and assess for trends ( community acquired vs in patient) Patient and staff infections

26 What should your program include? Plans to educate staff and patients including handwashing, bag technique. Observe your clinicians and ensure they understand safe and proper techniques per agency policy and CDC guidelines Evaluate staff flu vaccination date Make sure all staff have appropriate PPE and have policies in place for PPE Develop policies and procedures when new epidemics/infections are occurring (Zika, Ebola, etc.)

27 References tml

28 New CoPs regarding QAPI Requires HHAs to develop, implement, maintain and evaluate an effective, data driven quality assessment and performance improvement program. Five Standards Program Scope Program Data Program Activities Performance Improvement Projects Executive Responsibilities

29 Program Data Use quality indicator data, including measures derived from OASIS or other relevant data Focus on quality assessment efforts, including data collection on high priority safety and health conditions and other goals identified by your agency Identify opportunities for improvement Monitor the effectiveness and safety of your agency s services and quality of care

30 Agency Characteristic Report

31 Outcome Report

32 Process Quality Measure

33 Potentially Avoidable Event

34 Home Health Compare Quality of Patient Care Agency A Agency B Agency C

35 Agency A Agency B Agency C

36 SHP Reporting

37 PPS Quality Measures Report OASIS analysis software made by nurses for nurses Home Health Quality Measures From Date: 1/1/2015 To Date: 6/3/2016 Outcome Measure Referenced Affected PPS Plus % HHC % State Avg % National Avg % Improvement in Ambulation/Locomotion * % 51.2% 58.8% 65.2% Improvement in Bed Transferring * % 48.0% 51.2% 60.8% Improvement in Pain Interfering with Activity * % 47.9% 59.1% 69.2% Improvement in Bathing * % 58.8% 63.6% 69.7% Improvement in Management of Oral Medications * % 43.6% 47.7% 54.9% Improvement in Dyspnea (Shortness of Breath) * % 38.1% 52.6% 68.1% Acute Care Hospitalization ** % 19.0% 14.9% 16.0% Emergency Department Use without Hospitalization ** % 13.7% 12.4% 12.3% Improvement in Status of Surgical Wounds * % 87.3% 87.1% 89.6% * HHC, State, and National averages come from OASIS information collected by CMS during the time period of October 2014 September ** HHC St t d N ti l f OASIS i f ti ll t d b CMS d i th ti i d f J l 2014 J 2015

38 Pepper Reports Target Area Analysis for Home Health Agencies: Provides national level statistics for areas identified as at risk for improper payments in HH agencies for the most recent three years. Average Case Mix Average Number of Episodes Episodes with 5 or 6 visits Non Lupa Payments High Therapy Utilization Episodes Outlier Payments

39 Quarterly monitoring and reporting Chart Audits

40 Quality monitoring with Guidance

41 Quality Monitoring Trending

42 PI Activities Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Patient Infections x x x x Staff Infections x x x x Patient Incident Tracking x x x x Staff Incident Tracking x x x x Patient Complaint x x x x Medication Errors x x x x Quality Med Record Review x x x x PAE x x x x Outcome Measures x x x x HHCAHPS x x x x HR Audits x x x x Pepper Reports x Supervisory Visits x x x x x x x x x x x x

43 Program Scope Show measurable improvement in indicators for which there is evidence for improvement of health outcomes Measure, analyze, and track quality indicators, including adverse patient events and other performance indicators

44 Program Scope Communicate the message that the focus of QAPI is on identifying gaps in systems and processes, rather than individual performance Access all available data sources to look at the bigger picture to identify potential problem areas Trend outcome and process improvement indicators

45 Program Activities Focus on high risk, high volume, or problem prone areas of service, and consider the incidence, prevalence, and severity of problems in those areas Correct any immediate problems that directly or potentially threaten the health and safety of patients

46 Program Activities Track and analyze incidents and adverse patient events so your agency can implement preventative actions and mechanisms Continue to monitor the area(s) to assure that improvements are sustained over time Conduct a QAPI Awareness Campaign

47 Performance Improvement Projects July 13, 2018 Conduct PIPs (reviewed at least annually by Governing Body) reflecting the scope, complexity, and past performance of your agency s services and operations Utilize data collection and analysis to select focus areas Document QAPI projects and progress, including reason for project and measurable progress

48 Executive Responsibility Require your agency s governing body to assume responsibility for your QAPI program, ensuring it reflects your agency s complexity covers all provided services, including contracted staff and prevention/reduction of medical errors Define, implement, and maintain an ongoing agencywide program for quality improvement and patient safety developed from evidence based best practices

49 Executive Responsibility Ensure that performance improvement efforts are prioritized and evaluated for effectiveness to promote your agency s integrity and quality Include your governing body to approve the frequency and level of detail to be used in data collection Demonstrate clear expectations for patient safety Address any findings of fraud and waste to assure resources are appropriately used for patient care and that the patient is receiving the right care to meet their needs

50 Executive Responsibility Maintain documentary evidence of your agency s QAPI program to demonstrate to state surveyors

51 First, identify the objectives that you need to achieve. This gives you your future state the "place" where you want to be once you've completed your project. For each of your objectives, analyze your current situation. Once you know your future state and your current situation, you can think about what you need to do to bridge the gap and reach your project's objectives. Perform

52 Simple Example Future State Current Situation Next Actions/Proposals Effective and manageable QAPI program Quarterly chart audits put into a spreadsheet No way to track employee infections No QAPI Lead 1. Identify Data available to agency 2. See what policies are in existence for agency regarding QAPI or pieces of QAPI program

53 More Complex Gap Analysis Project: Implement QAPI Best Practice: Quarterly mtg Individual completing: JG Best Practice Best Practice Strategies How Your Practices Differ From Best Practice Barriers to Best Practice Implementation Will Implement Best Practice (Yes/No; why not?) QAPI program with effective PIPS that meets quarterly Identify methods of collecting and analyzing data Currently auditing charts quarterly to meet guidance Lack of staff dedicated to determining, tracking and implementing Yes; will shift some clinical manager duties to the new QAPI personnel.

54 Program Data Determine potential data available to collect or monitor Review, compare, and interpret data from various sources Establish benchmarks for comparisons against programs with high performance ratings Determine a plan for data collection (who, what, and how often) Gather additional input Identify areas of improvement, consolidate, prioritize, and set goals

55 Program Data What is agency baseline to measure? Objective data will give you concrete information on improvement, decline or maintenance of goals! Focusing on current national priorities and key indicators of quality care What are your disease specific re hospitalization rates?

56 Program Activities Use Root Cause Analysis (RCA) or another formal systematic process to identify contributing causal factors that lead to variations in performance Reference clinical standards to identify deviations Implement changes or corrective actions that will result in improvement

57 Program Activities Choose actions that address or target root causes Avoid quick fixes and focus on lasting/sustaining improvement Test in small pilots before rolling out to entire agency Review QAPI Plan every year (continuing to show improvement)

58 Performance Improvement Projects Consider each PIP as a learning process Create a timeline and communicate to leadership Identify any tools or resources needed, including clinical standards and best practices Test Changes Prepare and present results to executive leadership, including governing body

59 Performance Improvement Projects Utilize the Rapid Cycle Improvement ACT ON WHAT WAS LEARNED PLAN A CHANGE STUDY ITS EFFECTS DO IT IN A SMALL TEST PLAN DO STUDY ACT

60 Sample PDSA for Falls PLAN DO STUDY ACT Fall risk assessment is completed timely and accurately Admission assessment complete 8 hours Complete 14 days after admit Complete 30 days after admission Complete post fall Complete at significant change All clinicians responsible for admitting patients will be in serviced on the fall risk assessment Medication reconciliation Time frame in which to complete the fall risk assessment Admission clinician completes fall risk assessment within time frame Accuracy to be completed fall risk assessment Reduction in the number of falls Continue to monitor falls Continue education of staff Discuss and report any changes to team

61 Steps to PDSA Plan Step Recognize the problem and establish priorities. Problem may be outlined in very general terms based on information from several sources. Form the problem solving team. Interdisciplinary teams of individuals close to the problem are best. Define the problem and its scope clearly. Who, What, Where and When. Analyze the problem/process. Process flowcharts can be useful a useful tool. Determine possible causes. Cause and effect diagrams are helpful in identifying root causes of a problem. Identify possible solutions. Evaluate potential solutions.

62 Steps to PDSA Do Step Implement the solution or process change Monitor results and collect data

63 Steps to PDSA Study Step Review and evaluate the result of the change Measure progress against milestones Check for any unforeseen consequences

64 Steps to PDSA Check Step Standardize process changes Communicate to all involved Provide training in new methods

65 Executive Responsibilities Develop, implement, modify, and monitor QAPI policies and procedures Create a culture to support QAPI efforts (top down) Review and modify your vision, mission, values, and purpose statements to convey vision of QAPI Demonstrate the importance of QAPI and maintain its priority even with competing priorities or busy caseloads

66 Executive Responsibilities Develop a steering committee to provide QAPI leadership Provide resources for the QAPI team Create a climate of open communication and respect Ensure that all agency employees and contractors are educated on QAPI requirement, philosophy, policies, and processes

67 Executive Responsibilities Select various teams Ensure all staff are involved in a collaborative, crossdepartmental, and interdisciplinary approach Leverage technology to improve interdisciplinary communications Meet regularly and document all meetings and QAPI activities in meeting summaries

68 TIPS FOR BEGINNING ASSESS WHAT YOU CURRENTLY HAVE IN PLACE Initial QAPI plan will take time to create. It will be much easier going forward Review and revise on a quarterly basis Revise goals and other areas as needed on a yearly basis Identify your vision statement, mission statement, purpose, guiding principles and scope for QAPI prior to writing your plan Attach these as a preamble to the QAPI plan Are you part of a system wide QAPI plan? How will you meet these requirements?

69 Job Descriptions/Competencies/Onsite forms/policies

70 Governing Body Must approve all policies Approve administrator and alternate Fiscal matters Budget and capital expenditure plan EP Plan QAPI plan

71 Administrator Responsible for Day to day operations Actively involved ensure personnel qualified Reports to board Must be approved in writing to board. Regular alternate administrator must be approved in writing by board and administrator (policy 855)

72 Administrator requirements Prior to 1/13/18 must be A licensed physician Registered Nurse, or Has training and experience in health services administration and at least 1 year of supervisory administrative experience in home health care or related health care program After 1/13/18 must be Licensed physician, a RN, or holds an undergraduate degree, AND Has experience in health services administration, with at least 1 year of supervisor or administrative in home health care or a related health care program.

73 Clinical Manager Can be RN, Physician, PT, OT, SLP, Audiologist, MSW Assuring the development, implementation and updates to the individualized POC. Must have CM on duty at all times Can have multiple CMS rare that they can fulfill Administrator and CM functions Flexibility on how you structure function Clear on lines of authority and communication

74 Skilled Professionals

75 Clinicians/Field Staff Reporting complaints Abuse/neglect QAPI involvement Emergency preparedness involvement

76 Home Health Aide Added recognizing skin conditions Added communication skills Must be able to identify abuse/neglect Infection prevention and control Emergencies Knowledge of instituting emergency procedures

77 Home Health Aide 9 Standards Home Health Aide qualifications Content and duration of home health aide classroom supervised practical training Competency and evaluation Inservice training Qualification of instructors Eligible training and competency evaluation organization HHA assignment and duties Supervision of aides Personnel care only supervision

78 Home Health Aide Qualified Aide Successfully completed one of the following A training and competency evaluation program that meets the requirements or A competency evaluation program that meets the requirements A nurse aide training and competency evaluation program that is approve by the state and is currently in good standing on the state nurse aide registry A state licensure program that meets the requirements No lapse of work for 24months

79 Home Health Aide Training CMS will accept nurse aide training and competency from a nurse aide curriculum Program must be approved by the state as meeting the requirements AND Program is currently listed in good standing on the state nurse aide registry OR A state licensure program that meets the requirements described in (b) and (c )

80 Nurse Trainer Qualifications RN with 2 years of nursing experience at least one year in home health care. Other professionals can provide instruction to the aide, the general supervision must be from the qualified RN.

81 Supervision of Aides Still 14 days Aide does not have to be present (for skilled patients) If deficiency noted during a SV, the supervisor MUST make an onsite with the aide present to observe and assess If deficiency, must go back through that competency. The aide MUST have at least one annual onsite visit

82 Supervisory Content Aide success in completing the assignment: Completing tasks assigned Communicating with the patient, Patient rep, caregivers, and family Demonstrating competency with assigned tasks Complying with infection prevention and control policies and procedures. Reporting changes in the patients condition Honoring patient rights

83 Operational Housekeeping

84 Intake Process What needs to be added to your intake form for improved operational flow and to meet standards? Does intake coordinator JD need to be updated?

85 Subunits Branch or Parent Subunits eliminated Agencies with subunits will need to develop a plan to make subunits completely independent parents or branches The parent HHA is responsible for reporting all branch locations of the HHA to the state survey agency at the time of the HHA s request for initial certification, at each survey, and at the time the parent proposes to add or delete a branch. The parent HHA provides direct support and administrative control of its branches. Governing body will need to approve plan Separate corporate entity? Separate Governing Body

86 Contracts and Reviews of Contracts What all do we need to include and hold contractors responsible for? Language proficiency? Emergency Preparedness? Patient Rights? Coordination of care?

87 Clinical Records Content Comprehensive Assessment (including orders, notes, plan of care etc) All documentation must be TIMED All interventions including treatments, and medications and responses to those interventions Goals and progress toward achieving those goals Contact information for the patient, the patient s representative (if any), and the patient s primary caregiver(s) Contact information for the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA Completed DC summary

88 Record Authentication Electronic signatures Keeping paper copies Must be secure Record retention minimum 5 years

89 Records Request Clinical Record Release business days Major change Previously governed by HIPAA Governing body approval of policy changes

90 Orders LPN/LVN can take orders if allowed by state law with no co signature 48 hour ROC rule can be physician driven ROC date Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, and after an assessment of the patient to determine for contraindications.

91 EMR Assistance What are they doing about representative and multiple physicians? How does their integrated care plan work? What about EMP Patient specific goals and outcomes

92 Education Take Aways Patient Rights All staff QAPI all staff Home Health Aide Patient education

93 Questions J non Griffin, RN, WCC, MHA, HCS D, COS C, HCS H Home Health Solutions, LLC jnon@homehealthsolutionsllc.com