Developing an Organizational QAPI Plan

Transcription

1 Developing an Organizational QAPI Plan Kathleen Lavich, R.N. Senior Clinical Quality Consultant MPRO LeadingAge Michigan Annual Conference and Trade Show MPRO: Our Work QUALITY IMPROVEMENT REVIEW SERVICES CONSULTING SERVICES Evidence based, datadriven quality improvement insights Thoughtful, impartial utilization review and dispute resolution services Innovative problem solving solutions and technical assistance HELPING HEALTHCARE GET BETTER 1 Lake Superior Quality Innovation Network Serve in collaboration with Stratis Health of MN and MetaStar of WI as Lake Superior Quality Innovation Network (QIN). Assist CMS in improving healthcare for Medicare beneficiaries by convening and connecting providers to share knowledge and spread best practices in: Heart Health Antibiotic Stewardship Diabetes MIPS/APMs Nursing Homes QI Initiatives (BFCC) Care Coordination Adult Immunizations Adverse Drug Events Behavioral Health 2.39 Million FFS Medicare Beneficiaries 2

2 3 Objectives Identify the purpose of developing an organizational QAPI Plan Identify the Final Rule - Reform of Requirements for LTC Facilities regulations for QAPI and timeline Identify how to use the Lake Superior QIN QAPI Written Plan How-To-Guide to develop an organization-specific QAPI Plan Why Develop a Written QAPI Plan? CMS believes effective QAPI programs are critical to improving the quality of life and quality of care and services delivered in LTC facilities QAPI is mandated in the Affordable Care Act The QAPI Plan will be the roadmap that guides quality efforts and implementation of QAPI and how you do your work everyday 4 QA vs. PA Quality Assurance Reactive Episode or event-based Performance Improvement Proactive Aggregate data and patterns Prevent recurrence Sometimes anecdotal Retrospective Audit-based monitoring Sometimes punitive Optimize process Always measurable Concurrent Continuous monitoring Positive change 5

3 6 QAPI vs. QA Performance improvement is continuous Proactive effort to use data to understand and improve your own problems (internal governance) A philosophy that no matter how good we are, there is always room for improvement Final Rule Reform of Requirements for LTC Facilities (a) Requires facilities to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program, reflected in its QAPI plan, that focuses on systems of care, outcomes, and services for residents and staff (a)(1) The facility maintains documentation and demonstrates evidence of its QAPI program. This would include, but not be limited to, the QAPI plan 7 Final Rule Reform of Requirements for LTC Facilities (a)(2) QAPI Plan will be made available to the state agency, federal surveyor, or CMS upon request by the Phase 2 Implementation date of 11/28/ (h) Facilities, in order to demonstrate compliance with the requirements, may be required to disclose or provide access to certain QAPI information 8

4 9 Final Rule Reform of Requirements for LTC Facilities (c)(2) Policies and procedures include how the facility would identify, collect and use data from all departments, including how the information would be used to identify high risk, high volume or problem-prone areas (c)(4) Require that the systems, policies and procedures include the process for identification, reporting, analysis and prevention of adverse events and potential adverse events or near misses QAPI Written Plan How-to- Guide 10 What s in the Guide 11

5 12 Preamble for QAPI Plan Vision Statement Mission Statement Purpose Statement Guiding Principles Define Scope of QAPI Assemble Document Purpose of Your Organization s QAPI Plan Write the Purpose: A purpose statement describes how QAPI will support the overall vision and mission of the organization Reflects what your organization intends to accomplish through QAPI 13 Scope List services you provide Address key issues Current quality improvement activities Use of best available evidence 14

6 15 Exercise Design & Scope (15 Minutes) Based on your identified systems of care, develop a scope statement including: Clinical Care Quality of Life Resident Choice (Individualized goals for care) Safety Utilize best available evidence to define and measure goals Share with the group Guidance for Governance and Leadership Responsibility and Accountability Adequate resources QAPI staff training and orientation Framework for QAPI Reporting to governing body Implementation of a nonpunitive culture 16 In God we trust, all others must bring data. W. Edwards Deming Measurement is only a handmaiden to improvement but improvement cannot happen without it. Don Berwick 17

7 18 Feedback, Data Systems, and Monitoring Data sources to analyze performance Data sources to identify risk Data sources to collect feedback/input Feedback, Data Sources and Monitoring 19 Feedback, Data Sources and Monitoring 20

8 21 Feedback, Data Sources and Monitoring Exercise Group Activity (10 Minutes) Brainstorm and list sources of data that you will monitor through a QAPI Program Identify what benchmarks are available for that data Share with the group 22 Performance Improvement Projects (PIPs) Conducting PIPs Identifying potential PIPs Prioritizing and selecting PIPs PIP charters PIP teams Conducting the PIP Documentation and communication 23

9 24 Performance Improvement Process Develop a Goal Statement Monitor Improvement Describe the Current Process Implement Change Do a Root Cause Analysis Evaluate Pilot Testing Identify Changes that will Lead to Improvement Pilot Testing Develop Implementation Strategy Systemic Analysis and Systemic Action Systematic approach and tools Ensure planned changes are implemented and effective Preventing future events and promoting sustained improvement 25 QAPI Plan Report to Steering Committee Activities of Steering Committee Execute PDSA Collect, monitor and assess data Appoint PIP Team Select PIPs 26

10 27 CMS Guide for Developing a QAPI Plan I. QAPI Goals II. Scope III. Guidelines for Governance and Leadership IV. Feedback, Data Systems, and Monitoring V. Guidelines for Performance Improvement Projects VI. Systematic Analysis and Systemic Action VII. Communications VIII. Evaluation IX. Establishment of Plan Appendix: Writing Your Plan 28 QAPI Checklist 29

11 30 NNHQCC Change Package The National Nursing Home Quality Care Collaborative (NNHQCC) has a Change Package that was just updated to include a Change Bundle titled, To Build Capacity For QAPI Success Questions? Kathleen Lavich, RN Senior Clinical Quality Consultant MPRO klavich@mpro.org Thank you! Follow us MPRO represents Michigan in the Lake Superior Quality Innovation Network. This material was prepared by the Lake Superior Quality Innovation Network, 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. 11SOW-MI-C