United Methodist Association National Conference Integrating Risk Management and Quality Assurance and Performance Improvement (QAPI)

Transcription

1 United Methodist Association National Conference Integrating Risk Management and Quality Assurance and Performance Improvement (QAPI) March 11, 2015 Laura Lally, Caring Communities Victor Lane Rose, ECRI Institute

2 The Risk Management + QAPI + Environmental Safety and Security Equation Risk Management Safety and Security Quality Assurance & Performance Improvement (QAPI)

3 Risk, Quality, Safety and Security, and Compliance Single Campus

4 Risk, Quality, Safety and Security, and Compliance Multi Campus

5 Risk Management Activities Risk identification and mitigation Internal incident reporting Event management Claims management Insurance management Environmental safety and security Emergency response Risk Management Activities

6 QAPI Activities Monitor performance through key indicators Identify performance improvement opportunities Conduct Performance Improvement Projects (PIP) QAPI

7 Risk Management & QAPI Overlapping Activities Strengthen the Culture of Safety Trending and analysis of adverse event data Develop, implement, and evaluate change efforts to improve performance Education and development Risk Management Activities QAPI Activities

8 Strong QAPI Practices Leads to Better Claims Management and Defensibility Documentation Training and Skill Development Litigation Systems (care delivery) Staffing

9 QAPI Tentative Deadlines as of now! Step 1: Develop and provide technical assistance and resources before the promulgation of QAPI regulations. Mostly complete! Step 2: Promulgate the QAPI regulations. No target date yet! Step 3: Nursing homes must submit a written QAPI plan to CMS within 1 year after the final regulations are published.

10 Benefits of Implementing QAPI Now Easier than waiting until it is required Contributes to higher quality and more cost-effective care May decreased current litigation costs and prevent future litigation

11 Beyond Skilled Nursing An Organizationwide Approach to QAPI Nursing Center Adult Day Services Assisted Living Pace QAPI Independent Living Hospice Health Clinics Home Health

12 Quality Assurance & Performance Improvement Quality Assurance QAPI Performance Improvement

13 QAPI A working definition QAPI is a data driven, proactive approach to improving the quality of life, care, and services in nursing homes. The activities of QAPI involve members at all levels of the organization to: Identify opportunities for improvement Address gaps in systems or processes Develop and implement an improvement or corrective plans Continuously monitor effectiveness of interventions (CMS; QAPI at a Glance)

14 Five Elements of QAPI (CMS) Element 1: Design and Scope Element 2: Governance and Leadership Element 3: Feedback, Data Systems and Monitoring Element 4: Performance Improvement Projects (PIPs) Element 5: Systematic Analysis and Systemic Action

15 Element 1: Design and Scope A QAPI program must be ongoing and comprehensive, dealing with the full range of services offered by the facility, including the full range of departments.

16 Element 1: Develop Your QAPI Plan Plan elements include: QAPI goals and scope Governance and leadership guidelines Feedback systems Performance improvement project (PIP) team guidelines Systematic analysis and action QAPI

17 Element 2: Governance and Leadership The governing body and/or administration of the nursing home develops and leads a QAPI program that involves leadership working with input from facility staff, as well as from residents and their families and/or representatives.

18 Element 2: Governance and Leadership Creating a Culture of Safety and Just Culture

19 Element 3: Feedback, Data Systems and Monitoring The facility puts in place systems to monitor care and services, drawing data from multiple sources. Feedback systems actively incorporate input from staff, residents, families, and others as appropriate.

20 Element 3: Data-driven Improvement and Measurement Be accepted and meaningful to the key stakeholders (data demand) Be simple, logical and repeatable Be feasible and economical to collect (in this case, efficiency contributes to overall effectiveness) Provide quality data: accurate, complete, and timely for better decision making (data use) Facilitate/drive purposeful and appropriate action

21 Element 3: Sources of Data for Key Performance Indicators Deciding what data will be used to monitor routinely is a critical step. Considerations include: Adverse event reporting data (e.g., falls, falls with injury, medication errors, elopements, pressure ulcers, infections) Allegations of abuse and neglect Resident and family complaints and care concerns Hospitalizations and rehospitalizations Resident and caregiver satisfaction State survey results and deficiencies (CMS QAPI at a Glance )

22 Element 4: Performance Improvement Projects (PIPs) The facility conducts Performance Improvement Projects (PIPs) to examine and improve care or services in areas that are identified as needing attention.

23 Element 4: Prioritize Quality Opportunities and Charter PIPs The use of charter for PIP Teams: to create purpose, accountability, and mission CMS suggests the use of charter to describe the act of creating a team for each specific project. This: Gives the team the responsibility and authority needed to do the job; Sanctions the work of the team through formal organization position and power structures. Charter also provides a certain degree of formality. To build commitment, establish meeting rules, time-lines, and goals.

24 Element 4: Plan, Conduct and Document PIPs What changes are to be made? Next cycle? Objective Predictions Who, what, when, where Plan for data collection Act Plan Study Do Analyze data Compare results to predictions Summarize what was learned Carry out the plan Document observations Record data

25 Element 5: Systematic Analysis and Systemic Action The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change.

26 Element 5: Getting to the Root of the Problem Root Cause Analysis (RCA): processes for identifying contributing factors that underlie variations in performance. Looks for performance gaps between desired organizational performance (e.g., policies and procedures) and actual organizational performance. Evaluates desired performance during the analysis. Moves efforts from reactive actions to proactive improvement actions that prevent future events. Focuses on improving care and service delivery system design throughout the operation.

27 Questions?

28 QAPI Resources CMS QAPI Website: Certification/QAPI/NHQAPI.html QAPI Frequently Asked Questions (CMS): Certification/QAPI/Downloads/Aligning_QAPI_FAQ.pdf QAPI Process Tool Framework (CMS Index of Tools): Certification/QAPI/Downloads/ProcessToolFramework.p df

29 QAPI Resources Root Cause Analysis Resources: Agency for Healthcare Research and Quality (AHRQ): Center for Disease Control (CDC): National Center for Patient Safety (NCPS): Minnesota Department of Health:

30 References Center for Medicare and Medicaid Services (CMS). QAPI at a Glance: A step by step guide to implementing Quality Assurance and Performance Improvement (QAPI) in your nursing home. [Draft] Dec 14 [cited 2013 Feb 12]. Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions- Items/Survey-and-Cert-Letter html Joint Commission. Emergency Management (EM). In: Joint Commission. Comprehensive accreditation manual for long term care. Oakbrook Terrace (IL): Joint Commission Resources; 2010 Sep: EM1-26. U.S. Department of Veterans Affairs. National Center for Patient Safety Root Cause Analysis Tools. Retrieved from