QAPI: Driving Quality or Just Driving You Crazy Julie Kueker, MBA, MT(ASCP) Nursing Home QIN-QIO Task Lead Objectives Review the Final Rule Changes and Updates for QAPI Describe the format of QAPI methodology Know how to start a performance improvement project (PIP) Understand the components of a PIP using the PDSA approach Identify strategies to optimize and improve resident outcomes by utilizing QIO tools, resources and technical assistance 1
What is a QIN-QIO and How Can They Help? Medicare Quality Improvement Organization QIN-QIO: Quality Innovation Network Free Technical Assistance Webinars on cutting edge topics Free Tools and Resources The Final Rule: The QIO Makes it Easy Understand QAPI The Plan The Committee Performance Improvement Projects Where to start What do they look like Infection Control and Antibiotic Stewardship How should I prepare How to get started with an antibiotic stewardship plan 2
The Final Rule: Overhauling the Regulations The Centers for Medicare & Medicaid Services (CMS) recently released its final rule overhauling long-term care (LTC) facility participation requirements for Medicare and Medicaid ( Final Rule ) These requirements have not been comprehensively updated since 1991 Important Links All the information on the phases of implementation can be found on the Federal Register s website https://www.federalregister.gov/documents/2016/10/04/ 2016-23503/medicare-and-medicaid-programs-reform-ofrequirements-for-long-term-care-facilities The training that the surveyors are required to do for Phase 1 can be found on the CMS Surveyor Training website http://surveyortraining.cms.hhs.gov 3
Phase 2 Surveyor Training Modules https://surveyortraining.cms.hhs.gov/pubs/classinformation.aspx?cid=0cmsltcsme_vid 3-Phase Implementation 4
Phases of Implementation Phase 1 Quality Assurance Performance Improvement QAPI Program needs to be: Comprehensive Ongoing Data-driven Focus on systems of care Outcomes of care Quality of life Initial QAPI plan that will be submitted to the State Survey Agency on 11/28/2017 5
Form a Quality Assessment and Assurance (QAA) Committee Must have at least five staff members Leadership representative Administrator, owner, or board member, for example Medical Director or his/her designee Director of Nursing Services Choose good interdisciplinary staff members Phase 3 Infection Control and Prevention Officer Phases of Implementation 6
Phase 2 Quality Assurance Performance Improvement QAPI Plan: must be presented to surveyors at the first standard survey after effective date 11/28/2017 Evidence of ongoing implementation required upon request Maintain effective feedback from staff, residents and families/representatives Process for adverse events Performance Improvement Projects Measure and monitor success of QAPI projects Phase 2 QAPI Changes November 28, 2016 Phase 1 F520 Quality Assessment and Assurance November 28, 2017 Phase 2 F865 QAPI Plan F867 QAPI/QAA Improvement Activities F868 QAA Committee November 28, 2019 Phase 3 F865 QAPI Program/Plan F866 QAPI Feedback, Data & monitoring F867 QAPI/QAA Improvement Activities F868 QAA Committee 7
F865: QAPI Plan What Surveyors Look For A QAPI plan is the written plan containing the process that will guide the nursing home s efforts in assuring care and services are maintained at acceptable levels of performance, and continually improved. The plan describes how the facility will conduct QAPI and QAA committee functions. Key Points: On 11/28/17 the plan must address the QAA committee requirements On 11/28/19 the plan must be expanded to address the QAPI program requirements F865: Good Faith Attempts Good Faith Attempt a diligent and honest attempt to identify and correct an issue Consideration include: Severity of issue Timing Action taken 8
F867: QAPI/QAA Improvement Activities Develop and implement appropriate plans of action to correct identified quality deficiencies A quality deficiency is a deviation in performance resulting in an actual or potential undesirable outcome, or an opportunity for improvement. A quality deficiency is anything the facility considers to be in need of further investigation and correction or improvement Prioritize your opportunities for improvement F868: QAA Committee Frequency of Meetings Meet at least quarterly to identify issues with respect to which QAA activities are necessary, and develop and implement appropriate plans of action to correct identified quality deficiencies May meet more often as necessary to fulfill the committee s responsibility to identify and correct its own quality deficiencies effectively 9
Quality Assurance Performance Improvement (QAPI) QAPI: A process to continuously identify opportunities for improvement and address gaps in systems through planned interventions to improve the overall quality of care and services. QAPI at a Glance is available online at: http://cms.gov/medicare/provider-enrollment-and- Certification/QAPI/Downloads/QAPIAtaGlance.pdf 10
Quality Assurance Performance Improvement (QAPI) QAPI Plan Elements of the QAPI program must include: 1. Design and scope 2. Governance and leadership 3. Feedback, data systems and monitoring 4. Performance improvement projects 5. Systematic analysis and systemic action https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/qapiataglance.pdf 11
QAPI Steps 1-3 STEP 1: Leadership, Responsibility & Accountability STEP 2: Develop a Deliberate Approach to Teamwork STEP 3: Take your QAPI Pulse with a Self-Assessment QAPI Step 1: Leadership, Responsibility & Accountability Action Steps: Develop a steering committee, which is a team that will provide QAPI leadership. Provide resources for QAPI, including equipment and training. Establish a climate of open communication and respect. Understand your home s current culture and how it will promote performance improvement. 12
QAPI Step 2: Identify Your Gaps & Opportunities Action Steps: Assess the effectiveness of teamwork in your organization. Discuss how Performance Improvement Project (PIP) teams will work to address QAPI goals. Determine how direct care staff and residents and families can be involved in PIPs. Identify any communication structures that need to be implemented or enhanced. QAPI Step 3: Take Your QAPI Pulse with a Self-Assessment Action Steps: Determine a date and time for completing the Self-Assessment Tool. Assemble the right people to complete the Self-Assessment Tool. Complete the QAPI Self-Assessment Tool and record your answers for future comparison. Determine a date for the next Self-Assessment Tool review. 13
Group Activity: QAPI Self-Assessment Tool Don t Confuse With Your Annual Facility Assessment What kind of residents do you have Very complex illnesses What about dementia? Do our residents require a ventilator? Make sure the staff has the right skills to provide care Education and training That includes dementia management and resident abuse Does the physical environment and services match resident needs? Consider ethnic, cultural, or religious factors Health information technology 14
QAPI Steps 4-6 STEP 4: Identify Your Organization s Guiding Principles STEP 5: Develop Your QAPI Plan STEP 6: Conduct a QAPI Awareness Campaign QAPI Step 4: Identify Your Organization s Guiding Principles Action Steps: Locate or develop the following for your organization: Mission statement Vision statement QAPI purpose statement Establish guiding principles. Define the scope of QAPI in your organization. Assemble the document. 15
QAPI Step 5: Develop a QAPI Plan Action Steps: Determine date(s) and time(s) for writing the QAPI plan. Print copies of the Guide for Developing a QAPI plan for all team members. Work towards writing the QAPI plan. Determine a future date to review the QAPI plan. QAPI at a Glance: How to Write Your Plan 16
QAPI Step 6: Conduct a QAPI Awareness Campaign Action Steps: Inform everyone about QAPI (staff, residents, families, consultants, ancillary service providers, etc.). Provide training and education on QAPI. Develop a strategy for communication with all caregivers, residents and families. QAPI Steps 7-9 STEP 7: Develop a Strategy for Collecting & Using Data STEP 8: Identify Your Gaps & Opportunities STEP 9: Prioritize Opportunities & Charter PIPs 17
QAPI Step 7: Develop a Strategy for Collecting & Using Data Action Steps: Determine what data to monitor routinely. Set targets for performance in the areas you are monitoring. Identify benchmarks for performance. Develop a data collection plan, including who will collect which data, who will review it, then frequency of collection and reporting, etc. QAPI Step 8: Identify Your Gaps & Opportunities Action Steps: Review information to determine if gaps or patterns exist in your systems of care, or if opportunities exist to make improvements. Discuss any emerging themes with residents and caregivers. Notice what things your organization is doing well in this identified area. Set priorities for improvement. 18
QAPI Step 9: Prioritize Opportunities & Charter PIPs Action Steps: Prioritize opportunities for more intensive improvement work. Consider which problems will become the focus. Charter PIP teams by selecting a leader and defining the mission. The PIP team should develop a timeline and indicate budget needs. The PIP team should use the Goal Setting Worksheet to establish appropriate goals. QAPI Steps 10-12 STEP 10: Plan, Conduct and Document PIPs STEP 11: Get to the Root of the Problem STEP 12: Take Systemic Action 19
QAPI Step 10: Plan, Conduct and Document PIPs Action Steps: Determine what information is needed for the PIP. Determine a timeline and communicate it to the Steering Committee. Identify and request any needed supplies or equipment. Select or create measurement tools. Prepare and present results. Use a problem-solving model (e.g., PDSA). Report results to the Steering Committee. QAPI Step 11: Get to the Root of the Problem Action Steps: Using a methodical approach, determine all potential root cause(s) underlying the performance issue(s). Determine which factors are controllable. Ensure that the PSDA cycles address the root cause(s). 20
QAPI Step 12: Take Systematic Action Action Steps: Pick effective interventions Make sure interventions address systems issues not individual performance A mechanism to make sure things are working Start a Performance Improvement Project QAPI Performance Improvement Data My Quality Insights Composite Data Report CASPER Data Nursing Home Compare Five Star Internal Data Tracking 21
Performance Improvement Project 1 2 Overview include national guidelines and resources Root cause analysis 3 Goal-setting with timeline 4 Improvement data 5 Action plan and sustainability Phases of Implementation 22
Phase 3 QAA Committee for QAPI Membership minimum requirement Leader (administrator, board member, etc.) Director of Nursing Services Medical Director or his/her designee At least 3 other staff (leader is included) Infection Control and Prevention Officer Duties Meet at least quarterly/prn Coordinate/evaluate QAPI programs Develop/implement plans for quality deficiencies Review/analyze data The Start of the Performance Improvement Project 1. Choose the project Be proactive in your choice Is there data to support the need for change Will it improve the residents, families and staff lives 2. Team Members Multi-disciplinary Needs to be supported by leadership truly supported 3. Design the Project Timeline, scope, charter, tools needed, plan of action 23
Prioritizing Data Systems are in place to know what data to gather, who is gathering it, where your data falls in relation to benchmarks and thresholds and what your target is for each data point. You are now ready to prioritize areas for improvement. From the final rule F 520 : The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information. Must have a system to evaluate and prioritize 24
Prioritizing Data, cont. Factors such as high-risk, high-volume, or problemprone areas that affect health outcomes, quality of care, and quality of life should be considered Not all problems will require a Performance Improvement Project Some problems will require an immediate solution followed by a PIP to address systems Consider choosing something you believe will be easy to address for your first PIP Data: Where Most PIPs are Identified Data is the backbone of a strong QAPI program. Data comes from an almost limitless number of sources. The key is knowing what data is valuable to you in a given situation and understanding how to use the data to set, reach and maintain your goals. 25
Determine Where Your Information Comes From Internal Sources Resident/Family Council Resident Concern Logs Employee Feedback/Exit Interview Resident/Employee Incident Reports Satisfaction Surveys Facility Tools (rounding sheets, audits, IC reports, wound reports) External Sources Annual and Complaint Survey results CASPER Reports Nursing Home Compare Quality Insights Reports Adjacent Provider Feedback (Hospitals, Physicians, Transportation, Pharmacy, lab) Reports Contained on My Quality Insights Learning Platform 26
Reports Contained on My Quality Insights Learning Platform 27
Resident Roster Mix Pay Attention to the QM Count Nursing Home Compare, Five Star Rating and Casper Reports 28
Long Stay Quality Measures DATA in the Final Rule A facility must include, as part of its QAPI program, mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program (F490). A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following: Systems to obtain and use feedback and input from direct care staff, other staff, residents and resident representatives, including how information will be used to identify high risk, high volume or problem prone areas and opportunities for improvement Systems to identify, collect and use data and information from all departments and how such information will be used to develop and monitor performance indicators Develop, monitor and evaluate performance indicators, including the methodology and frequency for development, monitoring and evaluation Monitor adverse events, including the methods used to systematically identify, report, track, investigate, analyze and use data relating to adverse events to develop activities to prevent adverse events 29
Data Collection You ll want to develop a plan for the data you collect. Determine who reviews certain data, and how often. Collecting information is not helpful unless it is actually used. Be purposeful about who should review certain data and how often and about the next steps in interpreting the information. Data gathering should be well defined so it is reproducible Data Collection, cont. This data will require systematic organization and interpretation in order to achieve meaningful reporting and action. Otherwise, it would only be a collection of unrelated, diverse data and may not be useful. Resource: Measure/ Indicator Collection and Monitoring Plan What Measure are we using? When are we measuring this?(frequency) How do we measure this (where do we get our data)? Who is responsible for tracking this measure? What is our performance goal or aim? How will data findings be tracked and displayed? 30
Preparing Data For Use Data has been systematically gathered. This data will require systematic organization and interpretation in order to achieve meaningful reporting and action. Otherwise, it would only be a collection of unrelated, diverse data and may not be useful. Determining a benchmark, a target and threshold for each data set will allow you to identify gaps in performance using a predetermined framework. Set targets for performance in the areas you are monitoring. A target is a goal, usually stated as a percentage. May set both short term and long term goals. Identifying benchmarks for performance is an essential component of using data effectively with QAPI. A benchmark is a standard of comparison. May use state, national or internal benchmarks. Once a benchmark is achieved, consider resetting to foster continued improvement. Set threshold. In this case, a threshold is the point below which you deem unacceptable. Preparing Data For Use EXAMPLE Data gathered: Falls with injury on the dementia unit Benchmark: 1 fall (internal benchmark based on best month of past 12 months) Threshold: 6 falls ( based on internal data of most falls in a month of past 12) Target: 3 falls/month (short term) 1 fall (long term) 31
https://www.cms.gov/medicare/quality-initiatives-patient-assessment- Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-Users-Manual-V10.pdf 1. Percent of residents with one or more falls with major injury Important Tips: MDS question J1900C defines Major Injury as bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma A fall will trigger in the numerator for several quarters after the fact, potentially as long as a year 32
2. Percent of residents with a UTI Important Tips: A resident will not trigger this measure if the assessment is an admission assessment or a PPS 5-day or readmission/return assessment 3. Percent of residents who self-report moderate to severe pain Important Tips: 5-day look-back period A pain interview must be attempted on all residents Admission assessments are excluded Familiarize your Resident with your pain assessment tools 33
4. Percent of high-risk residents with pressure ulcers Important Tips: The CMS definition for high risk Capturing the diagnosis of malnutrition plays a big part in this measure s calculation 5. Percent of low-risk residents with loss of bowels or bladder Important Tips: 7-day look-back period Be aware of what MDS questions define low and high risk 34
6. Percent of residents with catheter inserted or left in bladder Important Tips: 7-day look-back period If a PU Stage II-IV is present, or frequent bowel incontinence in prior assessment will risk-adjust this score 7. Percent of residents physically restrained Important Tips: Bed/side rails ARE NOT part of the measure 7-day look-back period Restraints must be used daily in this lookback period to be in the numerator 35
8. Percent of residents whose need for help with ADL has increased continued Important Tips: This quality measure compares ADLs to the last assessment Hospice and life expectancy of less than 6 months are exclusions make sure to capture on MDS 36
9. Percent of residents who lose too much weight Important Tip: Reports those residents with a 5% or more weight loss in the last month, or 10% in the last 2 quarters not on a MD weight loss program 10. Percent of residents who have depressive symptoms Important Tips: 14-day look-back period Measure based on resident mood interview or a staff assessment of mood 37
11. Percent of residents who received antipsychotic medications Important Tips: There are only three conditions which exclude a resident It is a 7-day look-back period 12. Percent of residents assessed and appropriately given flu vaccine 38
13. Percent of residents assessed and appropriately given pneumococcal vaccine Let s Practice: Performance Improvement Project Now Showing: The Project 39
Step One: Choose the Project Does data reveal a great project Asking the resident and families Review incident reports Any near misses that shows your system needs to be redesigned Example: Antipsychotic Rate Shows And Opportunity for Improvement Data indicates that an antipsychotic reduction project is warranted Other good reasons: Focus for Survey CMS National Focus Reduces falls and lethargy in our residents Improves quality of life and ADLs Requires family education on quality journey 40
Antipsychotic Reduction: Starting Your QAPI Project Choose PIP team members that include: Front line staff Resident and/or family members Pharmacist Key clinical staff Leadership Gather your baseline data and initial project information. You have to know where you are going, to know how to set goals and improve. So, gather: Your CASPER Report Resident Roster Mix Report Pharmacy reports Chart review information The team may want to meet monthly to reach your goal Antipsychotic Reduction: Starting Your QAPI Project Antipsychotic reduction is a national focus: National Partnership to Improvement Dementia Care Final Rule released October 2016 Use of psychotropic drugs Gradual dose reductions and behavioral interventions How to make this your QAPI Performance Improvement Project (PIP) the project contains three elements: Root Cause Analysis Setting a stretch, yet attainable goal An action plan to improve with a plan for sustainability 41
Root Cause Analysis Keep asking why until you have identified the real causes to the problem An essential piece to any PIP because: Reviews all details to the problem All staff members provide input empowerment Focuses on the process, not people 42
The Fishbone Diagram This cause and effect diagram (fishbone) starts with a problem at the head of the fish, and for each category, answer the question, Why? Review all causes identified to drive the focus for the improvement plan There may be several causes of the problem Prioritize which item(s), if solved, would have the most positive impact Goal Setting for a QAPI Project Goal setting is important because you can quantify a measurable improvement result without guessing if you have gotten better. Goals should be a stretch, yet attainable. They should be clearly stated and describe what you intend to accomplish. Goals for your PIP are recommended to follow the SMART formula: Specific, Measureable, Attainable, Relevant and Time-Bound. 43
https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/qapiataglance.pdf Directions: Goal setting is important for any measurement related to performance improvement. This worksheet is intended to help QAPI teams establish appropriate goals for individual measures and also for performance improvement projects. Goals should be clearly stated and describe what the organization or team intends to accomplish. Use this worksheet to establish a goal by following the SMART formula outlined below. Note that setting a goal does not involve describing what steps will be taken to achieve the goal. Describe the business problem to be solved: Reduce antipsychotic quality measure rate by 25%, moving us from our current rate of 18.5% to 13.9% in six months. This will be accomplished by a multidisciplinary approach and person-directed principles to identify the root causes of unnecessary antipsychotic medication use. Limit use of psychotropic drugs, and institute non-pharmacological approaches to difficult behaviors. Use the SMART Formula to develop a goal: SPECIFIC Describe the goal in terms of a 3 W questions: What do we want to accomplish? Reduction of antipsychotic quality measure to 13.9% in six month, implementing best practices. Who will be involved/affected? Interdisciplinary team list out members (i.e. social worker, PT, DON, etc) Where will it take place? At our monthly QAPI meeting (i.e. the 1 st Wednesday of every month at 10 AM) MEASURABLE Describe how you will know if the goal is reached: What is the measure you will use? CASPER report; internal data tracking What is the current data figure (i.e., count, percent, rate) for that measure? December 2016 our CASPER antipsychotic quality measure rate is 18.5%. What do you want to increase/decrease that number to? We want to decrease the antipsychotic quality measure to 13.9% in six months. This example may or may not meet survey requirements. https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/qapiataglance.pdf 44
Action Plan for Improvement The Action Plan for Improvement needs to be based on the problem solving Plan, Do, Study, Act model Plan: Understanding the Antipsychotic Quality Measure https://www.cms.gov/medicare/quality-initiatives-patient-assessment- Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-Users-Manual-V10.pdf 45
Tools for PDSA to Improvement 46
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Track Your Progress Over Time 25 Antipsychotic PIP Project Antipsychotic Rate 20 15 10 5 Sunshine NH Rate National Average 0 Jan Feb Mar Apr May Jun Jul Aug Sep Questions For Your Team to Consider Is your staff ready for non-pharmacological interventions for difficult behaviors? Is staff educated to challenge antipsychotics on admission, to review for medical necessity? Is your medical director and/or nurse practitioners able to challenge an antipsychotic that was prescribed by a psychiatrist in the hospital? How are you using psychotropic drugs in your facility, is it PRN or off-label? Do you have criteria in place to review all psychotropic medications for medical necessity? Does your pharmacist have a good Gradual Dose Reduction mechanism? Do you review your quality measures at least monthly for improvement? Are nursing and MDS coders aware of how the Antipsychotic Quality Measure Works? 48
In Summary Using the following principles, you will be able to target areas to improve for your Antipsychotic Reduction Performance Improvement Project Ground work in the QAPI process Educate all staff on the improvement steps Assess system processes Perform Root Cause analysis Set stretch goal for the project Implement Plan-Do-Study-Act Cycles Monitor process change to secure improvement Learn from challenges and celebrate success Contact your Quality Insights for assistance with reaching your QAPI PIP goals In Summary Once you have reached your target goal, it is important to continue to monitor and educate to sustain your gains in this project. Celebrate successes to reward the hard work of improvement in your nursing home. 49
Resources to Make Things Easy http://qioprogram.org/nursing-home-training-sessions Whew! What if the Final Rule Has Me Overwhelmed? QAPI Resources Action Planning Worksheet QAPI at a Glance QAPI Toolkit Fishbone RCA 5-Whys RCA Goal Setting Worksheet Sustainability Guide Topic Example Documents Examples of our Topic Resources Antipsychotics Trigger Tools, Step-by-Step Guides to reduction Fall Management Care Plans, Risk Assessments Pressure Ulcer Prevention Skin Care Fair Pain Management Audit Tools, Team Tools 50
Still Overwhelmed? Call Me Julie Kueker 318-294-0458 jkueker@eqhs.org Thank you This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization for West Virginia, Pennsylvania, Delaware, New Jersey and Louisiana 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 number QI-C2-081817c 51