Quality Indicator Survey Preparedness: Enhancing Quality of Care and Life through Survey Compliance HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Beckie Dow, RN, RAC-MT Regional Consultant / Trainer Housekeeping Sign In Contact Hours Certificate A Little About Me Handouts Contact Information for Questions Harmony Healthcare International, Inc. 2 Welcome! Harmony Healthcare International, Inc. 3 1
Program Objectives Discuss process and stages of the QIS Define quality of care and life indicators (QCLIs) Define care areas Complaint investigations a discussion Extended survey a discussion Review QAA regulation (intent and requirements) Using the QIS Information in Facility QAA Activities Resources and Q&A Harmony Healthcare International, Inc. 4 Why Change to QIS? Improve consistency and accuracy in problem identification Be more objective and systematic Enhance documentation through automation Focus survey resources Provide tools for CQI Harmony Healthcare International, Inc. 5 QIS An Overview Survey process changes Regulations are unchanged Surveyors use customized software on PCs which guides them through a structured investigative process Survey is a two-staged process Every 9-15 month timeframe unchanged Harmony Healthcare International, Inc. 6 2
What Has Not Changed The Social Security Act The regulations The interpretive guidance The enforcement process Harmony Healthcare International, Inc. 7 Outcomes of QIS (QIS Study) According to the 2007 Final Report of the Evaluation of the Quality Indicator Survey (QIS) there was: Overall increase in the number of deficiencies cited G-level deficiencies increase Regulatory care areas cited increase Harmony Healthcare International, Inc. 8 Outcomes of QIS ( Real World ) 40% of facilities have the same number of or fewer surveys deficiencies Deficiencies in areas previously not fully investigated (i.e., QOL) There ARE zero deficiency surveys with QIS Source: LTL Magazine, 3/19/2008 Harmony Healthcare International, Inc. 9 3
Two Stages Stage I: Preliminary investigation of regulatory areas to determine resident care areas to determine resident care areas and facility practices for Stage II investigation Stage II: In-depth investigation to determine whether deficient practice exists, document deficiencies and determine severity and scope Harmony Healthcare International, Inc. 10 Three Steps in Each Stage Sampling (computer-generated) Investigation Synthesis Harmony Healthcare International, Inc. 11 Implementation QIS First Tested in. California Connecticut Kansas Louisiana Ohio Harmony Healthcare International, Inc. 12 4
Implementation Training Model Development Florida Connecticut Kansas A national training model was developed and refined in these states Harmony Healthcare International, Inc. 13 Nationwide Implementation Occurring in Bands Band One Delaware Maine Vermont Georgia Arizona Band Two Colorado Nebraska District of Columbia Indiana Oregon Utah New York Harmony Healthcare International, Inc. 14 Nationwide Implementation Occurring in Bands Band Three New Jersey Arkansas Hawaii South Carolina Tennessee Oklahoma Band Four Texas Rhode Island Wisconsin Missouri New Hampshire Kentucky Mississippi North Dakota Harmony Healthcare International, Inc. 15 5
Nationwide Implementation Occurring in Bands Band Five Wyoming Alabama Massachusetts Illinois Idaho Virginia California Alaska Band Six Pennsylvania Michigan South Dakota Puerto Rico Virgin Islands Montana Nevada Iowa Harmony Healthcare International, Inc. 16 Per the April 6, 2011 GAO Report: According to CMS officials, time needed to train all surveyors within a state could vary from one to three years depending on factors such as the number and availability of surveyors in any given state The last CMS training period is scheduled to begin between June 2014 and June 2015. Therefore, training of all surveyors nationwide may not be completed until 2018 Harmony Healthcare International, Inc. 17 Per the April 6, 2011 GAO Report: As of February 2011: 7 state survey agencies have completed training of all surveyors within their states 14 state survey agencies have started training surveyors within their states 32 state survey agencies are scheduled to start training surveyors between 2011 and 2015 Note: States includes DC, Puerto Rico and US Virgin Islands Harmony Healthcare International, Inc. 18 6
Gradual Roll-out of the QIS States QIS Training Status as of 2/2011 Source: GAO Analysis of CMS Data Harmony Healthcare International, Inc. 19 Harmony Healthcare International, Inc. 20 An Overview of the QIS Process (Additional Handout) Harmony Healthcare International, Inc. 21 7
QIS Tasks Task 1: Offsite Survey Preparation Task 2: Onsite Preparatory Activities and Entrance Conference Task 3: Initial Tour Task 4: Stage I Survey Tasks Finalize sample selection Stage I team meetings Information gathering Admission sample review Harmony Healthcare International, Inc. 22 QIS Tasks Task 4: Stage I Survey Tasks (Cont.) Census sample review Staff interviews Medical record review Resident interviews Resident observations Family interviews Harmony Healthcare International, Inc. 23 QIS Tasks Task 5: Non-Staged Survey Tasks Resident council president interview Dining observation Kitchen/food service observation Infection control/immunization policies and practices Demand billing review Quality assessment and assurance (QA&A) Review Medication Administration Observation Unnecessary Drug Review ** Harmony Healthcare International, Inc. 24 8
QIS Tasks Task 6: Transition From Stage I to Stage II Review surveyor-initiated residents and/or care areas Import all data into the primary laptop Team meetings Review the Relevant Findings Report Review the QCLI Results Report Harmony Healthcare International, Inc. 25 QIS Tasks Task 7: Stage II Survey Tasks Information Gathering Critical Element Pathways Facility-Level Triggered Investigations Environmental Observation Resident Funds Admission, Transfer, and Discharge Review Sufficient Staff Abuse Prohibition Harmony Healthcare International, Inc. 26 QIS Tasks Task 8: Analysis and Decision-Making: Integration of Information Decision-making regarding scope and severity (To cite or not to cite???) Task 9: Exit Conference Harmony Healthcare International, Inc. 27 9
Entrance Conference Worksheet provided from CMS as to what facility needs to provide immediately and very soon after the survey begins No 802! Harmony Healthcare International, Inc. 28 Initial Tour Surveyors introduce themselves to residents, staff and families Examine environment and general wellbeing of the residents Kitchen is included in initial tour Harmony Healthcare International, Inc. 29 Survey Team s Communication with Facility Staff During Stage 1, the team will not have completed full investigations and cannot yet discuss findings Subsequently, staff will have opportunities to clarify issues brought to their attention but surveyors are not to release information about ongoing concerns until their investigation is completed Harmony Healthcare International, Inc. 30 10
Initial Resident Samples Census sample 40 randomly selected current resident Admission sample 30 randomly selected recent admissions MDS sample All residents with an MDS within the last six months Harmony Healthcare International, Inc. 31 Why Three Samples? Ensures different types of residents are looked at (long-term via census sample and short-term via admission sample) MDS sample includes all residents (except those who have not yet had an MDS) Harmony Healthcare International, Inc. 32 What If Someone or Something Really Stands Out to a Surveyor? Surveyors can surveyor-initiate anyone else into the sample at any time Harmony Healthcare International, Inc. 33 11
Stage I Data Collection Pre-decisional Staff interview* Observation* Resident interview* Family interview* Record review** Facility-level tasks *admission sample **census and admission samples Harmony Healthcare International, Inc. 34 Stage I Data Collection Staff Interview Interview will be conducted with the licensed staff on the unit (i.e., charge nurses) Questions will be asked about all 40 residents in the Census Sample Use the charts! Have a plan to ensure that the work on the unit continues during the interview process! Harmony Healthcare International, Inc. 35 Stage I Data Collection Staff Interview Catheter use Nutrition Skin care/pressure ulcers Side rails Contractures Falls and fractures Harmony Healthcare International, Inc. 36 12
Stage I Data Collection Resident Interview & Observation Interview done with all interviewable residents from the Census Sample MDS determines if resident is interviewable Surveyor has opportunity to chat with resident and decide if they are or are not interviewable Harmony Healthcare International, Inc. 37 Is a Resident Interviewable? CPS BIMS Interviewable? 0,1 13-15 Resident 2 N/A N/A 3 8-12 Resident 4-6 0-7 Family Source: Nursing Home Quality (4/2011) QIS Update to Leading Age Colorado Harmony Healthcare International, Inc. 38 Stage I Data Collection Resident Interview & Observation Do staff treat you with respect and dignity? Activities needed equipment and availability on evenings, weekends Is this a comfortable building in which to live? Have you ever been treated roughly/rudely by staff? Harmony Healthcare International, Inc. 39 13
Stage I Data Collection Resident Interview & Observation Have you had any missing personal items? Does the food taste good and look appetizing? Do you feel there is enough staff available to make sure you get the care and assistance you need without having to wait a long time? Can you get your money when you need it, including on the weekends? Harmony Healthcare International, Inc. 40 Stage I Data Collection Resident Interview & Observation Unpleasant odors Food on hands, face Facial hair removed Glasses clean Fingernails clean Oral health problems Clothes fit properly Shoes appropriate Contractures Participation in activities s/sx dehydration s/sx pain Odor in PT room Evidence of pests Safety concerns Staff appearance and behavior with PT Harmony Healthcare International, Inc. 41 Stage I Data Collection Family Interview Three family members of noninterview-able residents will be interviewed (from the Census Sample) Interview to be conducted with a person that knows the resident well and visits the facility often enough to provide information about service provided Harmony Healthcare International, Inc. 42 14
Stage I Data Collection Family Interview Do staff treat with respect and dignity? Is there enough staff available in this facility to make sure that residents get the care and assistance they need without having to wait a long time? Have you ever noticed any staff member being rough with, talking in a demeaning way or yelling at or any other resident? Harmony Healthcare International, Inc. 43 Stage I Data Collection Census Sample Record Review Review includes: End stage disease Pressure ulcers Unnecessary medications Weight loss Harmony Healthcare International, Inc. 44 Stage I Data Collection Admission Sample Record Review Review includes: Discharge Rehospitalization Pressure ulcers Weight loss Admission Sample report now includes only closed records (i.e., no current residents) Harmony Healthcare International, Inc. 45. 15
Facility-level Tasks (non-staged) Resident Council President/Representative Interview Dining Observation Kitchen/Food Service Observation Infection Control Liability Notices and Beneficiary Appeal Rights Review Quality Assessment and Assurance Review Medication Administration Observation Medication Storage Harmony Healthcare International, Inc. 46 Facility-level Tasks (non-staged) Resident Council President or Representative Interview No more large group meeting Asks questions regarding Resident rights How grievances are handled by the facility Facilitation of resident council meetings Facility rules Harmony Healthcare International, Inc. 47 Facility-level Tasks (non-staged) Dining Observation Evaluates dining service for: Respect of resident preferences Promotion of maximum level of independence Positioning, equipment, etc. QOL, environment and sanitation of dining experience Sufficient staff to provide needed assistance Palatable food and available substitutes Harmony Healthcare International, Inc. 48 16
Facility-level Tasks (non-staged) Kitchen/Food Service Observation Evaluate: Food storage (including temperatures) Infection control practices Food handing practices (i.e., thawing of food) Food prep and services Dishwashing practices Equipment sanitation Refuse/pest control Harmony Healthcare International, Inc. 49 Facility-level Tasks (non-staged) Infection Control Includes: Infection control observations (i.e., hand washing, sharps disposal, PPE use, etc.) Review of infection control program Review of influenza and pneumococcal immunization programs Isolation/precautions Harmony Healthcare International, Inc. 50 Facility-level Tasks (non-staged) Liability Notices and Beneficiary Appeal Rights Review Examine denial notices Priority to examine demand billing for private pay resident Surveyor will: Review records and P&Ps Interview staff (SW, billing staff, etc.) Interview family or resident Harmony Healthcare International, Inc. 51 17
Facility-level Tasks (non-staged) Quality Assessment and Assurance (QAA) Review Goal is to determine if there is a committee that meets the requirements and examine if it is functioning Surveyor will Look for proof of when committee meets, who is involved, etc. Ask QAA coordinator questions Also will ask facility staff regarding QAA Harmony Healthcare International, Inc. 52 Facility-level Tasks (non-staged) Medication Administration Observation Observe 10 residents (randomly selected) Observe at least 50 medications Must observe meds administered by different routes Different shifts and staff are to be observed Harmony Healthcare International, Inc. 53 Facility-level Tasks (non-staged) Medication Storage Are meds stored safely, at correct temperatures, etc? Labeling, including expiration dates, checked Narcotic storage and records reviewed Narcotic disposal records reviewed Harmony Healthcare International, Inc. 54 18
Unnecessary Medication Review Not a Mandatory Task but acts like one Residents selected are those who are currently residing in the facility and have the most care areas identified for Stage II review Compliance with Medication Regime Review (MRR) requirement also reviewed Harmony Healthcare International, Inc. 55 Unnecessary Medication Review Medication regime evaluated to ensure: Adequate indication for use and monitoring Appropriate duration and dose Gradual dose reductions (unless medically contraindicated) Medication dose reduced or discontinued in presence of adverse drug reactions or side effects Harmony Healthcare International, Inc. 56 Complaint Investigation QIS is used for investigation of complaints during a QIS standard survey Surveyor-selected by survey team coordinator QIS is not used for investigation of complaint via abbreviated survey Harmony Healthcare International, Inc. 57 19
How Do Surveyors Move from Stage I into Stage II? Data collected in Stage I is combined with MDS data Outcome data is turned into 110 Quality of Care and Life Indicators (QCLIs): 78 Census 27 MDS 5 Admission QCLIs are compared to predetermined thresholds If threshold is exceeded, the Care Area (CA) is triggered Harmony Healthcare International, Inc. 58 Quality of Care and Life Indicators (QCLIs) Resident-centered and process indicators Calculations include numerator, denominator and exclusions When a QCLI exceeds its predetermined threshold, a care area is triggered for review in stage II QCLI Dictionary Harmony Healthcare International, Inc. 59 Quality of Care and Life Indicators (QCLIs) 13% 6% 5% 5% 13% 16% 26% 16% Resident Observation Resident Interview Family Interviews Staff Interviews Admission Chart Census Chart MDS QIs New MDS Indicators Harmony Healthcare International, Inc. 60 20
Care Areas CMS defines a Care Area as critical component of nursing home care If the threshold of a QCLI is exceeded, the care area will be triggered Care areas selected by the computer for review in Stage II of the QIS Harmony Healthcare International, Inc. 61 Stage II Sample Three residents from each triggered care area All surveyor-initiated residents Dialysis, hospice and ventilator residents Begin with one of each If problems found, expand to three and then further expand if needed for scope and severity All residents triggered for abuse Harmony Healthcare International, Inc. 62 How are Care Areas Investigated? Guidance to Surveyors from State Operations Manual (Appendix PP) General Critical Element Pathway (CEP) Specific Critical Element Pathway (CEP) Triggered Facility-level Task Harmony Healthcare International, Inc. 63 21
General Critical Element Pathway Is the comprehensive assessment complete? Is the care plan based on the assessment? Do the care and services meet professional standards of care? Is the care plan consistently implemented? Are revisions made to the plan of care as needed? Harmony Healthcare International, Inc. 64 Specific Critical Element Pathway Let s review two of them: Critical Elements for Pain Recognition and Management Critical Elements for Hospice, End of Life and/or Palliative Care Harmony Healthcare International, Inc. 65 Stage 2 Critical Elements for Pain Recognition and Management CEP instructs surveyor to: Observe resident, including receiving care Interview the resident, family, or responsible party Interview direct care staff Review record Harmony Healthcare International, Inc. 66 22
Stage 2 Critical Elements for Hospice, End of Life and/or Palliative Care CEP instructs surveyor to: Observe resident as well as resident and staff interactions Interview the resident, family, or responsible party Interview direct care staff and professional staff If appropriate, review practices related to communications with hospice Harmony Healthcare International, Inc. 67 Triggered Facility Level Tasks Abuse prohibition Admission/transfer/discharge Environment Sufficient nursing staff Personal funds Harmony Healthcare International, Inc. 68 Triggered Facility Level Tasks Abuse Prohibition Will include: Policy and procedure review Investigation of facility handing of allegations Interview of several resident and families to determine their awareness of how to report Interview of direct care staff re: reporting, etc. Interview of frontline supervisors re: monitoring of staff, preventing burnout, etc. Harmony Healthcare International, Inc. 69 23
Triggered Facility Level Tasks Admission/Transfer/Discharge Investigates residents rights, bed hold practices, facility-initiated resident transfer May include: Resident/family interview Record review Closed record review Harmony Healthcare International, Inc. 70 Triggered Facility Level Tasks Environment Includes: Observation of: Resident rooms Common areas Required postings Water temperatures Resident care equipment Harmony Healthcare International, Inc. 71 Triggered Facility Level Tasks Sufficient Nursing Staff Interview/review regarding: Sufficient licensed staff Regulatory minimums met? Supervision provided as needed? CNA assignments Families/residents to be interviewed regarding timeliness of assistance, etc. Determine is it a particular shift (etc.) that is problematic Harmony Healthcare International, Inc. 72 24
Triggered Facility Level Tasks Personal Funds Includes: Personal funds manager interview Record review Surety bond review Harmony Healthcare International, Inc. 73 Levels of Scope and Severity Harmony Healthcare International, Inc. 74 Determining Scope and Severity The computer does it automatically The surveyors determine severity for each resident as a deficient practice is found Scope is determined at the end of the survey as the team integrates data Harmony Healthcare International, Inc. 75 25
Exit Conference Varies by state procedures Should be no different than with the traditional survey Like the traditional survey, they likely will not disclose scope and severity but rather preliminary findings from survey Harmony Healthcare International, Inc. 76 Extended Survey Occurs with SQC level deficiencies in: 42 CFR 483.13, Resident Behavior and Facility Practices; 42 CFR 483.15, Quality of Life; and/or 42 CFR 483.25, Quality of Care. Harmony Healthcare International, Inc. 77 Extended Survey The Purpose To gather further information (unless already gathered during the standard survey) concerning the facility s nursing and medical services and administration Surveyors investigate 41 F-tags (through Guidance to Surveyors): 6 Nursing Services 7 Physician Services 6 Staff Qualifications 22 Administration Harmony Healthcare International, Inc. 78 26
Extended Survey The Timing At the discretion of the State Survey Agency, the QIS extended survey can be conducted either: Prior to exit of the standard survey Subsequent to standard survey but no longer than two weeks after completion of the standard survey Harmony Healthcare International, Inc. 79 The Plan of Correction (POC) If deficiencies are found during QIS, facility will be issued a CMS-2567 (SOD) just as in traditional survey Your SOD and POC will public documents In-depth analysis by the team of each deficiency leads to a POC that is meaningful and lasting Harmony Healthcare International, Inc. 80 The Plan of Correction (POC) Required Elements Corrective action for those found to be affected by the deficient practice How others potentially effected will be identified Systemic changes to ensure the practice does not recur Monitoring of corrective action Date of compliance Title of person responsible for compliance Harmony Healthcare International, Inc. 81 27
The QIS Post-Survey Revisit (Follow-up) Purpose: reevaluate the specific care and services that were cited as noncompliant and determine if the facility is and can remain compliant Facility must provide resident roster Information from standard survey will be used by surveyor Harmony Healthcare International, Inc. 82 The QIS Post-Survey Revisit (Follow-up) Areas reinvestigated using CE pathways (no Stage I activities) Surveyors will review SOD/POC off-site State, S/S of deficiencies and nature of deficiencies determine procedures for revisit QAA will be reevaluated as will areas found to be out of compliance on survey Harmony Healthcare International, Inc. 83 The QIS Post-Survey Revisit (Follow-up) Will evaluate at least three residents for each F-tag that facility was out of compliance with If not incompliance on revisit, procedures for enforcement action are initiated just as in standard survey Harmony Healthcare International, Inc. 84 28
Federal Oversight of a Quality Indicator Survey (FOQIS) Purpose of FOQIS is to: Evaluate the performance of a State Agency (SA) survey team during a certification survey To observe the SA team in determining compliance with Federal Certification requirements To determine the competence of the SA team in conducting the survey process Harmony Healthcare International, Inc. 85 Federal Oversight of a Quality Indicator Survey (FOQIS) Identify any low outliers for: Triggering rate for care areas and facility tasks Negative response rate by data source Facility task citation rate Care area/task citation rate when triggered at the state or district-level Harmony Healthcare International, Inc. 86 Federal Oversight of a Quality Indicator Survey (FOQIS) Federal Surveyors are told to review the state s survey schedule and select a survey for the FOQIS based on outliers Rather than trying to observe and evaluate all SA Stage I and Stage II investigations, FOQIS uses a targeted, data-driven approach to guide on-site investigations Harmony Healthcare International, Inc. 87 29
Federal Oversight of a Quality Indicator Survey (FOQIS) Unless logistically not possible, the federal surveyor should enter with the team First activity formally evaluated is the Initial Team Meeting Selection of tasks during the FOQIS is based on the state s survey history Federal surveyors will make parallel observations and attend interviews Harmony Healthcare International, Inc. 88 Federal Oversight of a Quality Indicator Survey (FOQIS) Each surveyor will be observed while conducting a resident interview and observation During Stage II, one care area or task for each surveyor will be observed, depending on which areas had a low citation rate when triggered Harmony Healthcare International, Inc. 89 Federal Oversight of a Quality Indicator Survey (FOQIS) When the state team is required to initiate a Stage II investigation due to a harm or IJ concern, a Stage II parallel investigation of the initiated care area and resident should be conducted by the federal surveyor Guidance is provided as to what to prioritize for parallel observation in Stage II if it is not possible to observe all tasks Harmony Healthcare International, Inc. 90 30
Differences Between the QIS and the Traditional Survey: Automation Traditional Survey team collects data and records the findings on paper The computer is only used to prepare the deficiencies recorded on the CMS-2567 QIS Each survey team member uses a tablet PC throughout the survey process to record findings that are synthesized and organized by the QIS software Harmony Healthcare International, Inc. 91 Differences Between the QIS and the Traditional Survey: Offsite Traditional Review OSCAR 3 and 4 report Survey team uses QM/QI report and review of complaint investigations offsite to identify preliminary sample of residents (about 20% of facility census) and areas of concern QIS Review the OSCAR 3 Report and current (uninvestigated) complaints Download the MDS data to tablet PCs DCT selects a random sample of residents for Stage I Harmony Healthcare International, Inc. 92 Differences Between the QIS and the Traditional Survey: Entrance Information Traditional Review of Roster Sample Matrix Form (CMS 802) QIS Obtain alphabetical resident census with room numbers and units List of new admissions over last 30 days Harmony Healthcare International, Inc. 93 31
Differences Between the QIS and the Traditional Survey: Tour Traditional Gather information about pre-selected residents and new concerns Determine whether preselected residents are still appropriate QIS No sample selection Initial overview of facility Harmony Healthcare International, Inc. 94 Differences Between the QIS and the Traditional Survey: Sample Selection Traditional Sample size determined by facility census Residents selected based on QM/QI percentiles and issues identified offsite and on tour QIS The ASE-Q provides a randomly selected sample of residents for the following: Admission sample is a review of up to 30 current or discharged resident records Census sample includes up to 40 current residents for observation, interview, and record review Harmony Healthcare International, Inc. 95 Differences Between the QIS and the Traditional Survey: Survey Structure Traditional Resident sample is about 20% of facility census for resident observations, interviews, and record reviews Phase I: Focused and comprehensive reviews based on QM/QI report and issues identified from offsite information and facility tour Phase II: Focused record reviews Facility and environmental tasks completed during the survey. QIS Stage I: Preliminary investigation of regulatory areas in the admission and census samples and mandatory facility-level tasks started Stage II: Completion of in-depth investigation of triggered care areas and/or facility-level tasks based on Stage I findings Harmony Healthcare International, Inc. 96 32
Differences Between the QIS and the Traditional Survey: Group Interview Traditional Meet with Resident Group/Council Includes Resident Council minutes review to identify concerns QIS Interview with Resident Council President or Representative Source: CMS Quality Indicator Survey/ASE-Q Brochure (4/11) Harmony Healthcare International, Inc. 97 Using the QIS Information in Facility QAA Activities Harmony Healthcare International, Inc. 98 Quality Assessment and Assurance Harmony Healthcare International, Inc. 99 33
F520 - Quality Assessment and Assurance A facility must maintain a quality assessment and assurance committee consisting of The Director of Nursing Services; A physician designated by the facility; and At least three other members of the facility s staff Harmony Healthcare International, Inc. 100 F521 - Quality Assessment and Assurance The quality assessment and assurance committee Meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and Develops and implements appropriate plans of action to correct identified quality deficiencies Harmony Healthcare International, Inc. 101 Intent of QAA Regulation.to ensure the facility has an established quality assurance committee in the facility which identifies and addresses quality issues, and implements corrective action plans as necessary Harmony Healthcare International, Inc. 102 34
Quality Assurance Should: Identify triggers that warn of an evolving problem Identify patterns Identify potential for reoccurrence Identify when changes are needed to interventions Ensure staff accountability Harmony Healthcare International, Inc. 103 So What QIS Tools Can Be Used as Part of Facility QAA? Harmony Healthcare International, Inc. 104 Tips to Using QIS Tools as QAA Ensure control over the documents they should be part of QAA and not end up in the charts! Decide how you will choose your sample Use the tools continually over time not once in a while for a review Harmony Healthcare International, Inc. 105 35
Tips to Using Interviews as QAA View the tools as a valuable means to gather information Look into any negative answer Ensure unbiased questioning when using the interviews Ask the questions exactly as written Ensure comments are documented and investigated Harmony Healthcare International, Inc. 106 Use Facility Level Tasks as Aids in Evaluating Facility Practices For example, consider: Using the Dining Observation tool to routinely evaluate processes, as a key when formulating policies and while providing staff education Allowing the Resident Council President/Representative Interview tool to guide facility staff regarding what to discuss with residents (i.e., resident right information) Harmony Healthcare International, Inc. 107 Use the Critical Element Pathways For instance: Use the Pressure Ulcer Critical Element Pathway to investigate a nosocomial pressure ulcer Use the Pain Management Critical Element Pathway to investigate pain management for a resident who is at end-of-life Use the Physical Restraint Critical Element Pathway while reviewing documentation for anyone with a restraint or a potential restraint Harmony Healthcare International, Inc. 108 36
The DPOC Model: Great for Problem Solving Assessment of Causative Factors Steps/Interventions Undertaken Triggers/Parameters to Signal of an Evolving Problem How the Facility Will Measure the Success of its Efforts Harmony Healthcare International, Inc. 109 Root Cause Analysis Step 1 Gather initial information Step 2 Fill in the gaps Step 3 Analysis Step 4 Action plan development Step 5 Evaluation of results Source: Oregon Patient Safety Commission Harmony Healthcare International, Inc. 110 Root Cause Analysis Step 1 Gather Initial Information Immediate data gathering; get the facts first Focus on what happened, not who did it Keep an open-minded attitude Source: Oregon Patient Safety Commission Harmony Healthcare International, Inc. 111 37
Root Cause Analysis Step 2 Fill in the Gaps Discuss the incidence as a team Identify gaps and reconcile differences of views Gather more information Investigate the scene of the incident and any involved equipment Source: Oregon Patient Safety Commission Harmony Healthcare International, Inc. 112 Root Cause Analysis Step 3 - Analysis Ask why until you can t ask it anymore! Review contributing factors Document Conduct the Common Sense Test on the conclusions or the investigation Source: Oregon Patient Safety Commission Harmony Healthcare International, Inc. 113 Root Cause Analysis Step 4 Action Plan Development Develop an immediate plan as well as (if needed) a long or short term plan Use the S.M.A.R.T.S. system for action plans Document the plan Implement the plan Consider the application of the plan to others Source: Oregon Patient Safety Commission Harmony Healthcare International, Inc. 114 38
A SMARTS Action Plan Specific Measurable Attainable Realistic Timely Supported Source: Oregon Patient Safety Commission Harmony Healthcare International, Inc. 115 Root Cause Analysis Step 5 Evaluation of Results Track the implementation Measure how each plan is doing Celebrate success Plan for maintaining the changes Source: Oregon Patient Safety Commission Harmony Healthcare International, Inc. 116 RCA A Case Study Harmony Healthcare International, Inc. 117 39
Root Cause Analysis Root Cause Analysis Materials for Long Term Care Facilities http://oregonpatientsafety.org/healthcar e-professionals/nursing-homes/rootcause-analysis-materials-for-long-termcare-facilities/283/ Harmony Healthcare International, Inc. 118 A Process to Consider for Revising Policies and Protocols Brain storm with the team regarding the steps Determine the specific and succinct steps Document each on a post-it, index card, etc. Layout steps Team dialogue and move/replace/add steps until process is agreed upon Harmony Healthcare International, Inc. 119 Process Improvement Considerations Evaluate policies/procedures/protocols Are they evidence-based? Are they followed? If not, why? Watch care practices Is the care plan available, understood and followed by staff? How is the care plan kept up-to-date? When changes are made, how is the team notified of them? Harmony Healthcare International, Inc. 120 40
Process Improvement Considerations How is resident noncompliance addressed by the team? Education Alternatives Documentation Reapproach Harmony Healthcare International, Inc. 121 Process Improvement Considerations Is staff knowledge an issue? Was formal education provided regarding the identified concern? How was attendance and retention of material documented? Are your policies and protocols the basis for education? Harmony Healthcare International, Inc. 122 Process Improvement Considerations What are documentation practices? Is documentation according to policy? Does the care plan, care card and chart all coincide? Are there multiple places to write the same thing? Are variations in the medical record explained (i.e., two disciplines see a different resident )? Is risk evaluation and care plan to address risks seen? Does documentation reflect that scope of practice limitations have been adhered to? Harmony Healthcare International, Inc. 123 41
Process Improvement Considerations Consider trends that may impact resident outcomes: New staff on a given unit Supervisor changes Issues with residents that may cluster on one caregiver s assignment Issues with residents that may coincide with changes in facility routines (i.e., meal time changes, activities programming changes) Harmony Healthcare International, Inc. 124 So Here s to Success!!! A few final tips: MBWA MDS accuracy Empower residents and staff Focus on satisfaction Use the tools in an ongoing fashion (not once in a while) Focus on any and all negative responses Harmony Healthcare International, Inc. 125 References Priority Order of QIS National Implementation (S&C Letter) http://www.cms.gov/surveycertificationgeninfo/ downloads/scletter09_50.pdf S & C Letter with Brochure describing the QIS http://www.cms.gov/surveycertificationgeninfo /downloads/scletter08-21.pdf QIS Forms and Worksheets https://www.qtso.com/qisdownload.html Harmony Healthcare International, Inc. 126 42
References QCLI Dictionary https://www.qtso.com/download/qcli/ju ly_2012_dictionary_for_posting.pdf Harmony Healthcare International, Inc. 127 Questions/Answers Harmony Healthcare International 1 (800) 530 4413 BDow@harmony-healthcare.com Harmony Healthcare International, Inc. 128 Harmony Healthcare International Have you Considered a Customized Complimentary HARMONY(HHI) MEDICARE PROGRAM EVALUATION or CASE MIX ANALYSIS for your Facility? Perhaps your facility has potential for additional revenue Benchmark your facility against key indicators and national norms Email us at for more information RUGS@harmony-healthcare.com Analysis is cost & obligation free Harmony Healthcare International, Inc. 129 43