9/27/2017. Getting on the Path to Excellence. The path we are taking today! CMS Five Elements

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1 Getting on the Path to Excellence QAPI DESIGN AND IMPLEMENTATION Demi Haffenreffer, RN, MBA The path we are taking today! The requirements at F944 (formerly F520) Key elements Survey Investigative Protocol Design Implementation Demonstrations throughout CMS Five Elements Design and Scope Feedback, Data Systems and Monitoring Systematic Analysis and Systemic Action Governance and Leadership Performance Improvement Projects 1

2 ROP F944 Must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life Maintain documentation and demonstrated evidence of its ongoing QAPI program that meets requirements ROP F944 Includes systems & reports demonstrating systematic identification, reporting, investigation, analysis, & prevention of adverse events, and Documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. Present your QAPI plan to State Survey Agency by November 28, 2017 and then annually. ROP F944 Many more components in the requirement: Program Design and Scope Program systematic analysis and systemic action (Implemented phase ) Governance and Leadership Quality Assessment and Assurance Disclosure Sanctions 2

3 ROP F944 Criteria for Compliance Functioning committee that includes DON, a physician, and at least three other staff members, and infection control preventionist Meets quarterly Identifies quality deficiencies Develops and implements appropriate plans of actions DESIGN & IMPLEMENTATION DESIGN STEPS Establish a systematic approach Adopt a QA Methodology Develop a written plan Policies Procedures - Responsibilities Identify what are the important aspects of the services you provide all departments What is your mission and your vision / guiding principles Focus on the important aspects of the requirements: QOC, QOL, & Resident Choice Aim for safety and high quality 3

4 DESIGN STEPS Establish goals / key measures Develop training and deliver that training to staff at all levels Make it part of everyone s job Teams Job Descriptions Setting Measures / Indicators / Goals Steps Define Operational definition How will it be measured Tools needed? Determine when will be collected Determine where data will be collected Determine who will collect Determine if training is needed 4

5 What to Measure Admissions/Discharges Care Transitions (Services and information flow across settings of care) Ethics and Compliance activities (OIG Guidance) Restraint use Activity Programs Palliative Care and End of Life Resident Satisfaction Family Satisfaction What to Measure Medical record review, closed and open Assessment timing and completion Medication use and management (including medication errors) Pressure Ulcer rates Resident Safety Issues Sentinel events (such as death or serious injury due to a fall, medication errors, or other facility identified events) Resuscitation and its outcomes What to Measure Staffing Absenteeism Employee satisfaction Dietary/food services weight loss Physician visits Rehabilitation services Utilization management Infection control Housekeeping Environment of care/safety/plant/facilities 5

6 What to Measure Financial services/business office Employee turnover & retention rates Staff competencies & training Performance improvement teams Radiology and other diagnostic services (provided by facility or under agreement) Laboratory (including blood and transfusion services) (provided by facility or under agreement) Staff views related to career development Contract and agreement services (includes dental, pharmacy, others) Risk management What to Measure Centers for Medicare and Medicaid Services improvement initiatives Quality of Life (Rights such as choice, autonomy Physician, Discharge Planner, Vendor Satisfaction Peer review trends Publicly reported data and comparative databases Regulatory issues Specific processes such as medication pass and other competencies How to choose? Prioritize according to vision and mission Prioritize according to strategic plan Prioritize according to requirements Prioritize according to satisfaction surveys Prioritize according to QAPI projects Prioritize according to services Make it multi-dimensional Make it fluid BUT REMEMBER... 6

7 YOU CAN T MEASURE EVERYTHING SIMULTANEOUSLY! Process Types of Data / Measures How something is occurring along the way, before the outcome occurs. Outcome The end result or output of a process. Observable Observation of a process Count Events counted and placed into categories Measurements Shows values on a continuous scale (temperatures, time in minutes) Example of a Measure / Goal Definition All falls as defined by the RAI that occurred in the past month All residents receiving an antipsychotic medication with only the diagnosis of Dementia Overall Measure Falls no greater than 25% of average daily census. No major injuries (RAI definition) Will decrease current antipsychotic use in residents with dementia by 15% of current rate in 2016 (35%) to 32% 7

8 Example of a Measure / Goal Numerator Total number of falls Total number of residents receiving antipsychotics with only the diagnosis of Dementia for the year (2016) Denominator For falls = Average daily census for the past 30 days X 100 For Meds = Average daily census for the year (2016) X 100 Example of a Measure / Goal Exclusions Falls related to resident:resident behaviors Residents receiving antipsychotics with diagnosis of schizophrenia How / When will data be collected Data will be collected monthly from incident reports/pharmacy report/census information by the 5 th of the next month Who is responsible Director of Nursing or other Where to get Data Quality Indicators/Quality Measures Profile and Resident Level Summary Publicly reported quality measures The QIS QCLI dictionary has indicators and measures for QIS survey OSCAR/CASPER and other CMS databases and reports Complaints and survey history Facility internal clinical reports such as recent falls, other accidents, skin breakdown, weight loss, reasons for discharges, infection control (e.g., overall infection rates), and medication errors Other facility reports such as employee and resident satisfaction surveys, grievances, financial reports, employee retention and turnover reports, and corporate compliance and/or other risk management reports Corporate scorecards, dashboards, or other data provisions Reports available from outside resources and organizations such as Ombudsmen, Resident Advocates, AHCA, AAHSA, State Quality Programs, State QIOs, Advancing Excellence, and others Outside the industry 8

9 How to Display what you Measure Flow charts Run Charts Pareto Charts Tables Graphs How do you analyze and solve problems / improve systems effectively within your organization? Root Cause Analysis Root cause is the most basic reason for an undesirable condition or problem which if eliminated or corrected, would have prevented it from existing or occurring. RCA helps you to determine: The series of events that actually happened What parts of your system worked well What parts of your system lined up to allow an error What meaningful steps your system can take to improve safety Prioritization of causes & therefore assists with prioritizing action plans Resident specific and employee specific problems 9

10 Root Cause Analysis Key Concepts The focuses is on safety and prevention: immediate & longrange and other dimensions of performance Everyone has a voice and the voices all ask why? five times & more All available evidence is used to analyze the situation The analysis is used to develop a goal and make an action plan Uses Tools for analysis such as flowcharts to understand processes and variation from processes; cause and effect diagrams (fish bone)to explore cause and effect variations in a process The plan is reassessed (evaluated / re-evaluated) and tweaked until it works Quality Improvement is a proactive process, not a reactive event Dimensions of Performance Safety is the degree to which the care, service, or environment is free from hazards or dangers. Timeliness is the degree to which the care or service is provided at the time that is most beneficial to or necessary for the resident. Dimensions of Performance Accuracy is the degree to which the care or service (e.g., test, procedure, or treatment) is correct, has no errors. Appropriateness is the degree to which the care or service is relevant to the resident s needs Availability is the degree to which the appropriate care or service is offered to meet the resident s needs. Continuity is the degree to which the care or service provided to the resident is coordinated among practitioners, across the organization and time. 10

11 Dimensions of Performance Effectiveness is the degree to which the care or service is provided in the correct manner to achieve the desired result (doing the right things). This includes avoiding under-use and overuse of services. Efficacy is the degree to which the care or service provides the desired result. Efficiency is the degree to which resources are effectively used to produce the result (doing things right). Dimensions of Performance Equity is the degree to which the care or service is provided with consistent quality regardless of an individual s personal characteristics such as gender, ethnicity, location, etc. Reliability is the degree to which the care or service is dependable and trustworthy. Resident centered is the degree to which the care or services meets the needs, expectations, goals, and desires of the resident. Respect and caring is the degree to which the care or service is provided with sensitivity and respect for the resident s needs, expectations, and individual differences including ethical considerations, rights, and responsibilities. Figure 3: RCA/Causal Tree Diagram 11

12 Fish Bone Develop an Action Plan Use a team What will keep this from happening again? Focus on the root causes Develop short range and long range goals Document the plan Implement start small Medication Errors 12

13 Medication Errors Action Plan Action Item Responsible Person(s) Completio n Date 1. Implement competency checks on hire and annually - Complete competency checks on all current medication aides 2. Place pictures of residents in all tackle boxes 3. Add communication specifics related to resident meds and packaging to admission packet. - Enforce medication packaging in 30 days of admission 4. Contact pharmacy for Tallman lettering review implementation date 5. Implement consistent med pass procedure Staff Education 9/1/12 Resident Coordinator Executive Director in collaboration with Admission Coordinator 8/15/12 9/1/12 Director of Nursing 8/15/12 Director of Nursing 9/1/12 Evaluation of the Results You have defined your goals earlier on, such as for a resident: Those measures we already discussed How successful have we been? Do we need a new plan? Develop a PIT? TRAINING 13

14 Communication and Training Announce it Staff Families Residents Governing body Other stakeholders / contractors Conduct trainings The requirements The Plan roles / responsibilities The Committee Others who may be involved QUESTIONS? Resources Dana, B. (2006). Developing a Quality Management System (2 nd edition). AHCA: DC* DeFeo, J & Barnard, W. (2004). Juran Institute s Six Sigma. McGraw Hill: NY. Deming, E. (1986). Out of Crisis. Fox, N. (2007). The Journey of a Lifetime: Leadership Pathways to Culture Change in Long-Term Care. Eden Alternative. 14

15 Resources Gawande, A. (2007). Better: A Surgeon s Notes on Performance. Picador: NY. Gawande, A (2010). The Checklist Manifesto: How to Get Things Right. Metropolitan Books: NY. Senge, P. M. et al (1994). The Fifth Discipline Fieldbook. Doubleday: NY. Senge, P. M. et al (2004). Presence: An Exploration of Profound Change in People, Organizations, and Society. Random House: NY. AHCA and WHCA demi@consultdemi.net www consultdemi net 15