Quality Assurance Performance Improvement

QAPI

11th Scope of Work Goals

Your Quality Innovation Network West Virginia, Delaware, Pennsylvania, New Jersey and

Louisiana have pooled resources for a combined force of quality improvement

Still have local contacts for local support that are responsive to your unique state needs and stakeholder projects

http://www.qualityinsights-qin.org

Quality Assurance Performance Improvement (QAPI) Mandated as part of the Affordable Care Act Expands current regulations for QAA Sets expectation for a sound, basic plan for QAPI that will

support systems of care and quality of life in every nursing home

Final Rule expected….

Definitions

Quality Assessment – an evaluation of a process to determine if a defined standard of quality is being achieved

Quality Assurance – the organizational structure, processes and procedures designed to ensure that care practices are consistently applied

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

What is QAPI?

Quality Assurance Measuring compliance with

standards Inspection Required, reactive Outliers, “bad apples”

Individuals Medical provider Few staff responsible

Performance Improvement Continuously improving

process to meet standards Prevention Chosen, proactive Processes or systems Resident care All staff responsible

QAPI Features

Using data not just to identify problems but to identify opportunities for improvement and setting priorities

Building on residents’ own goals for health, quality of life and daily activities

Incorporating caregivers broadly in a shared QAPI mission Developing Performance Improvement Project (PIP) teams

with specific “charters” Undertaking a systemic change to eliminate problems at the

source Developing a feedback and monitoring system to sustain

continuous improvement

5 Elements of QAPI

Design and Scope – ongoing and comprehensive Governance and Leadership Feedback, Data Systems and Monitoring Performance and Improvement Projects Systemic Analysis and Systemic Action

5 Elements of QAPI

Design and Scope– Comprehensive and ongoing plan– Includes all departments and functions– Addresses safety, quality of care, quality of life, resident choice– Based on best available evidence– Written QAPI plan

5 Elements of QAPI

Governance and Leadership– Systemic approach to gather input from staff, residents and

stakeholders – buy-in and support– Sufficient resources – money, time, staff, etc.– Ongoing and consistent staff training on QAPI– Non-punitive culture– Sustainability

5 Elements of QAPI

Feedback, Data monitoring Systems and Monitoring– Multiple sources, including resident and staff– Benchmarking and targeting– Adverse events– Establish goals– Ability to analyze, interpret and translate data into meaningful

actionable information

5 Elements of QAPI

Performance Improvement Projects– Prioritize topics– Improve care or services in areas identified as needing improvement– Gather information systematically to clarify issues or problems

5 Elements of QAPI

Systematic Analysis and Systemic Action– Organized approach to determine how an identified problem may be

caused– How did the system cause the problem– Improvement of systems and processes– Use of PDSA, RCA to improve systems and prevent future adverse

events

“Not all change is improvement, but all improvement is change.”

Donald Berwick, MD Former CMS

Administrator

Elements of the Model

What Are We Trying to Accomplish?

Improvement requires setting goals or AIMs Agreeing on the aim is crucial Goals or AIMs keep everyone on track They define the desired result or purpose Are guides to action

Setting Stretch Goals (AIMS)

Examples:– Reduce the injury rate for residents in our household by 50 percent in

12 months– Reduce the use of antipsychotic medications by 50 percent in 12

months– Reduce complaints about meals by 75 percent in 12 months– Improve Pain LS QM by 25 percent in 3 months– Improve Pneumonia Vaccine rate by 50 percent in 6 months

How Will We Know a Change is an Improvement Measurement for learning and process improvement Starting point for comparison of data Systematic gathering of information Gather objective data free from bias or opinion Personal observations may influence the results by seeing

what we want to see or what we expect to happen

Data Collection

What type of data do we need How can we collect data with minimum effort Seek usefulness, not perfection Set a time period for data collection Collect baseline data

Examples

Where in the process can we get this data to determine why we have a high Antipsychotic LS QM rate?

Who is ordering antipsychotic medications Has there been a change in staffing that is causing an increase

in antipsychotic med usage How do we know non-pharmacological interventions for

pain/behaviors are effective Are most transfers to a hospital made by a covering MD

Prioritize PIPS

Review QM report, NH Compare, pharmacy report Staff, resident and family surveys Begin with problems you feel are easy to solve then move to

more complicated issues Not all problems require a PIP

PIP Team

“Charter” a team Specific written plan to explore the problem PIP Team –staff closest to the issue

– i.e. small group activities – include NAs and activity aides What happened to allow the problem to occur What change in the process can we make to prevent the

problem in the future

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

PlanAct

DoStudy

PDSA Cycle

PLAN – Plan the test, make predictions about what will happen and why

DO – Carry out the plan on a small scale, document problems and unexpected observations

STUDY – Analyze the data, compare the data to your predictions

ACT – Decide next steps of adopting change or plan next test

Pilot Test

Test your action on a small scale Test over a short time period Observe the consequences Did staff like the new solution Evaluate

How Will We Know that a Change is an Improvement? Three types of measures:

– Outcome measures – voice of the customer – resident, family, staff– Process measures – the parts/systems performing as planned

(residents with decrease antipsychotics, wt. loss, falls)– Balancing measures – looking at system from different direction, have

improved changes caused new problems in another part of the system (reducing antipsychotics causing activity disruption, has change in meal times caused therapy and/or department issues)

What Change Can We Make That Will Result in Improvement All changes do not lead to improvement Improve work flow – weekly skin checks Optimize inventory – adequate adaptive utensils for meals Error Proofing – calibrate scale for accurate weights

Test the Change

Increase your belief that the change will result in improvement

Opportunity for learning from “failures” Learn how to adapt the change to conditions in different

environments Minimize resistance to implementation

Attributes of Changes that are Readily Adopted* The change has a clear advantage over the current system The change is compatible with the current system and values The change is easy to try and reverse Understanding and adapting the change requires minimal

complexity The change and its impact can be observed

*From Everett Rogers “Diffusion of Innovations”

Quality Improvement

Quality improvement is not an extra thing to do Monitor your QM report, staff and resident surveys, etc. Know and understand your numbers Share data with staff Quality improvement will improve your quality measure rates Quality improvement will improve resident, staff and family

satisfaction

QAPI Summary

All of QAPI may not be new to your home Think of your entire home as you assess your QAPI efforts Involve staff directly working in a process in order to improve

that process Communication about QAPI should continue throughout your

entire home Solicit resident and family viewpoints about their quality

experience

Composite Score Content

13 long-stay quality measures from Casper data Measures: Falls with injury, UTI, Pain, Pressure Ulcer,

Incontinence, Foley catheter, Physical Restraints, ADL, Wt. loss, Depression, Antipsychotic Meds

Flu and Pneumococcal vaccines All represent larger systems within long-term care settings Sum of 13 numerators divided by sum of 13 denominators

and multiplied by 100 = Composite Score

NNHQCC Composite Measure Score

Goal based on nearly 10% of nursing homes nationally having a composite score of 6 or less – Best Practice

Improving processes to impact QMs and achieve score of 6 or below may impact nursing home Star rating

QIN-QIO will assist you in improving processes

Centers for Medicare & Medicaid Services (CMS)

Transforming nursing homes through continuous attention to quality of care

and quality of life

QAPI Resources:http://go.cms.gov/nhqapi

11th Scope of Work 5-Year Goals for Nursing Homes Achieve a score of six or better on the Nursing Home Quality

Composite Measure Score Improve the mobility of long-stay residents Decrease unnecessary use of antipsychotic medications Decrease healthcare-associated infections and other

healthcare-acquired conditions Decrease potentially avoidable hospitalizations Actively participate in Learning and Action Network

Collaborative Goals are purposely designed for cross-setting improvement

opportunities

Thank You

Toni Daly, RN, Project CoordinatorPhone: 1.877.346.6180, ext. 7843

E-mail: mdaly@wvmi.org

Penny Imes, RN, Project CoordinatorE-mail: pimes@wvmi.org

Phone: 1.877.346.6180, ext. 7644

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-C2-120814