TRANSFORMING QUALITY IMPROVEMENT Joel Elsenbroek Christina Matzke LeadingAge MI Annual Conference 2014
QAPI Section 6102(c) of the Affordable Care Act requires CMS to establish regulations in Quality Assurance and Performance Improvement (QAPI) and provide technical assistance to nursing homes to help them develop best practices to comply with the forthcoming regulations QAPI is the coordinated application of two mutually - reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, comprehensive, and data -driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving. CMS QAPI at a Glance
QAPI QA is the specification of standards for quality of service and outcomes, and a process throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards. QA is on-going, both anticipatory and retrospective in its efforts to identify how the organization is performing, including where and why facility performance is at risk or has failed to meet standards. PI (also called Quality Improvement - QI) is the continuous study and improvement of processes with the intent to better services or outcomes, and prevent or decrease the likelihood of problems, by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems or barriers to improvement. PI in nursing homes aims to improve processes involved in health care delivery and resident quality of life. PI can make good quality even better. CMS QAPI at a Glance
QAPI As a result, QAPI amounts to much more than a provision in Federal statute or regulation; it represents an ongoing, organized method of doing business to achieve optimum results, involving all levels of an organization. CMS QAPI at a Glance
PROPOSED RULE - CMS HHS/CMS RIN: 0938-AR61 Publication ID: Fall 2013 Title: Reform of Requirements for Long-Term Care Facilities and Quality Assurance and Performance Improvement (QAPI) Program (CMS- 3260-P) Abstract: This proposed rule would reform the Medicare conditions of participation for long-term care facilities to reflect significant changes in the industry and remove obsolete or unnecessary provisions. In addition, under the Affordable Care Act, this rule would propose to expand the level and scope of required QAPI activities to ensure that facilities continuously identify and correct quality deficiencies as well as promote and sustain performance improvement. Agency: Department of Health and Human Priority: Other Significant Services(HHS) RIN Status: Previously published in the Unified Agenda Stage of Rulemaking: Proposed Rule Stage Agenda Major: Undetermined Unfunded Mandates: Undetermined CFR Citation: 42 CFR 483 Legal Authority: PL 111-148, sec 6102; secs 1102, 11281 and 1871 Social Security Act Legal Deadline: None Timetable: Action Date FR Cite NPRM 03/00/2014 Additional Information: Includes Retrospective Review under E.O. 13563. Regulatory Flexibility Analysis Required: Government Levels Affected: State Undetermined Small Entities Affected: Businesses Federalism: No Included in the Regulatory Plan: No www.reginfo.gov
Why change if you don t have to?
F520 483.75(O) QUALITY ASSESSMENT AND ASSURANCE (1) A facility must maintain a quality assessment and assurance committee consisting of-- (i) The director of nursing services; (ii) A physician designated by the facility; and (ii) At least 3 other members of the facility s staff. Intent 483.75(o) The intent of this regulation is 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.
F521 (2) The quality assessment and assurance committee -- (i) Meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and (ii) Develops and implements appropriate plans of action to correct identified quality deficiencies. (3) A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section. (4) Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.
TRADITIONAL QA SHORT COMINGS Members were leadership only Met monthly, but physician and pharmacy couldn t meet monthly Set additional quarterly QA meeting to satisfy the regulation of participation. And another quarterly corporate QA meeting to finish the circle to executive leadership and the Board of Directors limited feedback Long meeting reporting on everything. Little to no collaboration Data was reported, but questionable if processes were actually addressed Majority didn t know why we were reporting on what we were reporting on No one outside of the meeting knew what QA was No root cause analysis Redundant Nothing really ever came off the list Each staff member made up their own tools and data collection Lots of paper to be filed Many, many sub committee s that were QA related, but not contributing to the reports made at QA Felt like we were meeting a regulated standard but not accomplishing anything.
TIME & ENERGY DRAINED
PATHWAY TO CHANGE Recognize this traditional QA format isn t functional, or meaningful to the organization Started talking about QAPI concepts at leadership meetings; sparking interest in change, allowed people to start thinking about the what if s what if we had less to audit but more useful results? what if the staff on the floor had a way to contribute? what if we could combine some of our meetings for one purpose?
QAPI AT A GLANCE http://www.cms.gov/medicare/provider-enrollment-and- Certification/SurveyCertificationGenInfo/Downloads/Survey -and- Cert-Letter-13-05.pdf Determine do we want to do/need to do/should do from this. Like everything else, weed out the unnecessary parts. Don t overwhelm your team with things they don t necessarily need to know. Complete self assessment tool as a team. Gather input to priorities
DEVELOPMENT OF TOOLS Be sure your measurements are justified: Do you have to track this? Do you want to track this? Should you track this? What are you going to do with this information? Not all things tracked need to be discussed
Tracking Tool data driven, uniformed, accessible, easy to use
Reporting Tool basic trends & accountability
PERFORMANCE IMPROVEMENT PROJECT Use the data reported in the QAPI meetings to identify Problems or Opportunities that require a PIP. Assemble your PIP team Format & track your progress PIP Meeting protocols Trouble Shooting Case Studies
PIP TEAM Players Facilitator Owner(s) Front line staff (HR/Leadership support) Who picks the team? Direct Supervisor Facilitator DON/Administrator Who do you need on your team? Good ones Bad ones Team Players
FORMAT AND TRACK PIP PROGRESS Team Charter Ensure Compliance Get Buy-in Set Structure QAPI Performance Improvement Project This charter team has been specifically selected to address an opportunity for improvement. Being on this team is an important part of your job and requires that you actively engage and contribute to the discussion. This team is required to provide written reports to the QAPI steering committee detailing the following agenda:
FORMAT & TRACK PIP PROGRESS Agenda Based on the Scientific Method PDCA Culture of Continuous Improvement PLAN Define the Problem (what, where, when, magnitude, trend) SMART Goal (specific, measurable, assigned, realistic, time-bound) Determine Measures/Data Root Cause Analysis Brainstorm Solutions/Experiments
FORMAT & TRACK PIP PROGRESS Agenda DO Construct Hypothesis Implement Solutions/Experiments Gather Data CHECK Compare Data to Starting Condition/SMART Goal Successful Yes or No? Brainstorm Solutions/Experiments Determine Measures/Data
FORMAT & TRACK PIP PROGRESS Agenda ACT Continue. Spread, or Start Over Standardize Work Policies & Procedures Control/Continuous Improvement
FORMAT & TRACK PIP PROGRESS PIP Status Report Reported at monthly QAPI meetings PIP Status Report Subject/Date Problem Goal Report Status Pre-Selct Menus 1/22 70% compliance on turning in menus by 11 am Increase compliance to 95% Everyone feels that filling out menus with residents has become standard work. Monthly Avg. 95.5% Next meeting 2/13 Med Errors 1/30 Falls 1/21 Reduce med errors on routine passes Too many falls throughout the facility on 2nd shift that have the potential to harm residents. lower transcriptional errors to no more than 3 per month PCC upgrade coming in FEB; reducing interuptions root cause analysis; revising fall report form 6 transcriptional errors in JAN; next meeting 2/19 still need to establish a goal; next meeting 2/5
FORMAT & TRACK PIP PROGRESS PIP Tracking Report (page 1) Used for notes in PIP meetings Performance Improvement Project Project: Start Date: Team Members: Assess Problem: SMART Goal: Measurement: Baseline: Target: Date Current Date Current Date Current
FORMAT & TRACK PIP PROGRESS PIP Tracking Report (page 2) Used for notes in PIP meetings Performance Improvement Project Project: Start Date: Root Cause Analysis Findings: Brainstorming Solutions/Experiments: Hypothesis: Experiment Results/Analysis:
PIP MEETING PROTOCOLS Timing Hold meetings between shifts 1 hour max Frequency Ideally every week Realistically every two weeks Atmosphere Closed Door Meeting Confidential & Safe Provide Snacks Follow the Agenda! Facilitator should be a PDCA Purist
PIP TROUBLE SHOOTING Don t let your Team Rush the Process Let QAPI be the bad guy! When the Pathway is Unclear When is doubt, use the QAPI forms http://cms.gov/medicare/provider-enrollment-and- Certification/QAPI/Downloads/ProcessToolFramework.pdf Lack of Commitment (I m too busy!) Look for Champions Team Dynamics (personalities clash) Must have a Facilitator Loss of Momentum (we re stuck!) Learn to be Comfortable with Discomfort
PIP TROUBLE SHOOTING
PIP TROUBLE SHOOTING
PIP CASE STUDIES Pre-Select Menus Problem: Pre-select menus on all halls are not ready for pick up by 11 am. Lately, approximately 30% of them have not been ready, which results in loss time for dietary having to track them down, food-prep time is delayed, and food shortages occur during the next day s lunch and supper. (What, Where, When, Magnitude, Trend)
PIP CASE STUDIES Pre-Select Menus SMART Goal: Achieve 95% compliance on having CNAs turn in preselect menus by 11 am on all halls for 3 consecutive months. (Specific, Measurable, Assigned, Realistic, Time -bound)
PIP CASE STUDIES Pre-Select Menus Determine Measurement/Data: Dietary will track % turned in on-time daily, and compile monthly averages, reporting results at PIP meetings.
PIP CASE STUDIES Pre-Select Menus Root Cause Analysis: CNA s don t have time to help residents fill them out because they are busy toileting, dressing, feeding Call lights are top priority so menus get forgotten Each hall is a little bit different so they require different solutions Lakeshore has two breakfast times, 7:30 & 9 am, and all of the residents at 9 am require assistance Not enough volunteers to chart/help out at mealtime
PIP CASE STUDIES Pre-Select Menus Brainstorm Solutions: Put the menus on the breakfast trays when they are delivered Assign the task to one volunteer Have volunteers who chart/help out at breakfast do it Involve family and have them help resident fill them out a week in advance Write Refused on the menu if the resident is unavailable (sleeping, not responding, doesn t care) Fill them out two days in advance (Ex: fill out Wed menu on Mon) Have restorative aids assist residents in filling out menus (Lakeshore) Pass out menus first, and then pass out breakfast trays
PIP CASE STUDIES Performance Improvement Project Project: Pre-Select Menus Start Date: 8/22/13 Team Members: Julie Schmuker, Amanda Krulek, Joel Elsenbroek, Kristen Contreras, Jessica VanBelkum, Amanda Walsh, Bobbie J. Marzean, Chris Terelo Assess Problem: Pre-select menus on all halls are not ready for pick up by 11 am. Lately, approximately 30% of them have not been ready, which results in loss time for dietary having to track them down, food-prep time is delayed, and food shortages occur during the next day s lunch and supper. SMART Goal: Achieve 95% compliance on having CNAs turn in pre-select menus by 11 am on all halls for 3 consecutive months. Measurement: track % turned in on-time daily, and compile monthly averages Baseline: 70% Target: 95% Date Current Date Current Date Current Aug-13 86% Sep-13 81% Oct-13 94% Nov-13 92% Dec-13 97% Jan-14 95% Feb-14 97%
PIP CASE STUDIES Performance Improvement Project Project: Pre-Select Menus Start Date: 8/22/13 Root Cause Analysis Findings: CNA s don t have time to help residents fill them out because they are busy toileting, dressing, feeding Call lights are top priority so menus get forgotten Each hall is a little bit different so they require different solutions Lakeshore has two breakfast times, 7:30 & 9 am, and all of the residents at 9 am require assistance Not enough volunteers to chart/help out at mealtime Brainstorming Solutions/Experiments: Put the menus on the breakfast trays when they are delivered Assign the task to one volunteer Have volunteers who chart/help out at breakfast do it Involve family and have them help resident fill them out a week in advance Write Refused on the menu if the resident is unavailable (sleeping, not responding, doesn t care) Fill them out two days in advance (Ex: fill out Wed menu on Mon) Have restorative aids assist residents in filling out menus (Lakeshore) Pass out menus first, and then pass out breakfast trays Hypothesis: Compliance will improve if we can get everyone to do it the same way and it becomes a habit. Experiment Results: Created standard work: 1. Grab the menu when you bring the tray 2. Fill out menu while feeding resident. 3. If the menu is still there when you go to pick up the tray, help them fill it out. 4. put menu back in clearly marked folder on top of cart. Analysis: daily compliance fluctuates but overall is up; staff awareness increased; pizza party planned for day when we first hit 95% compliance. Continue monitoring, Change dietary policy regarding pre-select menu choices and add standard work to competencies.
PIP CASE STUDIES Pre-Select Menus 100% Pre-Select Menus Turned In 95% Goal: 95% Compliance 90% % Compliance 85% 80% 75% 70% Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Month
PIP CASE STUDIES Fall Prevention Problem: Too many falls throughout the facility on 2nd shift with no or minimum injury, but could have the potential to harm residents. (What, Where, When, Magnitude, Trend)
PIP CASE STUDIES Fall Prevention SMART Goal: The Falls PIP team will create an effective falls investigation process (including standardized written form, online documentation, and staff training)by the end of May to capture 100% complete & accurate information on all investigations. (Specific, Measurable, Assigned, Realistic, Time -bound)
PIP CASE STUDIES Fall Prevention Determine Measurement/Data: Continue to track falls by: Number of Falls Frequent Fallers Shift Unit Classification (witnessed, un-witnessed, lowered to the floor) Level of injury
PIP CASE STUDIES Fall Prevention Root Cause Analysis: Toileting demands Resident anxiety/confusion Staff confusion on difference between witnessed and lowered to the floor (inconsistent language in EMR and written reports) Medication changes/side effects Infections (UTI & other) Lack of sleep cycle information (gathering & sharing) Changes in assistance level Inconsistent shift reports Incomplete incident report forms
PIP CASE STUDIES Fall Prevention Brainstorm Solutions: Create shift hand-off report for high risk residents Add hand-off report to daily team meetings Standardize language in EMR and written report (Fall Witnessed, Fall Un-witnessed, Lowered to Floor) Revise Falls Incident Reporting Form
GET EVERYONE ON BOARD Consultants Physician Exec s Board Team Pip s Communication board Non-pip sub-committee meetings; roaming
GIVE IT A WHIRL Policy Edit as you go Create a culture of change it s okay to start and make adjustments as needed. May need to help individuals with their tracking tool s depending on their level of comfort with technology Don t need to spend any money to start
QUESTIONS