IS YOUR QAPI COP READY?

IS YOUR QAPI COP READY? Lisa Meadows/MSW Clinical Compliance Educator Accreditation Commission for Health Care OBJECTIVES Review the CMS requirements for the Medicare Condition of Participation: Quality Assessment Performance Improvement 1

NEW MEDICARE COPS CMS issued the final rule January 13, 2017 that includes the new CoPs and the responses to comments from the proposed CoPs. The original implementation date of the revised CoPs was July 13, 2107 CMS issued a proposed delay for January 13, 2018 Emergency Preparedness is to be implemented by 11-15-17 At this time the State Operations Manual, Appendix M has not been revised/published FEDERAL REGISTER 2017 Final Rule in the Federal Register of January 13, 2017 https://www.gpo.gov/fdsys/pkg/fr-2017-01-13/pdf/2017-00283.pdf COPs actually start on page 75 of 88 pages 2

WHY THE CHANGE? Promote high quality patient care at all times for all patients Continuous, integrated care process across all services, based on patient centered assessment, care planning, service delivery and quality assessment / performance improvement Interdisciplinary approach recognizing skills of all of the team members, very similar to the hospice IDT/IDG approach Outcome oriented- make quality improvements through QAPI specific to each HHA This will fold into the HHVBPM 484.65 Quality Assessment and Performance Improvement (QAPI) QAPI is the merger of two complementary approaches to quality management, Quality Assurance (QA) and Performance Improvement (PI). Both use quality-based information but differ in key ways. QA is a process of meeting quality standards and assuring that care reaches an acceptable level. QA is a reactive, retrospective effort to examine why a facility fails to meet certain standards. QA activities do improve quality, but efforts frequently end once the standard is met. PI (also called Quality Improvement - QI) is a pro-active, continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/ systemic problems. PI can make good quality even better. HHQI Home Health Quality Improvement 3

CULTURE OF QAPI Good is the enemy of great. -Jim Collins CULTURE OF QAPI Modify agency s vision, mission, values, and purpose statements to convey vision of QAPI Demonstrate the importance of QAPI and maintain its priority even with competing priorities or busy caseloads Cultivate and spread your organization s culture so that each employee takes ownership of quality of care Communicate the message that the focus of QAPI is on identifying gaps in systems and processes, rather than individual performance 4

CULTURE OF QAPI Develop a team QAPI Coordinator Priority cannot be an afterthought Data junkie Good communicator Good listener Everyone is on the QAPI team Quality is everyone s responsibility Ask staff how often they want to deliver quality care Always Alternative Beware of the data deniers 484.65 QAPI The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and readmissions; and takes actions that address the HHA s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. 5 Standards (a) Program Scope (b) Program Data (c) Program Activities (d) Performance Improvement Projects (e)executive Responsibilities 5

484.65 QAPI (a) Program scope (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations PROGRAM SCOPE Scope of the QAPI program needs to reflect the complexity of your program, services provided, population served, all locations per Medicare provider number Examples: High risk, high volume, problem prone areas of patient care Wound care/vac, pain pumps, foley care Regulatory requirements Documentation to support eligibility, homebound status, physician orders, face-to-face documentation Billing audits Orders and documentation support care provided 6

PROGRAM SCOPE Customer satisfaction surveys HHCAPS survey Home Health Compare Home Health Value Based Purchasing OASIS outcomes Adverse events that impact patient care Sentinel events Infection control (new COP) Agency acquired infections, communicable diseases 484.65- QAPI (b) Program data (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to (i) Monitor the effectiveness and safety of services and quality of care; (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA s governing body. 7

PROGRAM DATA Define the frequency in which data will be collected and reviewed and establish acceptable thresholds Monthly Quarterly Bi-annually One time events EMR /by hand Governing body approval of thresholds 484.65- QAPI (c) Program activities (1)The HHA s performance improvement activities must (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the or potentially threaten the health and safety of patients. (2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. (3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained 8

PROGRAM ACTIVITIES Correct any immediate problems that directly or potentially threaten the health and safety of patients Sentinel events Frequency of activities varies based on the issues identified Prioritize activities Regulatory Safety of patients 484.65- QAPI (d) Performance improvement activities Phased in because it will take additional time to collect the data necessary to identify areas for improvement that are appropriate for performance improvement. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. ACHC customers should already have implemented projects based on data collected 9

IMPLEMENTING A PROJECT PDSA model Continuous, rapid improvement PDSA CYCLE MODEL Plan. Plan a change. Formulate specific aim statements, develop a detailed data collection plan, and establish project timelines. Do. Test the change. Carry out your data analysis plan, document any unexpected problems or challenges, track progress against timeline benchmarks. Study. Review the tests. Analyze collected data, compare results to project aims, summarize and present data. Act. Take action based on what you have learned. If the change did not work, go through the cycle again with a different change. If the change was successful, use what you learned to begin planning new improvements. 10

ESTABLISH MEASUREABLE GOALS SMART Goals Specific What do you want to accomplish? Measureable How will you know you have achieved your goal? Achievable How are you going to get to the goal? Relevant What is the purpose of project? Time-based How long will it take to accomplish? PRIORITIZING PROJECTS Brainstorming Encourages participation Encourages creativity-no judgement Produces options Leads to Decision making Multi-voting Rank ordering 11

IMPLEMENTATION Identify system failures Understand why current process isn t reaching desired levels Implement corrective action Education/training Developing of pathways Revision of process Adopting of a new process Utilizing technology SYSTEM FAILURES Flow charting Pictorial representation that promotes understanding of the process Can be a training tool for employees Shows breakdown in established processes 12

SYSTEM FAILURES Fishbone diagram Helps to determine the root causes of a problem or quality characteristic using a structured approach Indicates possible causes of variation in a process Increases knowledge of the process Identifies areas where data should be collected for additional study CORRECTIVE ACTION Choose corrective actions that will result in improvement Choose actions that address or target root causes Avoid quick fixes and focus on lasting/sustaining improvement Pilot in small groups before rolling out to entire agency 13

MONITOR DATA Hawthorne effect Variability in data (average vs spread) Trend data for negative and positive outcomes Is the action step producing sustainable results? Results are not producing the desired results? Action step resulted in a negative result or no change MAINTAINING PERFORMANCE Continue to monitor to ensure desired threshold is maintained Establish policy/procedure/standard operating processes Educate staff 14

484.65- QAPI (e) Executive responsibilities The HHA s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; (4) That any findings of fraud or waste are appropriately addressed. EXECUTIVE RESPONSIBILITIES Require your agency s governing body to assume responsibility for your QAPI program ensuring it reflects your agency s complexity covers all provided services, including contracted staff Include your governing body to approve the frequency and level of detail to be used in data collection Maintain documentary evidence of your agency s QAPI program to demonstrate to surveyors 15

START NOW Implementation is January 13, 2018 and projects are to be implemented 6 months later Develop the framework to determine what is to be monitored Agency mission statement Policies and procedures Team and leadership involvement Educate staff RESOURCES Free resources from HHQI- Home Health Quality Improvement http://www.homehealthquality.org Home Health QAPI Fact Sheet Hospitalization PIP (to prevent hospitalizations or emergent care) Medication Management PIP 16