2017 CALTCM Best Practices Summit QAPI in Action
Welcome and Introductions Dan Osterweil, MD, CMD CEO and Past President CALTCM
Disclosure Statement It is the policy of California Association of Long Term Care Medicine (CALTCM) to ensure balance, independence, objectivity, and scientific rigor in all of its sponsored educational programs. All faculty participating in any activities which are designated for AMA PRA Category 1 Credit(s) are expected to disclose to the audience any real or apparent conflict(s) of interest that may have a direct bearing on the subject matterof the CME activity. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker with a potential conflict of interest from making a presentation. It is merely intended that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It remains for the audience to determine whether the speakers outside interests may reflect a possible bias in either the exposition or the conclusions presented. The following faculty and planners have indicated any affiliation with organizations which have interests related to the content of this conference. This is pointed out to you so that you may form your own judgments about the presentations with full disclosure of the facts. All conflicts of interest have been resolved in accordance with the ACCME s Standards for Commercial Support.
Disclosure Statement
Disclosure Statement Faculty and Planners Role Affiliation/ Financial Interest Name of Organization Janice Hoffman, PharmD Planner Researcher, Grant Recipient Novartis Barbara Hulz Planner None Ashkan Javaheri, MD, CMD Planner None Jim Jensen, MHA, MA Planner None Albert Lam, MD Planner None Ezrah Lasola, BSN, RN, RAC-CT Faculty None Vanessa Mandal, MD Planner None Yamaira Moreno Staff None Dan Osterweil, MD, FACP Principal Investigator/Researcher None Novartis KJ Page, RN-BC, LNHA Planner None
Disclosure Statement Faculty and Planners Peter P. Patterson, MD, MBA, FCAP, FACMQ Role Faculty Affiliation/ Financial Interest None Name of Organization Rachel Price Planner None John Pizzo, RD Faculty None Denise Rettenmaier, DO Planner None Rajneet Sekhon, MD Planner None Jennette Silao, MBA, MPH Faculty/Planner None Karl Steinberg, MD, CMD, HMDC Planner Ad Board, Panel, Honoraria Non-branded Speakers Bureau, Honoraria Sunovian Boehringer Ingelheim Angelo Vargara Faculty None Mike Wasserman, MD, CMD Planner Editorial Board, Honoraria Merck Manual
Thank You to Our Sponsors!
Learning Objectives At the completion of this training participants will be able to: Describe best practices on managing chronically ill patients. Utilize Quality Assurance & Performance Improvement (QAPI) techniques for creating, modifying, and sustaining implementation plans. Identify barriers and develop contingency plans to overcome barriers for implementation. Disseminate resources and tools for facility -wide performance improvement project (PIP) implementation plans.
Agenda
Agenda (cont.)
Health Services Advisory Group and Quality Improvement Jennette Silao, MPH, MBA Director, Nursing Homes HSAG
HSAG: Your Partner in Healthcare Quality Nearly 25 percent of the nation s Medicare beneficiaries HSAG is the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands.
What is a QIN-QIO? Funded by the Centers for Medicare & Medicaid Services (CMS) QIN-QIO in each state Dedicated to improving health quality at the community level Ensures people with Medicare get the care they deserve, and improves care for everyone Department of Health & Human Services Centers for Medicare & Medicaid Services
Manage Diabetes Improve Coordination of Care Improve Medication Safety Improve Cardiac Health Patient is at the center of care. Improve Nursing Home Quality Improve Health Through Health Information Technology Reduce Hospital Infections
Join a Community to Reduce Admissions and Readmissions Goal: By December 2018, reduce admissions/readmissions to hospitals by 20%. Resources: Readmissions data Back to the basics Re-admission Reduction at the Skilled Nursing Facilities by Michael Tehrani, MD, CEO Apple Health, SNF Division HSAG website https://www.hsag.com/carecoordination-california Contact HSAG Angie Minasian, BS Quality Improvement Specialist 818.265.4683 aminasian@hsag.com
What and Who Make up the NNHQCC? The NNHQCC is a nationwide CMS initiative focused on improving quality of care in nursing homes. 915* NHs have joined the California NHQCC. 186 NHs enrolled in the CDC NHSN CDI** project * Nursing homes with signed participation agreements as of March 2017 ** Centers for Disease and Control and Prevention, National Healthcare Safety Network, Clostridium difficile Infection
National NHQCC Aims
California NHQCC Successes *RIR=Relative Improvement Rate Source: Minimum Data Set (MDS) 3.0 National Coordinating Center (NCC) Scorecard. Antipsychotic Rate baseline 1/1/13 12/31/13. Antipsychotic Rate and RIR metric calculated using the timeframe of 10/1/15 9/30/16. Composite Score metric calculated using the timeframe 4/1/15 9/30/16
Collaborative Approach: All-Teach, All-Learn Model Broadcast: One Speaker, Nine Listeners Peer-to-Peer: Seven Speakers, Seven Listeners vs.
The NHQCC Collaborative II: Learning Sessions and Action Periods
HSAG Assistance During Action Periods Conduct webinars and phone conferences. Communicate through e -mails. Present at company meetings via webinar or in-person. Review HSAG-developed nursing home data reports. Help finalize performance improvement projects and assist with developing PDSA cycles.
Peer Coach Support Help instill quality improvement methods in nursing homes Share success stories/best practices through The NHQCC newsletter Learning sessions One-on-one basis with nursing homes A Resident s Perspective on Quality Improvement YouTube Video: https://goo.gl/3he7jp Let HSAG know if you would like to receive peer coach support.
Learn, Adopt, and Sustain Learn about the five best practices Identify a best practice to adopt Develop an action plan and PIP charter Implement the action plan Measure your goal achievement
Round Robin Process Opportunity to quickly learn about five best practices Each speaker will present five times Presentation will include question and answer period No recording or photography is allowed Reminder: Please complete scoring form
Scoring Matrix
Introduction of Best Practices A Better Life Without Anti-Psychotic Medication Hugo Gozos, RN, BSN, Mesa Verde Post-Acute Care Center Antibiotic Stewardship Results-Oriented Protocol 2.0 Peter P. Patterson, MD, MBA, FCAP, FACMQ, Covenant Health Network Falling Star Program Ma. Teresa Caipang, RN, BSN, Norwalk Skilled Nursing and Wellness Center Liberalization of Therapeutic Diets in Long-Term Care: Effects on Health, Efficiency, Cost, and the Quality of Life John Pizzo, RD, Edgemoor Hospital D/P SNF Thanks for the Memories Angelo Vargara, Orange Healthcare & Wellness Centre
QAPI In Action and Best Practice Resources Jennette Silao, MPH, MBA
Objectives Utilize Quality Assurance & Performance Improvement (QAPI) techniques for creating, modifying, and sustaining implementation plans. Disseminate resources and tools for facility-wide performance improvement project (PIP) implementation plans.
Final Rules Reform of Requirements for Long-Term Care Facilities (LTCFs) QAPI Implementation Dates Phase 1 November 28, 2016 Phase 1 Quality Assessment and Assurance (QAA) Committee Phase 2 November 28, 2017 Phase 2 QAPI Plan Phase 3 November 28, 2019 Phase 3 QAPI Implementation and Include Infection Prevention and Control Officer (IPCO) in QAA Committee Federal Register (July 16, 2015). CMS. Reform of Requirements for LTCFs. Vol. 80, No. 136. Available at https://federalregister.gov/a/2015-17207
Final Rules Reform of Requirements for LTCFs Quality Assurance & Performance Improvement (QAPI) ( 483.75) To develop, implement, and maintain an effective comprehensive, data-driven QAPI program that focuses on systems of care, outcomes of care, and quality of life Federal Register (July 16, 2015). CMS. Reform of Requirements for LTCFs. Vol. 80, No. 136. Available at https://federalregister.gov/a/2015-17207
Final Rules QAPI, NH will Maintain documentation and demonstrate evidence of its QAPI program. Submit the QAPI plan to the State Agency or federal surveyor at the first annual recertification survey 1 year after the effective date. Present the QAPI plan at each annual recertification survey and upon request. Program addresses all services and programs. Federal Register (July 16, 2015). CMS. Reform of Requirements for LTCFs. Vol. 80, No. 136. Available at https://federalregister.gov/a/2015-17207
QAPI at a Glance Step-by-step guide to implementing QAPI, including the steps to write a QAPI plan Excellent problemsolving models (e.g., RCA) outlined in this resource http://cms.gov/medicare/provider-enrollment-and- Certification/QAPI/Downloads/QAPIataGlance.pdf
Companion Guide https://goo.gl/y4vazw
Five Elements of QAPI
PIP Charter Steps Review and analyze data, and assess for trends. Use MDS 3.0 Certification And Survey Provider Enhanced Reporting (CASPER) reports. Set Specific, Measurable, Attainable, Relevant, Timebound (SMART) goals.
PIP Charter Steps
QAPI Action Steps 1 to 6
TeamSTEPPS* Can you think of an example where communication was inadequate and led to a mistake or resident harm? What are some ways you have improved communication processes or systems to help staff provide the right information at the right time to avoid repeating that mistake? *Team Strategies and Tools to Enhance Performance and Patient Safety
What is TeamSTEPPS? An evidence-based framework that optimized resident care by improving communication and teamwork skills Includes specific tools and strategies that can help reduce the chance of error and help provide safer care
TeamSTEPPS in Long Term Care Video https://www.youtube.com/watch?v=ogdrvvqdhdc
Situation Background Assessment Recommendation (SBAR) SBAR developed in the military We are being attacked, surrounded on all sides, send help now! A framework to communicate about a situation that needs action and designed to reduce errors with miscommunication or lack of information.
SBAR (cont.) Situation: What is happening to the resident? Background: What is the clinical background? Assessment: What do I think is the problem? Recommendation : What would I recommend?
QAPI Action Steps 7 to 12
QAPI Self-Assessment Brief Survey What is your facility s QAPI implementation status? Not Started Just Started On Our Way Almost There Doing Great https://www.surveymonkey.com/r/caqapisa
Other QAPI Tools: QAPI SA Long Version
Other QAPI Tools (cont.)
Other QAPI Tools (cont.)
Develop Your QAPI Plan Tailor the plan to fit your NH including all units, programs, and resident groups Some large organizations or corporations may choose to develop a general plan for all NHs in the group (e.g., a corporate Quality Plan)
Key Components of a QAPI Plan Vision Mission Purpose Guiding Principles Scope and Design Governance and Leadership Feedback, Data Systems, and Monitoring Performance Improvement Projects Systematic Analysis and Systemic Action Communications Evaluation Establish of Plan https://www.hsag.com/ca-qapi-plan
Other QAPI Tools (cont.)
Develop SMART Goals Specific: What, who, and where? Measurable: Count, percent, rate? Attainable: Rationale for setting the goal. Relevant: How will the goal address the problem? Time-bound: Set target date to achieve goal. By December 2017, Green Acres, with leadership from the Antipsychotic Medication Reduction PIP Team, will decrease the long-stay antipsychotic quality-measure rate at Green Acres from the baseline rate of 25 percent (December 2016) to 10.0 percent, based on the MDS 3.0 CASPER Reports, and thereby improve the quality of care for residents with discontinued antipsychotics, especially those with dementia.
Change Package Source: Change Package NHQCC (March 2015) 11SOW-QINNCC-00109-02/24/15
NNHQCC Change Package Components Strategies Change Concepts Action Items Source: National Nursing Home Quality Care Collaborative Change Package
Change Package Strategies Strategies 1. Lead with a sense of purpose. 2. Recruit and retain quality staff. 3. Connect with residents in a celebration of their lives. 4. Nourish teamwork and communication. 5. Be a continuous learning organization. 6. Provide exceptional compassionate clinical care that treats the whole person. 7. Construct solid business practices that support your purpose.
Strategy 6: Provide exceptional compassionate clinical care that treats the whole person Change Concepts Transition with care (between shifts, departments, and all care settings). Action Items 6.c.2 Ensure that all changes in resident status have been communicated by having staff (for examples, nurses and nursing assistants or nursing assistants and nursing assistants) round together at the change of shift. Source: National Nursing Home Quality Care Collaborative Change Package
Best Practice Bundle: Steps to Prevent HAIs Source: http://www.hsag.com/en/medicare-providers/nursing-home/healthcare-associated-infections/
Best Practice Bundle: Steps to Avoid Unnecessary Antipsychotics
National Coordinating Center Nursing Home Training Sessions 1. TeamSTEPPS in LTC: Communication Strategies 2. Exploring Antibiotics and their Role in Fighting Bacterial Infections 3. Antibiotic Resistance: How it Happens and Strategies to Decrease the Spread of Resistance 4. Antibiotic stewardship 5. Clostridium difficile Part One: Clinical Overview 6. Clostridium difficile Part Two: Strategies to Prevent, Track and Monitor C. difficile Website: http://qioprogram.org/nursing-home-training-sessions Nursing continuing education certificates available.
Music and Memory Outcomes and Benefits Outcomes and Benefits Reduction in antipsychotics and other meds Effective approach to relieving boredom, reducing anxiety or pain Increase staff and family satisfaction Great opportunity for intergenerational relationships Regulatory focus on dementia care policies and practices Public image opportunities through media, fundraisers
Music and Memory Program Overview Letitia Rogers Regional Director, Western US 619.538.0878 lrogers@musicandmemory.org CAHF Music and Memory Project 4,500 residents in 300 nursing homes UC Davis research component Certification and training Equipment UCD-QAPI resource/tools Enrolling for Phase Two and Phase Three Amanda Davidson, Project Coordinator adavidson@cahf.org (916) 432-5209
CA NHQCC II Go For the Gold Qualification Criteria Sign Participation Agreement Submit facility team roster Complete QAPI self-assessment for Collaborative II Complete QAPI Plan Complete PIP Charter Meet bronze-level criteria Attend at least two learning opportunities* Achieve PIP goal established in the Charter Meet silver-level criteria Achieve a Quality Measure Composite Score of 6 percent or less at least once during the collaborative *Education opportunities include HSAG in-person learning sessions, webinars, and onsite staff visits. Education may also include partner opportunities.
Qualification Criteria (continued) Meet bronze, silver, and gold-level criteria Achieve 5% on antipsychotic medication rates among long-stay residents during the Collaborative*. *The nursing home antipsychotic data will be reviewed based on the data from the National Coordinating Center for Collaborative II.
Collaborative I Recognition Autumn Hills Healthcare Country Manor Healthcare
HSAG Website QAPI Resources www.hsag.com/qapi
Are You Receiving Monthly Email Updates? Email us to be added! canursinghomes@hsag.com
CMS QAPI Tools http://www.cms.gov/medicare/provider-enrollment-and- Certification/QAPI/qapitools.html
Call to Action Start developing your QAPI plan. Complete your QAPI self-assessment. Apply elements of the best practices resources. Aim high and achieve the platinum level in the Go For the Gold recognition program.
Using QAPI to Implement Antibiotic Stewardship in Nursing Homes Ezrah Lasola, BSN, RN, RAC-CT Quality Improvement Specialist, Nursing Homes, HSAG
Objectives 1 Review the performance improvement project (PIP) process. 2 Utilize QAPI tools and techniques for creating, modifying, and sustaining infection control teams. 3 Practice completing a PIP charter.
Transforming the lives of nursing home residents through continuous attention to quality of care and quality of life
Five Elements of QAPI
PIP Process
Start a PIP Charter
Form a PIP Team Which staff is appropriate for your project? Who are the early adopters? Who are those that resist change? Who has the experience and knowledge for your project? Antibiotic Stewardship Core Element: Leadership Commitment
Select Team Members Antibiotic Stewardship Core Element: Accountability
Identify Areas for Improvement Identify Problem Areas State survey results Complaints (staff, family, residents) Quality Measures Facility reports (surveillance, fall logs) Problem to be solved: The team observed that the number of Clostridium difficile (C. diff) events increased from 1 event in January 2017 to a total of 7 events in March based on their surveillance report. Based on the National Healthcare Safety Network (NHSN), an event is defined as a facility acquired C. diff infection.
Identify Areas for Improvement Identify Problem Areas State survey results Complaints (staff, family, residents) Quality Measures Facility reports (Surveillance Log) Background leading up to the need for this project: Increased incidence of C. diff events over the last three months from 1 event per month from January to February 2017 to 7 events in March 2017 based on the surveillance report. These incidents seem to be affecting the patient population in Station A of the facility.
Set SMART Goals Specific Measurable Achievable Realistic Time Dated The goal(s) for this project: To decrease the number of C. diff events within Station A of Happy Acres Nursing Center from 7 events to 0 events by October 31, 2017 based on the March 2017 surveillance report.
Project Plan Recommended Project Time Table: Project Phase Start Date End Date Initiation: Project charter developed and approved Planning: Specific tasks and processes to achieve goals defined May 1, 2017 May 1, 2017 May 1, 2017 May 1, 2017 Implementation: Project carried out May 2, 2017 June 1, 2017 Monitoring: Project progress observed and results documented Closing: Project brought to a close and summary report written May 2, 2017 October 31, 2017 October 31, 2017 November 10, 2017
Project Plan (cont.) Project Team and Responsibilities: Title Role Person Assigned Project Sponsor Project Director Project Manager Provide overall direction and oversee financing for the project Coordinate, organize, and direct all activities of the project team Manage day-to-day project operations, including collecting and displaying data from the project and infection prevention and control duties Dr. Feelgood, Medical Director Jack Doe, Director of Nursing (DON) Susie Lookup, Assistant Director of Nursing (ADON) and Infection Control Officer (ICO) Team members* Assisting in examining policy and procedures Jose Reyes, Consultant Pharmacist John Smith, Director of Staff Development Susie Anne, Housekeeping Supervisor Assist in data collection Antibiotic Stewardship Core Element: Drug Expertise Anna Cruz, Charge Nurse John Smith, Director of Staff Development
Project Plan (cont.) Material Resources Required for the Project: 1. Project Binder, labeled 2. Surveillance log/checklist 3. Monthly Surveillance Report Print-out 4. Hand washing signs 5. Enrollment to National Healthcare Safety Network (NHSN) for the Infection Preventionist and additional staff (including Notary for Identity Verification) 6. Staff In-service materials: Power Point presentation (Topics: C. Diff Prevention, Antibiotic Stewardship), Projector, Screen, Computer, Paper Handouts 7. Education Tools for family and residents (Paper Tip Sheets: C. Diff, Power Point presentation, Projector, Screen, Computer) 8. Possible overtime pay (for in-service trainings)
Conduct a Root Cause Analysis (RCA) Identify root causes of your area(s) of concern. Performing a Root-Cause Analysis can help you focus on issues you have more control over and prioritize those that you can easily address.
RCA: Fishbone
Develop and Implement Quality Initiatives Education System changes Policy changes Enhance communication procedures Situation, Background, Assessment, Recommendation (SBAR) Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) Antibiotic Stewardship Core Element: Education
Develop and Implement Quality Initiatives (cont.) Action Item Person(s) Responsible Start Date End Date Educate all staff on their responsibility to prevent C. diff Conduct competency testing for nurses and nursing assistants on proper hand washing techniques Request the Medical Director to speak with other Physician s regarding new guidelines in antibiotic administration Establish an Infection Prevention and Control Team, identify an Infection Control Officer Start an Antibiotic Stewardship Program (including policies and procedures) Infection Prevention and Control Officer, Director of Staff Development May 2, 2017 May 12, 2017 Director of Staff Development May 2, 2017 May 19, 2017 Nursing Home Administrator May 2, 2017 May 31, 2017 Director of Nurses May 2, 2017 May 12, 2017 Infection Control Officer, Director of Nurses, Medical Director, Nursing Home Administrator May 2, 2017 May 31, 2017
Test Changes Using the PDSA Cycle During a PIP, attempt some changes and then see whether or not they made a difference in the area you were trying to improve using the PDSA cycle. Antibiotic Stewardship Core Element: Action *PDSA=Plan, Do, Study, Act
Monitor the QI Plan to Sustain Improvement Which data resources do you plan to use to measure your project process and outcomes? Administrative data, chart audits Quality measures MDS data Fall/Surveillance Log National Healthcare Safety Network (NHSN) Antibiotic Stewardship Core Element: Tracking
Look at Your Data Residents in Station A with C. difficile Antibiotic Stewardship Core Element: Reporting
Follow Through to Completion
Resources https://goo.gl/bprf6a
Infection Surveillance http://www.cdc.gov/nhsn/ltc/index.html
Starting an Antibiotic Stewardship Program Source: https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html
Questions?????
Action Plan Activity Create an action plan based on best practice interventions.
Where to Go From Here?
Closing Remarks Successful implementation tip: Be selective, choose one innovation with high priority and documented need. Focus on one innovation at a time. Select champion(s) who are passionate about the topic. Someone who has a personal interest and wants to see it succeed. Provide dedicated time to the champion and project manager.
Tips Invest in a collaborative environment in your organization. Develop a new work flow, including changes to communication paths and staff roles. Invest in building relationships with attending providers. Consult HSAG staff for any assistance and resources on your innovation.
Evaluations If you do not want CME/CEU credit, please turn in a paper evaluation today. If you do want CME/CEU credit, you must complete the online Survey Monkey evaluation to receive credit. It will be emailed to attendees.
Best Practice Award CALTCM will present the best practice award tomorrow afternoon!
HSAG CA Nursing Home Team Jennette Silao, MPH, MBA Director jsilao@hsag.com Evangeline Molnar, NHA, BS Quality Improvement Specialist emolnar@hsag.com Rose Chen, MPH, RD, RAC-CT Associate Director rchen@hsag.com Rachel Price, MSG Quality Improvement Specialist rprice@hsag.com Ezrah Lasola, BSN, RN, RAC-CT Quality Improvement Specialist elasola@hsag.com Joel Wingelman Event Planner jwingelman@hsag.com Team email canursinghomes@hsag.com
CALTCM Contact Barbara Hulz Project Director bhulz@caltcm.org
CALTCM Poster Session The CALTCM Poster Session is an accredited event. The Poster Session offers two viewing opportunities; if you are attending the annual meeting we suggest attending the evening session. A Survey Monkey link will be emailed to all registered participants.
This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for California under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. CA-11SOW-C.2-04182017-01