LeadingAge New York Technology Solutions

LeadingAge New York Technology Solutions How to Measure for QAPI Success Susan Chenail, RN, CCM, RAC CT Senior Quality Improvement Analyst Todays Objectives Define QAPI Provide background of QAPI initiative Importance of QAPI Explain the meaning and use of data for QAPI Demonstrate use of LeadingAge tools for QAPI Describe steps to performance improvement using Analytic tools Introduce Quality Apex for demonstrating performance improvement 2 1

What exactly is QAPI? The merger of two complementary approaches to quality: Quality Assurance (QA) + Performance Improvement (PI) = QAPI QA meets quality standards; efforts can end once standard is met PI aims to improve processes to make good quality even better QAPI is a data driven, proactive approach to improving the quality of life, care and services in nursing facilities. Activities of QAPI involve members at all levels of the organization to identify opportunities for improvement; address systems issues, develop and implement corrective plans; and continuously monitor effectiveness of interventions. QAPI is not so much a program; rather it s the way we want to do our work on a daily basis. 3 Facility Assessment and Competency Based Approach Facilities need to know themselves, their staff, and their residents. Not a one size fits all approach. Accounts for and allows for diversity in populations and facilities. Focus on each resident achieving their highest practicable physical, mental, and psychosocial wellbeing. 4 2

Five Elements of QAPI 5 Why QAPI Now? CMS hopes QAPI efforts will prevent adverse events. March 2010: Provision set forth in Affordable Care Act, Section 6102(c) states that CMS shall establish QAPI program standards and provide technical assistance to nursing facilities. September 2011: CMS launches a prototype QAPI program in a small number of nursing facilities which results in best practices and the establishment of QAPI tools and resources in advance of an QAPI regulation. February 2014: OIG released its report Adverse Events in SNFs: National Incidence among Medicare Beneficiaries. It reported that one in three SNF beneficiaries were harmed by an adverse event or temporary harm event within the first 35 days of their skilled stay. The OIG determined that nearly 60 percent of those events were preventable. November 2016 Nursing Facilities required to Establish a QAPI Plan November 2017 Nursing Facilities required to present their Plan to Surveyors November 2019 Full implementation of QAPI 6 3

Adverse Events and Temporary Harm 7 Phased In Implementation Schedule Phase 1 Phase 2 Phase 3 November 2016 November 2017 November 2019 Existing Requirements All Phase 1 Requirements All Phase 1 and 2 Requirements Those requirements relatively straightforward to implement Require minor changes to survey process Those that providers need more time to develop Foundational elements Those requirements that need more time to implement Personnel hiring and training New survey process can assess compliance Implementation of systems Approaches to quality 8 4

Phased In Implementation Schedule 483.75 Quality Assurance and Performance Improvement Phase 1 Phase 2 Phase 3 November 2016 November 2017 November 2019 Existing Requirements All Phase 1 Requirements All Phase 1 and 2 Requirements Participation in QAA Committee and maintain existing QAA requirements QAPI Plan as required by Affordable Care Act Full Implementation of QAPI 9 Phased In Implementation Schedule 483.35 Nursing Services Phase 1 Phase 2 Phase 3 November 2016 November 2017 November 2019 Existing Requirements All Phase 1 Requirements All Phase 1 and 2 Requirements This section contains many existing requirements that will be implemented in this phase Need both sufficient and competent staffing based on resident population. This determination is tied to Facility s Assessment 10 5

Phased In Implementation Schedule 483.12 Freedom from Abuse, Neglect, and Exploitation Phase 1 Phase 2 Phase 3 November 2016 November 2017 November 2019 Existing Requirements All Phase 1 Requirements All Phase 1 and 2 Requirements Strengthens existing protections, in addition to review of policies and procedures Regulatory inclusion of 1150B requirements (Reporting reasonable suspicion of a crime) QAPI must be involved in review of allegations/incidences of abuse, neglect, and exploitation Adds language related to resident right to be free from neglect and exploitation This is an existing requirement under the Statute 11 QAPI and Customer Satisfaction Residents Residents report increased care satisfaction when they are actively engaged in the facility s care processes. CMS is promoting resident engagement, voice and choice. Staff Staff report increased job satisfaction when engaged in the QAPI process like PIP s. They report pride in their job and ownership of improvements leading to better sustainability. 12 6

QAPI can help you improve your Quality Measures which are updated on the 5 Star Rating System quarterly 13 New York s Average Overall Rating is just above 3 Stars and just below the National Average https://www.cga.ct.gov/2016/rpt/2016 R 0162.htm 14 7

What exactly is Data? Collection of facts, such as numbers, words, measurements, observations or even just descriptions of things. It can be collected, tracked, reviewed and used as a basis for reasoning, discussion or calculation. Data values can be meaningless by itself. To create information out of the data, we need to interpret the data. Nursing Facilities collect all sorts of data: Incident and Accident Reports, Staffing Hours, Survey Findings, Resident and Family Satisfaction, Complaints and MDS Quality Measures (QMs). 15 Data Guides Performance Improvement Some data is easier than others to put a system in place for collection Quality measures vs. spontaneous comments from residents or families For all data sources, create a process to collect and document Everyone has a role in identifying data for QAPI! Select a range of data that reflects your organization s unique characteristics and services Financial, clinical, resident quality of life, staffing, and rehabilitative service 16 8

So.Don t Just Collect Data! Review it Analyze it Identify opportunities for improvement Check for data integrity Set a goal or aim Benchmark Monitor Provide Feedback 17 Leading Age Data Tools Quality Metrics 5 Star NH Trend Report 18 9

Use LeadingAge Tools Here Five Elements of QAPI Use LeadingAge Tools Here Use LeadingAge Tools Here 19 Leading Age Tools and QAPI compliance Identify PIP Dashboard NH Trend Report 5 Star Analysis Quality Apex Story Board Quality Metrics Goal setting Communication 20 10

Where does Quality Metrics NH Trend Report fit into your QAPI? Element #4 21 Nursing Home Trend Report: Identify Performance Improvement Opportunities Use Quality Metrics NH Trend Report to Identify areas to include in your QAPI performance improvement project (PIP). The provider is the line in red. 22 11

Where does Quality Apex fit into your QAPI? Project where you are here Element #3 Set Goal 23 Dashboards and QAPI What is a dashboard? A dashboard is a system to track key performance indicators within an organization. It is meant to be designed so that it is easy to read and quick to understand, providing signals of where things are going well and where there are problems to address. Why is a dashboard important? Regular monitoring of data is critical for effective decision making in any organization. A dashboard is an ideal way to prioritize the most important indicators for a particular organization and encourage regular monitoring of the results. Step 1 Review dashboard basics: Step 2 Decide how your dashboard will be used: Step 3 Create your dashboard: Step 4 Use your dashboard: Step 5 Revisit your dashboard: 24 12

Quality Apex Dashboard Dashboard displays up to date information based on uploads. User set goals and indicator outlines when you are meeting/not meeting those goals. Facility specific rates and where you are in the cut point for 5 Star. 25 Quality Apex Goal Setting and Projects Add your QAPI PIP. Set a goal. Communicate with team members. 26 13

Where does Quality Metrics fit into Your QAPI Element #5 27 What is a Storyboard? A storyboard is a tool that can be used to simply and clearly communicate the story of a performance improvement project (PIP). The aim of a storyboard is to allow audiences to quickly grasp the main points of the story by providing only the most essential information and including one or more easy to understand charts that demonstrate the impact of the plan. https://www.cms.gov/medicare/provider Enrollment and Certification/QAPI/downloads/PIPStoryBdGuide.pdf 28 14

Use Quality Metrics for your Storyboard New Philosophy for restraint use New Assessment of Enabler vs Restraint Initiated music therapy for Dementia Residents CNA Education Campaign 29 Use Quality Metrics to Communicate Progress Toward Goal Rate Now Goal Rate 30 15

Where does 5 Star Analysis fit into Your QAPI Element #5 31 Nursing Home Five Star Analysis Two examples of QAPI s effect On the 5 Star Rating System 16

In July 2016 this NY Facility decided to study and implement a PIP on Successful Community Discharges After root cause analysis and plan do study act this facility improved its rate from 49.052 to 56.175 and gained 10 points in October 2016 Positioning itself to double its points in January 2017 the rate stayed the same but the facility gained 30 points and earned a 5 Star QM Rating 33 In April 2016 this NY Facility decided to study and implement a PIP on Moderate to Severe Pain (SS). The facility started with a QM Rating of 3 Stars. After root cause analysis and plan do study act this facility improved its rate from 31.138 to 25.333 and gained 20 points in July 2016. Improving its QM Rating to 4 Stars. By October of 2016 the facility rate improved again down to 18.75 gaining another 20 points and finally improving its QM Rating to 5 Stars. 34 17

Celebrate Your Success! 35 Questions? Contact information: Quality Metrics, NH Trend Report or 5-Star qualitymetrics@leadingageny.org Quality Apex contact@qualityapex.com 36 18

The Requirements for Participation are found at 42 CFR 483 Subpart B. Additional guidance can be found in the State Operations Manual, Appendix PP. Quality Assurance and Performance Improvement http://www.cms.gov/medicare/provider Enrollment and Certification/QAPI/nhqapi.html CMS Transmittal regarding Episode Payment Model Operations https://www.cms.gov/regulations and Guidance/Guidance/Transmittals/2017Downloads/R169DEMO.pdf Email Inquiries to Nhqapi@cms.hhs.gov OIG Report Adverse Events in skilled Nursing Facilities https://oig.hhs.gov/oei/reports/oei 06 11 00370.pdf QAPI Plan How to Guide https://www.lsqin.org/wp content/uploads/2017/01/ls3 QAPIPlanHow To Guide.pdf Reporting Reasonable Suspicion of a Crime 1150B SSA https://www.cms.gov/medicare/provider Enrollment and Certification/SurveyCertificationGenInfo/downloads/SCLetter11_30.pdf 37 19

Garnet Mountain Health Care Facility Sample QAPI Plan Preamble November 28, 2016 G a r n e t M o u n t a i n H e a l t h C a r e F a c i l i t y Page 1

Garnet Mountain Health Care Facility QAPI Plan Preamble: Purpose, Guiding Principles and Scope I. Vision Statement: We strive to be a leader in providing the highest quality long-term care services by ensuring that residents live with the greatest dignity and comfort possible. II. Mission Statement: We, the employees of Garnet Mountain Health Care Facility, are committed to providing an environment that promotes a sense of physical, social, emotional and spiritual well-being to all residents and persons associated with our home. III. QAPI Statement: The purpose of QAPI in our organization is to take a proactive approach to continually improving the way we care for and engage with our residents, caregivers and other persons associated with our home so that we may realize our vision to be a leader in providing the highest quality in long-term care services. To do this, all employees will participate in ongoing quality assurance and performance improvement (QAPI) efforts which support our mission by ensuring that all residents and their families needs and expectations are met or exceeded. The QAPI program achieves this through systematic performance implementation, evaluation, review, problem analysis and implementation of corrective measures. IV. QAPI Guiding Principles: In our organization: a. QAPI is a priority. It guides our day to day operations and is a barometer for how we are providing quality of care and quality of life for our residents. b. Management and the governing board take an active role in assuring the QAPI program is adequately resourced to conduct its work and that policies are established to sustain the QAPI program. c. QAPI includes all employees, all departments and all services provided. d. Data from multiple sources (performance indicators, tracking of adverse events and input from residents and families) are utilized to monitor care and services. G a r n e t M o u n t a i n H e a l t h C a r e F a c i l i t y Page 2

e. QAPI focuses on a systemic approach to identify problems, their causes and implications of a change, and focuses on processes rather than addressing individual behaviors. f. Performance Improvement Projects (PIPs) examine and seek to improve care or services in areas that have been identified as needing improvement. V. Scope of QAPI: The scope of the QAPI Program is comprehensive and addresses both the quality and safety of clinical care and quality of services provided to Garnet Mountain Health Care Facility s residents. We incorporate all care settings and services in QAPI activities, including Post- Acute/Rehab, Dementia Care, Adult Day Health Care, Dietary services, Recreational activities, Housekeeping, Environmental Services, Pharmacy and other ancillary services. Care and Services that impact clinical care, quality of life, resident choice and care transitions Post-Acute/Rehab Clinical Care Adult Day Health Care Dietary Recreational Activities Environmental/Housekeeping/Laundry Pharmacy Each uses QAPI to assess, monitor and improve performance on an ongoing basis. Data is collected and reviewed from: Patient/Family satisfaction surveys, Quality Measure rates, census info, discharge info, billing records Resident/Family Satisfaction Surveys, Quality Measure rates, Incident and Accident reports, Infection reports, Resident change of status reports, MDS/CAA audits, Care Planning to reflect resident voice Registrant/Family Satisfaction Surveys, Incident and Accident reports, census info, reason for discharge reports Resident/Family Satisfaction Surveys, Meal prep and food storage audits, weight loss records Resident/Family Satisfaction Surveys, Activity log audits Equipment maintenance audits, environmental safety audits, Lost/damaged laundry records, Incident and Accident reports Delivery and storage of meds, medication administration observations, medication error records G a r n e t M o u n t a i n H e a l t h C a r e F a c i l i t y Page 3

Garnet Mountain Health Care Facility Sample QAPI Plan November 28, 2017 G a r n e t M o u n t a i n H e a l t h C a r e F a c i l i t y Page 1

I. 2018 QAPI Goals: Garnet Mountain Health Care Facility (GMHCF) will strive to meet the following goals in 2018: 1. Decrease antipsychotic use in long-stay residents by 15% of current rate in 2017 (29%) to 24% as measured by the CMS Quality Measure: Percent of Residents Who Received an Antipsychotic Medication (Long-stay) rate as reported in Q4 2017. 2. Decrease hospital readmission rate by 15% of current rate in 2017 (30%) to 25.5% as measured by the CMS Claims-based measure: Percentage of Short-stay Residents who were Re-Hospitalized after a Nursing Home Admission rate as reported in October 2017. 3. Develop and implement an I-Format care planning approach to create more individualized, person-centered care plans by December 1, 2018. II. Scope: A. QAPI is incorporated into our culture throughout all disciplines and service lines: a. QAPI training is an integral component of new employee orientation. b. QAPI is included in all staff job descriptions, in annual evaluations and staff competencies. c. Employees understand and can describe their role in identifying opportunities for improvement. d. All staff attend an annual mandatory in-service in February for a review of the facility s vision and mission statements, prior year s goals and results of performance improvement projects (PIPs). e. Goals and progress of PIPs are displayed on bulletin boards in staff break rooms. f. The QAPI Steering Committee oversees QI projects and establishes PIPs and PIP teams to address specific issues and problems. g. The PIP teams are made up of representatives of relevant stakeholders (residents, family, members of the interdisciplinary team and medical team, administration, staff and board members as appropriate). Each PIP team will have a coordinator who will report their progress back to the steering committee. h. Department managers participate in reviewing reports on measures relevant to their area and to the organization, suggest areas for performance improvement and participate formally in PIPs. Managers also offer support for all staff that need to take part in PIPs. i. When small problems are identified, there may not be a need to charter a PIP. Staff on a unit, along with their manager, may be able to try a solution for a particular problem on their own, without the need to establish an actual project. G a r n e t M o u n t a i n H e a l t h C a r e F a c i l i t y Page 2

B. The QAPI program assesses quality in all areas: a. Clinical: quality monitoring of resident outcomes, care processes and rehabilitation services by auditing and monitoring medical records, incident reports, infection reports, billing records and quality measures. b. Quality of Life: quality monitoring of food service, recreational activities, spiritual needs and safety by auditing and monitoring medical records, complaint logs and satisfaction surveys. c. Resident choice: quality monitoring of resident satisfaction related to autonomy, comfort, food enjoyment, meaningful activities, religious practice and security by auditing and monitoring complaint logs and satisfaction surveys. d. Care transitions: tracking and monitoring of avoidable hospitalizations. C. The QAPI program aims for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents by: a. Making decisions about areas to focus improvement efforts on based on what is going to make the most difference to resident care and resident safety. b. Considering residents perspectives when setting QAPI priorities. c. Ensuring that all residents and families know that their views are sought, valued and considered in facility decision-making and process improvements by announcing and discussing QAPI activities in resident and family councils. d. Being proactive by asking residents and family members to tell us about their quality concerns through our resident/family satisfaction survey. e. Educating residents about the changes that are being implemented. We include information about the PIPs in resident council meetings and describe how the change may impact their daily routine. We solicit and seriously consider input from residents regarding the change. f. Monitoring to see whether or not improvement has occurred and whether it has made a positive or negative impact on residents. D. The QAPI program utilizes the best available evidence to determine appropriate care and to define and measure goals by: a. Collecting subjective data such as observations about care and processes and resident/staff/family complaints to see if any of these present opportunities for improvement. b. Collecting objective data at regular intervals over time such as QM rates, number of falls, number of avoidable hospitalizations, number of unsatisfied family members etc., comparing the facility rates (if applicable) to national benchmarks and observing for trends in this data. c. Researching published evidence-based information, best practices and clinical guidelines to determine appropriate and high quality of care. G a r n e t M o u n t a i n H e a l t h C a r e F a c i l i t y Page 3

III. Guidelines for Governance and Leadership A. QAPI is integrated into the responsibilities and accountabilities of top-level management and the Board of Directors by: a. Establishing a QAPI multi-disciplinary steering committee that is a policy-making body under authority of GMHCF s CEO and Board of Directors. The steering committee shall establish policies to sustain the QAPI program and report its findings and recommendations to the CEO and to the Board of Directors as required. b. Having leadership (board or executive) representation on performance improvement projects or teams. c. Allocating resources to support QAPI efforts. d. Assuring that leadership can clearly describe to someone unfamiliar with the organization our approach to QAPI, and give accurate and up-to-date examples of how the facility is using QAPI to improve quality and safety of resident care. e. Senior managers (Director of Nursing, Director of Rehabilitation, Director of Dietary services, Director of Finance etc.) incorporate QAPI into their daily activities. Formally, they assist with the selection of measures and performance improvement projects (PIPs). They may also participate in the QAPI Committee. They have the responsibility of assuring that their teams are allocated sufficient resources, and individuals are given sufficient time to accomplish tasks related to QAPI. f. Establishing and promoting an open door policy and a Just Culture where staff feels free to bring quality concerns forward to any top-level or mid-level manager without fear of punishment. B. QAPI will be adequately resourced by: a. Designating the Director of Nursing (DON) as Coordinator of the QAPI steering committee. The DON will report directly to the CEO in all matters related to the QAPI and be accountable for QAPI leadership and coordination. i. The DON will attend a specialized quality improvement training program as needed. ii. The DON will work closely with the Director of In-service Education to establish a curriculum for facility-wide training on QAPI, which will consist of new orientation education, mandatory annual training and other training as needed for performance improvement projects. iii. The DON will meet with each PIP team leader to determine resources needed for QAPI and all efforts will be made to meet these needs for staff, training and equipment when applicable. b. Budgeting time, equipment and technical training needs on a yearly basis and adjusting the budget as needed. c. Assuring that staff is proficient with process improvement tools and techniques by providing continuing education that includes pre-and post-testing and routine skill checks. G a r n e t M o u n t a i n H e a l t h C a r e F a c i l i t y Page 4

d. Randomly assessing proficiency on a monthly basis by asking staff if they can describe GMHCF s approach to QAPI and give up-to-date examples of projects the facility is working on. e. Providing time for caregivers to attend team meetings during working hours and requiring others to cover their clinical duties during that time. f. Providing team-building sessions to help with effective teamwork among departments and caregivers. C. QAPI leadership: a. QAPI leadership (the QAPI steering committee) consists of (at minimum) the Director of Nursing (coordinator), the Administrator, a member of the governing board, the Medical director and the Director of Social Services. Other staff members will be invited to attend when their expertise is needed or by assignment. b. The QAPI steering committee s responsibilities include, but are not limited to the following: i. Annual establishment of GMHCF s QAPI plan in its first meeting of the calendar year. ii. Annual report submitted to the CEO/Governing Board by December 15 th of each year, encompassing a summary of the activities, results and findings of the committee during the previous year. iii. Attend meetings to conduct business and to review the activities of the PIP committees. These meetings are held monthly, at minimum, on the first Tuesday of each month. The committee shall maintain written meeting agendas, minutes, and activity reports related to data analysis and development and progress of PIPs. iv. Communicate with members in between meetings when performance issues of an urgent nature are identified. v. Analyze Resident/family satisfaction survey findings, CMS Quality Measures, clinical record reviews, billing record reviews and other data as deemed necessary. vi. Charter and oversee Performance Improvement Projects (PIPs) when problems are identified. Each PIP will be assigned a member of the QAPI steering committee to facilitate coordination and communication efforts between the PIP committee assigned task activities and the QAPI committee. Each PIP committee will provide the QAPI committee with a report at minimum monthly, or more frequently where required. The report will contain a summary and analysis of activities and requests for resources if needed. vii. Ensure that there exists an atmosphere in which staff is encouraged to identify and report quality problems as well as opportunities for improvement. G a r n e t M o u n t a i n H e a l t h C a r e F a c i l i t y Page 5

viii. Tour the facility regularly, meet with residents and caregivers where they live and work. c. QAPI activities will be reported to the governing body; i.e., the Board of Directors in the following manner: i. The QAPI steering committee submits its annual report to the CEO and governing board by December 15 th of each year that summarizes QAPI activities and findings from the previous calendar year. ii. The QAPI steering committee submits its annual plan for the coming year to the CEO and governing board for review, modifications and approval by January 15th. The final approved plan becomes the basis by which the committee will direct its efforts over the coming year. The plan may be modified during the year, with CEO/Governing Board approval, based on circumstances. IV. Feedback, Data Systems and Monitoring A. Overall System: i. GMHCF has systems in place to monitor care and services drawing from multiple sources of data: 1. Feedback from caregivers, residents, families and others will be collected via staff and resident/family satisfaction surveys annually by the approved survey provider and a suggestion box at the lobby desk and an open-door policy where staff, resident and family members feel comfortable bringing quality concerns to mid-level and senior level staff. 2. Tracking, monitoring and investigating adverse events such as falls, medication errors, injuries and infections through incident/accident reports and infection reports. 3. Tracking, monitoring and analyzing CMS Quality Measures, 5-star ratings and other performance indicators through QM reports, 5-star preview reports and other measurement data as provided through software programs that are available to GMHCF. 4. Acting on survey findings that are reported on the survey statement of deficiencies and OSCAR reports. 5. Tracking, monitoring and responding to verbal and written complaints. ii. Data will be analyzed monthly and compared to our own and national benchmarks (when available). Formal tracking of outcomes will allow us to identify trends and problem areas. Identified issues will be prioritized for PIPs. iii. The analysis of data and status of projects will be communicated by the QAPI steering committee at monthly staff meetings. G a r n e t M o u n t a i n H e a l t h C a r e F a c i l i t y Page 6

iv. Information will be disseminated at the monthly meetings by providing updates to the Project Performance Dashboard, posting updates to the staff bulletin boards and announcing new PIPs when necessary. V. Guidelines for Performance Improvement Project (PIP) Teams A. Overall plan for conducting PIPs to improve care or services: i. Topics for PIPs will be identified by the QAPI steering committee after reviewing and analyzing data. ii. PIPs will be prioritized and selected based on what is going to make the most difference to patient care and patient safety. This process takes into consideration input from multiple disciplines, residents and families and identifies problems that pose a high risk to residents and/or caregivers, is frequent in nature or otherwise impact the safety and quality of life of the residents. iii. PIP charters will be developed once a particular PIP had been decided upon. The charter describes the scope and objectives of the project and lists assigned team members and timelines for accomplishing the goals of the project. iv. The PIP team will use the PDSA (Plan-Do-Study-Act) Model for problem solving, set a timeline to carry out the cycle, and present the activities, observations and data to the QAPI steering committee on a monthly (or more frequently as needed) basis. B. Designation of PIP teams: i. The QAPI steering committee will consider who the stakeholders are, that is, which staff and disciplines on the various shifts and which residents and family are affected by the issue, keeping in mind that for confidentiality reasons, family members and residents may not review certain data that may identify individual residents if they are chosen for the team. ii. The committee will select one or two people to act as coordinator(s) of the PIP team. C. Characteristics ideally suited for PIP teams: i. Each team is composed of interdisciplinary members who, because of their knowledge/skills can achieve the purpose of the PIP. ii. The team has a clear purpose as evidenced by a charter. iii. The team has defined roles for each team member. iv. Each member has a commitment to being actively engaged on the team. D. All PIPS will be documented on GMHCF s Performance Improvement Project template and filed electronically in the QAPI folder on the shared drive. The PIP form will be utilized for communication to the steering committee. G a r n e t M o u n t a i n H e a l t h C a r e F a c i l i t y Page 7

VI. VII. VIII. Systematic Analysis and Systemic Action A. When system changes are made, we observe for positive and negative consequences resulting from changes: i. Plans for improvement will be trialed in a small way (on one unit) before it is rolled out to the entire facility to identify unintended consequences of the change. ii. Continual monitoring to see whether improvement has occurred. B. To identify contributing causal factors that underlie variations in performance, the PIP teams will use one or more of the following root cause analysis methods that focus primarily on systems and processes, not individual performance: i. Plan Do Study Act (PDSA) cycle of problem solving ii. Asking 5 whys iii. Fishbone diagrams C. Ensure that interventions or actions are implemented and are effective in making and sustaining improvements: i. Eliminate the root cause of a problem whenever possible. ii. Decide on a long-term solution to the problem. iii. Employ interventions/actions that modify, change or re-design the process. iv. Avoid, as a sole solution, interventions/actions that merely enhance or enforce existing processes. v. Strive for a greater positive than negative impact on other already existing processes. Communications A. QAPI activities will be communicated: i. During orientation of all new employees ii. Annually during a mandatory QAPI in-service for all employees iii. In resident and family council meetings iv. To consultants, contractors and collaborating agencies (example: hospice, podiatrist) v. By conveying the message that any and every caregiver is expected to raise quality concerns and to think about systems and is safe to do so. Evaluation A. The QAPI steering committee, along with all department heads, will utilize CMS QAPI at a Glance self-assessment tool on a bi-annual basis to help identify educational and skill needs, and to assure that QAPI is reaching every aspect of the organization. Once the steering committee is satisfied that the QAPI is fully established and part of the organization s culture, the self assessment will be performed on an annual basis thereafter. G a r n e t M o u n t a i n H e a l t h C a r e F a c i l i t y Page 8

IX. Establishment of Plan A. This current QAPI plan is dated November 28, 2017 B. The QAPI plan will be reviewed on a quarterly basis, beginning at the January QAPI committee meeting and every three months thereafter. C. If modifications are warranted upon review, the plan will be revised, dated and saved as a new copy of the original plan. All copies of the plan, including the original will be saved in a folder on the shared drive entitled QAPI_Plan_(year) Signatures: QAPI Steering Committee Coordinator Date: C.E.O. Date: Board of Directors representative Date: Modified Final G a r n e t M o u n t a i n H e a l t h C a r e F a c i l i t y Page 9