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 Describe steps to performance improvement using Analytic tools Introduce Quality Apex for demonstrating performance improvement 2
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
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
Adverse Events and Temporary Harm 7
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 8
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 9
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 10
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. 11
QAPI can help you improve your Quality Measures which are updated on the 5-Star Rating System quarterly 12
https://www.cga.ct.gov/2016/rpt/2016- R-0162.htm 13
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). 14
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 15
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 16
Leading Age Data Tools Quality Metrics 5-Star NH Trend Report 17
Use LeadingAge Tools Here Five Elements of QAPI Use LeadingAge Tools Here Use LeadingAge Tools Here 18
Leading Age Tools and QAPI compliance Identify PIP Dashboard NH Trend Report 5-Star Analysis Quality Apex Story Board Quality Metrics Goal setting Communication 19
Where does Quality Metrics NH Trend Report fit into your QAPI? Element #4 20
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. 21
Where does Quality Apex fit into your QAPI? Project where you are here Element #3 Set Goal 22
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: 23
Live Demo Quality Apex https://app.qualityapex.com/mds/qualitymeasures/dashboard 24
Where does Quality Metrics fit into Your QAPI Element #5 25
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 26
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 27
Use Quality Metrics to Communicate Progress Toward Goal Rate Now Goal Rate 28
Where does 5-Star Analysis fit into Your QAPI Element #5 29
Nursing Home Five Star Analysis Two examples of QAPI s effect On the 5-Star Rating System
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 31
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. 32
Celebrate Your Success! 33
Questions? Contact information: Quality Metrics, NH Trend Report or 5-Star qualitymetrics@leadingageny.org Quality Apex contact@qualityapex.com 34
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 35