Enlarge the Pie: Leadership and QAPI Traci Treasure, MS, CPHQ, LNHA Quality Improvement Consultant LeadingAge Washington Annual Conference 2013 Qualis Health is one of the nation s leading healthcare consulting organizations, partnering with our clients across the country to improve care for millions of Americans every day Serving as the Medicare Quality Improvement Organization (QIO) for Idaho and Washington QIOs: the largest federal network dedicated to improving health quality at the community level 2
Enlarge the Pie 3 Outline Identify Best Practice QAPI National Change Package Qualis Health Collaborative Identify Opportunities Four steps for improvement PI model review Leaders role for transformation 5
PPACA Requirements The Affordable Care Act of 2010 requires nursing homes to have an acceptable, written, QAPI plan in place within 1 year of the promulgation of a QAPI regulation. Nursing Homes in the US will soon be required to develop QAPI plans. Written plan must be unique to the facility. QAPI is not new to the healthcare industry it is already required regulation in hospitals, hospice, ambulatory care, dialysis centers, transplant programs. 6 QAPI for Nursing Homes QAPI is Person-Centered: Resident & Family input is essential QAPI is broad in scope and continuous: All Staff, at All Levels, in All Departments use QAPI daily as part of their routine job duties, it is not just a program or project! QAPI is about systems thinking: Requires proactive analysis Is data and measurement driven Is supported by tools 7
The Five Elements of QAPI 1 1 Centers for Medicare & Medicaid Services http://www.cms.gov/medicare/provider-enrollment-and- Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-05.pdf 8 QAPI Pre-assessment Results 106 responses from homes in ID & WA 9
QAPI Status At least 3 or more homes have achieved stage 3 for every question The most homes at stage 3 for Just culture Governance Board support of QAPI The fewest homes at stage 3 for questions involving training and support of frontline caregivers in QAPI 10 Two Collaboratives National Best Practice nursing home tour Culture change 7 Guiding principles 3 Learning event webinars Qualis Health QAPI focus AP use and Dementia Care Affinity groups to support clinical changes of your choice 11
CMS Studied Nursing Homes Identify high performing nursing homes in order to learn more about their systems and processes that contribute to overall quality Specific focus HAI, HACs, antipsychotics Focused on successful practices of high performers Consistent high CMS 5-Star rating; Good performance on Quality Measures. Utilize the findings to share with any nursing home seeking to improve quality 12 Eligible for visits 13
Where they visited 14 Best Practice Principles 1. Lead with a sense of purpose 2. Recruit and retain a 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 15
Great, but what s that got to do with QAPI? Five elements of QAPI Design and scope Governance & Leadership Feedback, data systems, monitoring Performance Improvement Projects Systematic analysis and action Best practice guiding principles Lead with purpose Quality staff Connect with residents Teamwork/communication Continuous learning Clinical care Business practices 16 Changes You Can Try CMS Best Practices Change package QAPI at a Glance Focuses on the Five Elements and 12 Steps Qualis Health Change Ideas Specific to our Focus Topics: AP, Falls, Pain management, Re-hospitalization, others Sources: CMS change package, other known best practices and literature review www.qualishealthmedicare.org/nhcollaborative 17
Qualis Health Nursing Home Quality Care Collaborative February 2013 July 2014 Integrates with national collaborative Provides local support at in-person events Recaps content in webinars Supports peer-to-peer sharing and learning together Website with best practice and peer resources 18 Collaborative Activity To Date 133 Washington homes signed-up 70 homes have attended at least one learning event 11 shared storyboards 106 homes from ID and WA completed the QAPI self-assessment Action Period Reports from homes due by June 15 th! 19
Qualis Health Activity to Date In-person education and webinar series for Learning Session 1 QM data reports X3 QAPI pre-assessment report Organized affinity groups for clinical topics Enhanced website www.qualishealthmedicare.org/nhcollabo rative In-person and webinar events for Learning Session 2 20 Table Talk with Tip Sheets 21
Four Steps for Improvement Use your data and observe current practices Identify the gap from best practice Match the change to test to the gap/cause Train and support front line staff to do PI 22 1.a. Use Your Data Monitored QM rates not meeting goal Adverse event tracking New infection, pressure ulcer, fall, other HAC Unplanned readmission Incident report Survey citation Near-miss events Medication errors Resident/staff satisfaction scores 23
Internal Data Use data already readily available Management system data EHR or other system data Monitor QM on QIES monthly after 10 th of month Weekly logs (e.g. skin sheets) Other logs (e.g. transfers, calls) Collect new data within usual workflow One person, one shift, one time sample Tally sheets Days since last... 24 Comparison Data QIES Nursing Home Compare Corporate/Sister Facilities Published Best Practice 25
Speed of Improvement Gather just enough data one step faster than needed outcome Hourly By shift Daily Weekly Monthly Quarterly Annually 26 1.b. Observe Current Practice Go to the gemba Ask 5 people for an objective view of what usually happens and how standardized the process now is Use gap & cause system assessments May use RCA 27
2. Identify Best Practice Use a standardized system assessment Pressure ulcer system self-assessment QAPI self-assessment Others Use literature Change package best practice ideas Qualis Health website change ideas Use your own best-practice leaders 28 3. Match Change to Test Include people closest to the process in decisions about which changes to try Identify which best practice change ideas most closely match the system issues you identified in step 1 Make a short list of ideas to consider for testing in your organization 29
Selecting Changes to Test Requirements Repercussions Breadth of contributing factors Complexity of system Time & resources available Biggest impact Easy and low cost 30 A Few Models for PI IHI Model for Improvement Shewhart s PDSA Cycle Lean Just Culture Root Cause Analysis Any or all may be used in building your QAPI capacity 31
The Institute for Healthcare Improvement (IHI) Model for Improvement 2 What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? 2 http://www.ihi.org/knowledge/pages/howtoimprove/default.aspx 32 PDSA Cycle for Learning Improvement Act Adopt, Adapt, or Abandon? What changes are to be made? Next cycle? Study Complete the analysis of the data and compare to predictions. Summarize learning. Plan Charter your Team! Make Predictions - Who, What, When, Where? Do Carry out the plan use Lean? Document problems, unexpected observations. Begin analysis. 33
Definition of Lean in Healthcare An organization s cultural commitment to applying the scientific method to designing, performing, and continuously improving the work delivered by teams of people leading to measurably better value for patients and other stakeholders John Toussaint, MD ThedaCare Center for Healthcare Value 34 Title: What you are talking about. Background Recommendations Why are you talking about it? Current Situation What is your proposed countermeasure(s)? Where do we stand? What s the problem? Goal Where we need to be? What is the specific change you want to accomplish now? Plan What activities will be required for implementation and who will be responsible for what and when? Analysis -What is the root cause(s) of the problem? - Follow - up How we will know if the actions have the impact needed? What remaining issues can be anticipated? Verble/Shook 35
Lean Healthcare Six Principles 1. Value creation for patients 2. Unity of purpose (True North) 3. Continuous improvement (pursuing perfection) 4. Visual management 5. Standard work 6. Respect for people Excerpted from John Toussaint The Promise of Lean for Healthcare accepted for publication Mayo Clinic Proceedings July 2012 36 The Just Culture Designing systems to prevent errors from causing harm Encouraging transparency about errors and error reporting Creating a learning organization Developing appropriate responses to errors and harms: the CULTURE is JUST Does not mean lack of accountability Implementing Just Culture is a core element of QAPI! 37
The Just Culture Human Error Product of our current system design and behavioral choices Manage through changes in: Choices Processes Procedures Training Design Environment At-Risk Behavior A Choice: risk believed insignificant or justified Manage through: Removing incentives for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness Reckless Behavior Conscious disregard of substantial and unjustifiable risk Manage through: Remedial action Punitive action Console Coach Punish Thanks to the Just Culture Community and David Marx for this content 38 Root Cause Analysis? 39
Gap and Cause System Analysis Less formal and structured than Root Cause Analysis May use a formal system assessment tool May use standard questioning to collect organizational knowledge 40 System Assessments Use evidence-based best practice instruments Examples Pressure Ulcer System Assessment Emory Falls Management Self-Assessment TeamSTEPPS Readiness Assessment CLIP WHO Surgery Checklist Project RED 41
Go to the Gemba What happened to create the negative result? What usually happens? How standardized is the process now? What is in place to reduce risk of errors? Who/where in your organization has the best results? How do you share the learning from success with others throughout the organization? 42 Process Flow Diagram Answers the question what happened? Shows GAP not CAUSE Put bread on plate Spread peanut butter Spread jelly Put bread pieces together 43
5 Whys Method Event Why? Why? Why? Why? Why? Why? Why? Root Cause Root Cause Root Cause 44 Six-Factors for Human Performance Howard Sommerfeld 45
New Approach to RCA 1. Is this really a person or a system issue (apply Just Culture )? 2. Identify System Issue 3. Gap and Cause Analysis 4. Quality Improvement 46 4. Train and Support Front Line Staff Include PI tools in orientation Train & competency test for PI skills yearly Identify front-line staff PI champions Create space in schedules for PI activities Provide resources Computer Bulletin board Meeting space & time Materials Learning circles/sharing boards 47
Four Steps for Improvement Use your data and observe current practices Identify the gap from best practice Match the change to test to the gap/cause Train and support front line staff to do PI 48 How Do I Empower Front-line Staff? 49
The single most important critical factor missing in healthcare organizations is a management system that supports improvement A way to do it right the first time John Toussaint, ThedaCare Center for Healthcare Value 50 Most of what we call management consists of making it difficult for people to get their work done -Peter Drucker 51
Management by objectives: It nourishes short term performance, annihilates long term planning, builds fear, and demolishes teamwork. It leaves people bitter, crushed, bruised, battered, desolate, and despondent. - W. Edwards Deming 52 Management by Process A3 thinking define the problem first Daily status sheet Daily performance and defect review huddle Unit-based leadership teams Standard work for leaders and supervisors Standard work audits Visual progress tracking Lean Enterprise Institute: Toussaint webinar A Roadmap to Lean Healthcare Success originally presented: April 16, 2013 53
Change in Leader Behaviors All knowing In charge Autocratic Buck stops here Impatient Blaming Controlling Humility Curiosity Facilitator Teacher Student Communicator Perseverance 54 Can you say Yes every day? Are staff and doctors treated with dignity and respect by everyone in our organization? Do staff and doctors have the training and encouragement to do work that gives their life meaning? Have I recognized my staff and doctors for what they do? 55
The No Meeting Zone Theda Care best practice Create scheduled white space Use time for purposeful rounding at the front line Learn from front-line staff Use standard-work for leaders 56 56 Daily Stat Sheets - Alignment 57
Monthly Scorecard Alignment 58 Summary Identify Best Practice QAPI National Change Package Qualis Health Collaborative Identify Opportunities Four steps for improvement PI model review Leaders role for transformation 59
How will you enlarge your pie? 60 Online References Canadian RCA Framework http://www.patientsafetyinstitute.ca/english/toolsresources/rca/pag es/default.aspx Sommerfeld, H. (Feb 2011) Lean Production, Quality, Change and Training Take a System Approach. Automated Learning Corporation. http://www.automatedlearning.com/resources/lpperfsystem.pdf Lean Enterprise Institute: Toussaint webinar A Roadmap to Lean Healthcare Success originally presented: April 16, 2013 http://www.lean.org/events/webinarhome.cfm?utm_source=icontact &utm_medium=email&utm_campaign=chet%20messages&utm_co ntent=april26webarch#hcroadmap A3 Template www.lean.org/downloads/a3_ppt_templates.ppt Qualis Health Nursing Home Collaborative www.qualishealthmedicare.org/nhcollaborative 61
Questions? Traci Treasure, MS, CPHQ, LNHA Quality Improvement Consultant tracit@qualishealth.org 208-383-5947 For more information: www.qualishealthmedicare.org/nhcollaborative This material was prepared by Qualis Health, the Medicare Quality Improvement Organization for Idaho and Washington, 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. ID/WA-C7-QH-1116-05-13 62
Sources: Best Practices Tip Sheet Dementia Care and Appropriate Antipsychotic Medication Use Lead: Traci Treasure tracit@qualishealth.org 208-383-5947 Educate staff and family on different types of dementia, and approaches to care, including medication use, in order to reduce/eliminate the use of anti-psychotic medications. View disruptive behaviors as attempts to communicate needs. Explore patterns, times, potential causes to help understand the needs that are being communicated. Involve direct care staff on all shifts in identifying and sharing approaches that work for behavior disorders. For example, meet with nursing assistants to gather creative ideas and ways they have identified and met resident needs without the use of anti-psychotics. Provide individualized care based upon the resident s response. Empower the nursing assistants to use their best judgment and knowledge of the resident when caring for them. When anti-psychotic medications are used, document the specific reason for use. For example, instead of stating paranoia, describe specific symptoms such as not eating because of fear of being poisoned by food. Encourage staff to meet the resident s needs rather than accepting behaviors as typical. Promote an environment that has been proven to be supportive: quiet; normal routine of home, familiar areas, consistent staff, etc. National Nursing Home Quality Care Collaborative Change Package, Strategy 6.d. Change Concepts 29-35, page 35 http://www.qualishealthmedicare.org/sites/default/files/nhchangepackagev1.2.pdf CMS Partnership to Improve Dementia Care http://www.nhqualitycampaign.org/star_index.aspx?controls=dementiacare Advancing Excellence Campaign Medications goal http://www.nhqualitycampaign.org/star_index.aspx?controls=medicationsexploregoal Qualis Health Focus Topic web page on Dementia Care http://www.qualishealthmedicare.org/healthcareproviders/nursing-homes/quality-care-collaborative/focus-topics/dementia-care This material was prepared by Qualis Health, the Medicare Quality Improvement Organization for Idaho and Washington, under a 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. ID/WA-C7-QH-1113-05-13 DRAFT May 1, 2013 Qualis Health
Non-Drug Management of Problem Behaviors and Psychosis in Dementia STEP 1: Assess And Treats Contributing Factors FOCUS on one behavior at a time Note how often, how bad, how long, & document specific details Ask: What is really going on? What is causing the problem behavior? What is making it worse? IDENTIFY what leads to or triggers problems Physical: pain, infection, hunger/thirst, other needs? Psychological: loneliness, boredom, nothing to do? Environment: too much/too little going on; lost? Psychiatric: depression, anxiety, psychosis? REDUCE, ELIMINATE things that lead to or trigger the problems Treat medical/physical problems Offer pain medications for comfort or to help cooperation Address emotional needs: reassure, encourage, engage Offer enjoyable activities to do alone, 1:1, small group Remove or disguise misleading objects Redirect away from people or areas that lead to problems Try another approach; try again later Find out what works for others; get someone to help DOCUMENT outcomes If the behavior is reduced or manageable, go to Step 3 If the behavior persists, go to Step 2 STEP 2: Select and Apply Interventions CONSIDER retained abilities, preferences, resources Cognitive level Physical functional level Long-standing personality, life history, interests Preferred personal routines, daily schedules Personal/family/facility resources DEVELOP a Person-Centered plan Adjust caregiver approaches Adapt/change the environment Select/use best evidence-based interventions tailored to the person s unique needs/interests/abilities This material was prepared by University of Iowa and Agency for Healthcare Research and Quality, which has granted permission to duplicate for educational purposes. This copy has been provided by Qualis Health, the Medicare Quality Improvement Organization for Idaho and Washington, under a 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. ID/WA-C7-QH-1081-03-13
STEP 2: Select and Apply Interventions (continued) ADJUST your approach to the person Personal approach: cue, prompt, remind, distract; focus on person s wishes, interests, concerns; use/avoid touch as indicated. Do not try to reason, teach new routines, or ask to try harder. Daily routines: simplify tasks and put them in a regular order; offer limited choices; use long-standing patterns and preferences to guide routines and activities Communication style: simple words and phrases; speak in short sentences; speak clearly; wait for answers; make eye contact; monitor tone of voice and body language Unconditional positive regard: do not confront, challenge or explain misbeliefs (hallucinations, delusions, illusions); accept belief as real to the person; reassure, comfort, and distract ADAPT or CHANGE the environment Eliminate things that lead to confusion: clutter, TV, radio, noise, people talking; reflections in mirrors/dark windows; misunderstood pictures or decor Reduce things that cause stress: caffeine; extra people; holiday decorations; public TV Adjust stimulation: if overstimulated reduce noise, activity, and confusion; if under-stimulated (bored) increase activity and involvement Help with functioning: signs, cues, pictures help way-finding; increase lighting to reduce misinterpretation Involve in meaningful activities: personalized program of 1:1 and small group or large group as needed Change the setting: secure outdoor areas; decorative objects; objects to touch and hold; homelike features; smaller, divided recreational and dining areas; natural and bright light; spa-like bathing facilities; signs to help way-finding SELECT and USE evidence-based interventions Work with the team to fit the intervention to the person Check care plan for additional information Contact supervisor with problems/issues STEP 3: Monitor Outcomes and Adjust Course as Needed Track behavior problems using rang scale(s) Assure adequate dose (intensity, duration, frequency) of interventions Adapt/add interventions as needed to get the best possible outcomes Make sure all people working with the person understand and cooperate with the treatment plan and are trained as needed
QUALIS HEALTH Nursing Home Quality Care Collaborative Webinar recordings, materials, tools, news and progress and updates on learning sessions are available at www.qualishealthmedicare.org/nhcollaborative. Learning Session Action Period P D A S Plan-Do-Study-Act Enroll Participants Set Aim Study High Performers Prework P A D S P A D S P A D S Recruit Faculty Develop Framework and Changes LS1 Feb 2013 AP1 LS2 Apr/May 2013 AP2 LS3 Fall 2013 AP3 Summative Congresses and Publications Feb 2014 Supports: Email Visits Phone Conferences Team Reports Assessments This material was prepared by Qualis Health, the Medicare Quality Improvement Organization for Idaho and Washington, under a 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. ID/WA-C7-QH-1127-05-13 QUALIS HEALTH Nursing Home Quality Care Collaborative Webinar recordings, materials, tools, news and progress and updates on learning sessions are available at www.qualishealthmedicare.org/nhcollaborative. Learning Session Action Period P D A S Plan-Do-Study-Act Enroll Participants Set Aim Study High Performers Prework P A D S P A D S P A D S Recruit Faculty Develop Framework and Changes LS1 Feb 2013 AP1 LS2 Apr/May 2013 AP2 LS3 Fall 2013 AP3 Summative Congresses and Publications Feb 2014 Supports: Email Visits Phone Conferences Team Reports Assessments This material was prepared by Qualis Health, the Medicare Quality Improvement Organization for Idaho and Washington, under a 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. ID/WA-C7-QH-1127-05-13