Building a Solid Foundation for QAPI Using Your · PDF file“Building a Solid Foundation for QAPI Using Your Measures” Patricia J. Boyer, MSM, RN, NHA [email protected]

“Building a Solid Foundation for g fQAPI Using Your Measures”

Patricia J. Boyer, MSM, RN, [email protected]

Boyer & Associates, LLC16655W. Bluemound Rd. Ste. 170

Brookfield, WI 53005Phone: 262‐754‐0525

Fax: 262‐754‐0528www.boyerandassociates.com

Focal AreasFocal Areas

• New Quality MeasuresNew Quality Measures

• New Calculation Methodology

d f• Everyday Use of Data

• Integrating QMs into QA/QAPI Program

Affordable Care ActAffordable Care Act

• Accountability Requirements for FacilitiesAccountability Requirements for Facilities– QAPI Program

Establish Standards related to Quality Assurance– Establish Standards related to Quality Assurance and Performance Improvement

– Facility has to submit a plan to meet the Standards– Facility has to submit a plan to meet the Standards

DefinitionDefinition

• Quality Assessment: an evaluation of a process to Qua ty ssess e t: a e a uat o o a p ocess todetermine if a defined standard of quality is being achieved

• Quality Assurance the organizational structure, processes, and procedures designed to ensure th t ti i t tl li dthat care practices are consistently applied

• Quality Improvement (Process or Performance Improvement): ongoing interdisciplinary processImprovement): ongoing interdisciplinary process that is designed to improve the delivery of services and resident outcomes

Why is Nursing Home QAPI Important?Why is Nursing Home QAPI Important?

• It’s the right thing to doIt s the right thing to do

S h Q / i i i• Strengthens QA/PI requirements in nursing homes

• Nursing Homes are more accountable then gever for quality

Who Uses the QM Data?Who Uses the QM Data?

• State Surveyors – Percentile ranking above 75thpercentile

• CMS Data Trends• CMS – Data Trends• Five Star Rating System – Subset of 9 Quality Measures

• Your consumer – Nursing Home Compare• Your facility – QA/QAPI Process

Quality MeasuresQuality Measures

• Information derived from MDS data that is available to the public as part of the Nursing Facility Quality Initiative.

• The Quality Measures are designed to provideThe Quality Measures are designed to provide consumers with additional information for them to make informed decisions about the quality of care in nursing facilitiesnursing facilities.

• 18 measures endorsed by National Quality Forum • Short Stay Measures• Long Stay Measures

DefinitionsDefinitions

• Target PeriodTarget Period– Span of time that defines the QM Reporting Period (e g a calendar quarter)Period (e.g. a calendar quarter)

• Stay – Set of contiguous days in a facilityPeriod of time between entry and either a– Period of time between entry and either a discharge or end of target period, whichever comes firstcomes first


• Episode p– Period of time spanning one or more stays– Begins with an admission and ends with either a discharge or end of the target of timedischarge or end of the target of time

– Start of Episode• Admission entry record

– End of Episode• Discharge Assessment with return not anticipated OR• Discharge Assessment with return anticipated but does not g preturn within 30 days of discharge OR

• Death in facility tracking record OR• End of target period


• Admission – Admission entry (A0310F= [01]Admission Admission entry (A0310F [01] and A1700 = [1] is required when any one of the following occur– Resident has never been admitted to this facility before OR

– Resident has been in facility previously discharged with return not anticipated ORResident has been in facility previously and was– Resident has been in facility previously and was discharged with return anticipated but did not return within 30 days of dischargey g


• Reentry – A reentry record (A0310F = [01] andReentry A reentry record (A0310F = [01] and A1700 = [2] is required when all of the following occurred prior to this entryfollowing occurred prior to this entry– Discharge return anticipated AND

Returned to the facility within 30 days of– Returned to the facility within 30 days of discharge


• Cumulative days in the facility (CDIF)Cumulative days in the facility (CDIF)– Total number of days within an episode during which the resident was in the facilitywhich the resident was in the facility

– Sum of the number of days within each stay included in an episodeincluded in an episode

– If an episode has more than one stay separated by periods outside the facility (hospitalization), only p y ( p ), ythose days in the facility count towards CDIF

DefinitionsDefinitions• Cumulative Days in Facility (CDIF)

Counting number of days until the end of the– Counting number of days until the end of the episode, counting stops with the last record being a discharge assm’t, last record is a death in facility or end of target period is reached, whichever is earlierCo ntin d ration of sta ithin an episode– Counting duration of stay within an episode –include day of entry but not day discharge unless they are the same day, then count as 1 dayy y, y

– When death in facility ends CDIF, record is not used as target record as they do not include li i l i f i f QM l l iclinical information necessary for QM calculation


• Short Stay – Episode with CDIF less than or equal to 100 days as of the end of the target period

• Long StayLong Stay– Episode with CDIF greater than or equal to 101 days as of the end of the target period

• Target Date the event date for an MDS record• Target Date – the event date for an MDS record– For entry record – target date is equal to entry date [A1600]F di h d th i f ilit d t t d t i– For a discharge or death in facility record – target date is equal to discharge date [A2000]

– For all other records – target date is equal to the ARD [A2300][A2300]

QM Sample SelectionQM Sample Selection• Two Resident Samples

– Short – Stay SampleShort Stay Sample– Long – Stay Sample

• Selection ProcessSelection Process– Select all residents whose latest episode either ends during the target period or is ongoing at the end of the

i d L i d i l d f QMtarget period. Latest episode is selected for QM calculation

– For each episode selected, compute the CDIFFor each episode selected, compute the CDIF– CDIF less than or equal to 100 days – Short Stay Sample– CDIF greater than or equal to 101 days – Long Stay Sample

• Two samples are mutually exclusive

Key Records for Calculating y gIndividual Measures

• Short Stay RecordT A

• Long Stay RecordT A– Target Assessment

– Initial Assessment

– Lookback Scan

– Target Assessment

– Prior Assessment

– Lookback Scan– Lookback Scan – Lookback Scan

RFA – Reason for Assessment

Look Back ScanLook Back Scan

• Episode and Stay Determination Logicp sode a d Stay ete at o og c– Starts from most recent assessment and works backwards

– Determines Episode to utilzie– Determines if the resident fits the Short‐Stay or Long‐Stay definitionStay definition

• Missing Records– Entry RecordEntry Record– Discharge Record– Normal Assessment

Th N Q lit MThe New Quality Measureshttp://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐

Instruments/NursingHomeQualityInits/Downloads/MDS30QM‐Instruments/NursingHomeQualityInits/Downloads/MDS30QMManual.pdf

Components of MeasuresComponents of Measures

• Measure DescriptionMeasure Description

• Measure SpecificationsN t– Numerator

– Denominator

– Exclusions

Components of MeasuresComponents of Measures• Risk Adjustment

– After Exclusions ‐ Facility level observed QM scoreAfter Exclusions Facility level observed QM score– After Resident – Level Covariates – Resident – Level expected QM score (the probability that the resident will evidence the outcome given the presence orwill evidence the outcome, given the presence or absence of characteristics measure by the covariates)

• Note: Only three QM are adjusted using the resident level covariates for public reporting– Short Stay ‐ % of residents with Pressure Ulcers that are New or Worsenedare New or Worsened

– Long Stay ‐ % of residents who Self‐report Moderate to Severe PainLong Stay % of residents who have/had a catheter– Long Stay ‐ % of residents who have/had a catheter Inserted and Left in their Bladde

Short Stay Measures• Self‐reported Moderate/Severe Pain• New/Worsened Pressure Ulcers

l fl• Seasonal Influenza Vaccine– Appropriately Given Seasonal Influenza Vaccine– Received the Seasonal Influenza Vaccine– Were Offered and Declined the Seasonal Influenza Vaccine– Did not Receive, Due to Medical Contraindication, the Seasonal Influenza VaccineSeasonal Influenza Vaccine

• Pneumococcal Vaccine– Assessed and Appropriately Given the Pneumococcal VaccineVaccine

– Received the Pneumococcal Vaccine– Offered and Declined the Pneumococcal Vaccine– Did not Receive, Due to Medical Contraindication, the Pneumococcal Vaccine

Long Stay MeasuresLong Stay Measures• Seasonal Influenza Vaccine

– Appropriately Given Seasonal Influenza Vaccine

• Falls with Major Injury• Self‐Reported Moderate/Severe

PainInfluenza Vaccine– Received the Seasonal Influenza

Vaccine– Were Offered and Declined the

Seasonal Influenza Vaccine

Pain• High‐Risk residents with Pressure

Ulcers• Urinary Tract InfectionSeasonal Influenza Vaccine

– Did not Receive, Due to Medical Contraindication, the Seasonal Influenza Vaccine

• Pneumococcal Vaccine

y• Lose Control of Bowel or Bladder• Low‐Risk residents who Lose

Bowel/Bladder controlh d d f• Pneumococcal Vaccine

– Assessed and Appropriately Given the Pneumococcal Vaccine

– Received the Pneumococcal Vaccine

• Catheter inserted and Left in Bladder

• Physically Restrained• Need for Help with ADLs hadVaccine

– Offered and Declined the Pneumococcal Vaccine

– Did not Receive, Due to Medical Contraindication the

Need for Help with ADLs had increased

• Lose too much weight• Depressive Symptoms

Contraindication, the Pneumococcal Vaccine

Surveyor Quality MeasuresSurveyor Quality Measures

• Prevalence of Falls (Long Stay)Prevalence of Falls (Long Stay)

• Prevalence of Psychoactive Medication Use, in the Absence of Psychotic or Relatedthe Absence of Psychotic or Related Conditions (Long Stay)

P l f A i i /H i U (L• Prevalence of Antianxiety/Hypnotic Use (Long Stay)

• Prevalence of Behavior Symptoms Affecting Others (Long Stay)

SurveyorsSurveyors

• Traditional Survey ProcessTraditional Survey Process– Flagged at 75th percentile for survey focus

Entrance Tour focus on flagged areas– Entrance Tour – focus on flagged areas

– Phase 1 • Focus Care Areas + Resident Triggered Areas• Focus Care Areas + Resident Triggered Areas

– Phase 2 • Focus Care Areas identified in Phase 1 as areas of• Focus Care Areas identified in Phase 1 as areas of concern

Five Star RatingFive Star Rating

• Subset of Nine (9) QMs – three most recent quarters– Short‐Stay

• % of resident with pressure ulcers that are new or worsened• % of residents who self‐report moderate to severe pain

– Long‐Stay• % of residents whose need for help with activities of daily living has increased

• % of high‐risk residents with pressure sores• % of residents who have/had a catheter inserted and left in their bladder

• % of residents who were physically restrained• % of residents who were physically restrained• % of residents with a urinary tract infection• % of residents who self‐report moderate to severe pain• % of residents experiencing one or more falls with major injury% of residents experiencing one or more falls with major injury

Everyday Use – QMsEveryday Use QMs

• Restorative NursingRestorative Nursing• Care Planning• Part B Medicare• Part B Medicare• Target for Critical Pathways/Investigative ProtocolsProtocols– Skin Care Management– Pain Management– Pain Management– Incontinence Care– Accident SupervisionAccident Supervision


Restorative NursingRestorative Nursing

• The resident has recently fallen and is listed under that QMunder that QM

• What might be some appropriate RN id f h i POC?programs to consider as part of their POC?


Restorative NursingRestorative Nursing

• The resident has recently fallen and is listed under that QIQ

• What might be some appropriate RN programs to consider as part of their POC?p– ROM Transfer ST

– Splint/Brace Walking BR

– Bed Mobility Amputation/prost


Care PlanningCare Planning

• The percentage of increased residents whose locomotion in/around their room worsenedlocomotion in/around their room worsened

• What might be some care planning h id ?approaches to consider?


Care PlanningCare Planning

• The percentage of increased residents whose locomotion in/around their room worsenedlocomotion in/around their room worsened

• What might be some care planning h id ?approaches to consider?

– Risk for Disuse Syndrome

– Risk for Injury

QMs that may indicate benefit from M di P t B R t ti N iMedicare Part B or Restorative Nursing

Ways to identify residents who may benefit

• Quality Measures Report• Quality Measures Report– Falls with Major Injury– Prevalence of falls– Residents who lose too much weight– Residents whose need for help with daily activities have increased

– Residents who are physically restrained– High Risk residents with pressure ulcers– New/worsening pressure ulcersNew/worsening pressure ulcers– Self‐reported moderate/severe pain


Medicare Part BMedicare Part B– Falls with Major Injury Prevalence of falls – Prevalence of falls

What might be an approach that can assist to d f ll & f tdecrease falls & fractures


Medicare Part B– Falls with Major Injury – Prevalence of falls

What might be an approach that can assist to decreaseWhat might be an approach that can assist to decrease falls & fractures– Therapy screening quarterly– Therapy screening after each fall– Therapy eval as appropriate

• Positioning • Rehab• Adaptive Equipment

“Those who say it can’t be done yshould get out of the way of

h h d i i ”those who are doing it.”

Joel Arthur Barker

(The Business of Paradigms)

I t ti QM i t f ilitIntegrating QMs into a facility quality programquality program

d !And Now QAPI !

Nursing Process/System ProcessNursing Process/System Process

IdentifyMonitor

and

Clinical ConditionQuarterly, Annual

Identifyand Modify

RiskCondition Change

EvaluateImplementCATs/CAAsCNA Assignments

Develop the POCClinical Standards of Practice

Facility QM Profile Characteristics ReportFacility QM Profile Characteristics Report

• Lists all QM and Facility % in Each• Identifies the facility percentile rankingD i % f St t & N ti• Does comparison % for State & Nation

• Flags any indicators above 90%• Identifies the Sentinel EventsIdentifies the Sentinel Events• Used by the Surveyors up to past 3 months prior to inspection to help target resident sample

• Use to verify accuracy of MDS and avoidable issues

QM Facility DATA BASEQM Facility DATA BASE

QM is an official agency DATABASEErrors in MDS result in misrepresentation in p

the QM system reportsTracks clinical outcomes

Review the content of MDS coding related to QM results to verify accuracy

Monitoring QM ReportsMonitoring QM Reports

• First review of QM report to assess accuracy of MDS data entry

• Use the QM results with Nursing Compare to evaluate your outcomes:

http://wwwmedicare gov/NursingHomeCompare/searhttp://www.medicare.gov/NursingHomeCompare/search.aspx?bhcp=1

• Facility CQI/QA/QAPI program should include routine it i f RAI ti i h d li MDSmonitoring of RAI practice issues: scheduling, MDS

coding, timeliness, completion and submission, appropriateness of communications with billing staff

Integrating the QMs into the QAPI Program

10 Steps1. Review the QMs and identify the “champion” for each

oneone2. Develop the Quality Assurance Monitoring Report

(per “champion”)(per champion )3. Complete the report per frequency of the calendar.4. Analyze data.y5. Determine change(s) in systems / processes

Integrating the QMs into the QAPI ProgramIntegrating the QMs into the QAPI Program

6. Implement change(s) in systems / processes7. Evaluate impact of change(s) in systems / processes

f (8. Trend data at regular specified intervals (e.g. week to week, month to month)

9 Monitor facility QMs at regular intervals9. Monitor facility QMs at regular intervals10. Demonstrate flexibility to QM data to change

systems, processes, structures in the dynamic data y , p , ydriven environment

Keys to Managing your QMsKeys to Managing your QMs

• MDS Coding ACCURACY!!

S b i S i l d i• Submit MDSs timely and in proper sequence

• Know your outliers

• Be prepared for the savvy consumer

Uses of QM data in Your FacilityUses of QM data in Your Facility• Trend and benchmark

– Visually graph your performanceVisually graph your performance– Set your facility goal (compare to your peer’s)– Company your results to your goal and your peer goalp y y y g y p g

• Know exclusions for each QM and document if present– Educate staff in data elements that exclude resident and documentation needed

R i Ad i i /Ch t D t ti• Review Admission/Chart Documentation– Collect information for numerator/denominatorCollect information for exclusions– Collect information for exclusions

Prospective Use of QMsProspective Use of QMs

• Use numerator list of residents as triggers forUse numerator list of residents as triggers for daily/weekly review– Ask staff what can be done to prevent trigger in– Ask staff what can be done to prevent trigger in the future

– Target residents in numerators to identifyTarget residents in numerators to identify residents with “special focus”

– “Teaching points” with staffTeaching points with staff

– Focused charting of “special focus” residents

Uses of QM DataUses of QM Data• Talk with Families

– Ask for input on what changes need to occurp g

• Talk with Peers– Area facilities with good scoresg– State Association focus

• Talk with Staff – how can we improve QMs– Root Cause analysis

• Reward your staff– Financial reward– Feel Good reward

In the race for In the race for In the race for In the race for quality, there is no quality, there is no quality, there is no quality, there is no

finish line.finish line.finish line.finish line.

5 Elements of QAPI5 Elements of QAPI

• Design & Scope

G & d hi• Governance & Leadership

• Feedback, Data Systems and Monitoring

• Performance Improvement Projects (PIPs)

• Systematic Analysis & Systemic ActionSystematic Analysis & Systemic Action

Design and ScopeDesign and Scope

• Comprehensive and Ongoing Plan

l d ll d d f i• Includes all departments and functions

• Addresses safety, quality of care, quality of life, resident choice, transitions

• Based on best available evidence

• QAPI plan

Governance and LeadershipGovernance and Leadership

• Boards/owners and executive leadershipB i d t– Buy in and support

• Training and organizational climate– Administration sees value

• Sufficient resources

• Sustainability

Feedback, Data Monitoring Systems dand Monitoring

• Multiple sources, including resident and staff

• Benchmarking and targeting

• Adverse eventsAdverse events

Performance Improvement Projects ( )(PIPs)

• Prioritized topicsN b f PIP d d th f ilit– Number of PIPs depend on the facility program

• Team Chartered

• PDSA cycle

Systematic Analysis and Systemic Action

• Root Cause Analysis

• Systems thinking

• Systematic changes as neededSystematic changes as needed

Plan Do Check Act (PDCA)Plan Do Check Act (PDCA)

PDCAPDCA• PLAN ‐

– Establish the objectives and processes necessary toEstablish the objectives and processes necessary to deliver results in accordance with the expected target or goals. By establishing output

i h l d fexpectations, the completeness and accuracy of the specification is also a part of the targeted improvement. When possible start on a small scaleimprovement. When possible start on a small scale to test possible effects.

• DO – Implement the plan, execute the process, make the product. Collect data for charting and analysis in th f ll i "CHECK" d "ACT" tthe following "CHECK" and "ACT" steps.

PDCA• CHECK

– Study the actual results (measured and collected in "DO" above) and compare against the expected results (targets or goals from p g p ( g gthe "PLAN") to ascertain any differences. Look for deviation in implementation from the plan and also look for the appropriateness/completeness of the plan to enable the execution i e "Do" Charting data can make this much easier toexecution i.e., Do . Charting data can make this much easier to see trends over several PDCA cycles and in order to convert the collected data into information. Information is what you need for the next step "ACT".

• ACT – Request corrective actions on significant differences between

actual and planned results. Analyze the differences to determine h h l h h lltheir root causes. Determine where to apply changes that will include improvement of the process or product. When a pass through these four steps does not result in the need to improve, the scope to which PDCA is applied may be refined to plan andthe scope to which PDCA is applied may be refined to plan and improve with more detail in the next iteration of the cycle, or attention needs to be placed in a different stage of the process.

QAPIQAPI

• The facility is provided data through monitoringy p g g– A potential problem is identified

• Next steps will be to evaluate if a true problem i texists

– Look at root causes, analyze and interpret data and develop interventionsp

– Monitor and re‐evaluate• All part of an overall program to proactively monitor facility processes of care in order tomonitor facility processes of care in order to ensure the highest quality of care and quality of life

South Dakotahtt // df /http://www.sdfmc.org/Phone: (605) 336‐3505Phone: (605) 336 3505 Fax: (605)373‐0580

Boyer & Associates, LLCy ,16655W. Bluemound Rd. Ste. 170

Brookfield WI 53005Brookfield, WI 53005

b d i twww.boyerandassociates.com

Documents

Building a Solid Foundation for QAPI Using Your · PDF file“Building a Solid Foundation for QAPI Using Your Measures” Patricia J. Boyer, MSM, RN, NHA [email protected]