Show-Me Quality

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Recognizing your home’s achievements in Show-Me Quality: QAPI in Action

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Show-Me Quality Games ProgramPrimaris is pleased to offer an exciting new program to help you track your facility’s improvement efforts as you prepare for the upcoming QAPI regulations. As a member of the Show-Me Quality: QAPI in Action collaborative, you get to decide how your facility makes improvement while gaining recognition for your progress. We will provide education and networking opportunities, and you get to decide what areas or topics in your home need improvement. The Show-Me Quality Games are a simple way for you to improve your resident care while you test the use of quailty improvement techniques needed for QAPI.

Participating is simple. Here is what you do:

1. Attend Show-Me Quality Educational Offerings.

• Your PDSA report does not have to focus on a big change. In fact, working on small steps is the best way to make improvements.

• Don’twaittoshareyourfinalsuccesswithus.We want to acknowledge the small cycles of changes your team is working on to achieve the ultimate goal.

• Remember that quality is everyone’s responsibility.

2. Select an improvement project and form a project team. 3. Fill out QAPI at a Glance: Self Assessment Tool Appendix A on page 8 or online and submit to Primaris.4. Complete and share the Using PDSA in Preparation for QAPI worksheet on page 6 with Primaris by fax at (573) 777-9003.5. Submit second Using PDSA in Preparation for QAPI worksheet and share one story of success using the form on page 14.

Helpful Tips

Achievement Levels

►Form project team and send Primaris a photo of the team►Attend a total of two Show-Me Quality educational offerings

►Complete and submit the QAPI at a Glance: Self-Assessment Tool Appendix A on page 8►Attend a total of four Show-Me Quality educational offerings►Complete Using PDSA in Preparation for QAPI form on page 6

►Attend a total of six Show-Me Quality educational offerings (including one in-person)►Complete second Using PDSA in Preparation for QAPI form on page 6►Share one story of success using the form on page 14

►Join Show-Me Quality: QAPI in Action

[Starting Out]

[Teaming Up & Training]

[Assessing Progress]

[Reviewing & Reporting]

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6. Your home’s contact will receive certificates for each achievement level listed to the right, including a Gold level certificate once you complete all goals.7. Celebrate! Proudly display your certificates in your lobby, break room or other common area.

MO-13-43-NH July 2013 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health andHumanServices.ThecontentspresenteddonotnecessarilyreflectCMSpolicy.

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(You’ve already reached this milestone!)

[Don’twaituntiltheendtoshareyourfinalsuccesswithus.We want to acknowledge the small cycles of change your team is working on to achieve the ultimate goal.]

Steps to Show-Me Games Gold

Copper

Use this checklist to track your progress as you move through the program. This is for your own records as Primaris also has this information available.

Signed commitment form for collaborative

BronzeFormed facility project team and submitted photo/team member names to rwhite2@primaris.org

Attended 2 Show-Me Quality educational offerings

1. ________________________________________

2. ________________________________________

SilverSubmitted QAPI At A Glance: Self-Assessment Tool Appendix A (page 8)

Attended 2 more Show-Me Quality educational offerings (for a total of 4)

3. ________________________________________

4. ________________________________________

Completed first Using PDSA in Preparation for QAPI Plan (page 6)

GoldAttended 2 more Show-Me Quality educational offerings (for a total of 6; be sure one of the six is in person!)

5. ________________________________________

6. ________________________________________

Completed second Using PDSA in Preparation for QAPI plan (page 6)

Shared one story of success (page 14)

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Using PDSA for Quality Improvement

• What causes you the most trouble most often?• What does your customer complain about most

often?• What Quality Measures are most challenging?• What would help make the job easier, service faster,

theprocessmoreefficient,greaterproductivityandthe operation less costly?

• Can you measure the success?

• Who should be on the team?• Do we have the right people?• Are the necessary departments represented?

• How will you know you have eliminated or improved the problem?

• What are existing measures you can use?• Do you have a baseline measure of where you are

right now?• What will the outcome measure goal be?

• What is not happening?• What is not known?• How is the customer affected?• What are the known data and the symptoms?

• What would be the ideal condition?• What are the elements of the ideal?• What are the priorities of the elements?

• Haveyouanalyzedallthesignificantsymptoms?• Formulate theories for the root causes.• Prioritize the root cause solutions.• Who will implement the corrective action?• How will the corrective action be implemented?• How will you overcome cultural resistance?• What can be done to anticipate and eliminate

potential roadblocks?• What resources will be needed? What

communications are required to minimize disruptions and garner support?

• What method will be used to check progress?• Who are the most important people to ensure

successful implementation?• What factors will determine whether they will do

what is needed?• What is the time, amount, and effectiveness of the

feedback needed?

• Cantheresultsbeverified?• Who will collect the data and to whom will it be

reported to maintain its effectiveness?• What will ensure this new state is maintained and

does not deteriorate over time?• Who will audit the process to maintain its

effectiveness?• What would have made the implementation go

easier?• How can what was learned be used for something

else?

• Was the study successful? If yes, how will you implement the solution throughout the organization?

• If the study was unsuccessful, where was the breakdown? In the implementaiton phase? In the diagnosis of root causes?

• Are there other root causes? If yes, begin the PDSA cycle again.

PDSA is a method widely used to successfully improve services. PDSA uses “cycles” to incrementally test ideas for change. It is also used to monitor a process or discover, assess and diagnose problems. Through PDSA, changes are implemented, evaluated, and spread. Initially, changes are tested on a small scale and if successful, they are spread throughout the organization.

PDSA=Plan, Do, Study, Act

Project Selection

Organize the Team

Clarify

Understand the Problem

Formulate the Ideal State

Derive a Solution

Implementing Corrective Action

Study the Results

Implement and Evaluate

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Please submit this page to Primaris.Use an additional sheet if more space is needed. Fax reports to Primaris at (573) 777-9003.

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Nursing Home Name and Reporting Team: Report Date:

Project Aim Statement:

Strategy:

Cycle Number: Beginning Date: Completion Date:

We plan to...

In order to...

Prediction:

What we did was...

What happened was...

We learned that...

Surprises...

What decisions were made based on what was learned?

What we plan to do next is...

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Reporting Team: Report Date:

Project Aim Statement: This statement clearly communicates what you are trying to accomplish. Your aim should be concise (only one sentence preferably,) and include important details like your goal date for completion, who will be involved, what is the process you are impacting, and what is your numerical goal for the new process.

Strategy:

Cycle Number: Beginning Date: Completion Date:

The department or team assigned to this project. The date you start the PDSA cycle.

A simple statement of “how” you hope to achieve your aim in the broadest sense of explanation. Your detail will be explained later in the Plan section

Identifies the number of tests you have done with a particular strategy. Each time your project aim or strategy changes, you will start over with 1. If you run a test cycle and decide to simply “tweak” your strategy and re-test, it would be cycle 2, 3, and so on.

The date you start the test of the new process.

The date you end the test of the new process. Your test period should be less than one month.

This is where you enter what you are going to do, what you hope to accomplish, what you predict the results of your test will be (hypothesis) and what data will be collected during the test to prove if your idea for change was an improvement.

This is where you enter what you did when you ran the test.

This is where you complete your analysis of the process. What did the data tell you? What did you learn? What surprised you? Did you run into anything new that you hadn’t realized or considered earlier?

This is where you enter the decisions you have made based on what you learned as well as what your next steps may be. You may decide that you would like to tweak the test and re-run it. You may decide the idea didn’t accomplish what you had hoped so you will scrap the idea. Or you may decide that the results were right on target and you are ready to implement.

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Using PDSA in Preparation for QAPI

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[SAMPLE]

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Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor does its completion ensure regulatory compliance.

QAPI Self-Assessment Tool

Directions: Use this tool as you begin work on QAPI and then for annual or semiannual evaluation of your organization’s progress with QAPI. This tool should be completed with input from the entire QAPI team and organizational leadership. This is meant to be an honest reflection of your progress with QAPI. The results of this assessment will direct you to areas you need to work on in order to establish QAPI in your organization. You may find it helpful to add notes under each item as to why you rated yourself a certain way.

Date of Review: Next review scheduled for:

Rate how closely each statement fits your organization Not started

Just starting

On our way

Almost there

Doing great

Our organization has developed principles guiding how QAPI will be incorporated into our culture and built into how we do our work. For example, we can say that QAPI is a method for approaching decision making and problem solving rather than considered as a separate program.

Notes:

Our organization has identified how all service lines and departments will utilize and be engaged in QAPI to plan and do their work. For example, we can say that all service lines and departments use data to make decisions and drive improvements, and use measurement to determine if improvement efforts were successful.

Notes:

Our organization has developed a written QAPI plan that contains the steps that the organization takes to identify, implement and sustain continuous improvements in all departments; and is revised on an ongoing basis. For example, a written plan that is done purely for compliance and not referenced would not meet the intent of a QAPI plan.

Notes:

Our board of directors and trustees (if applicable) are engaged in and supportive of the performance improvement work being done in our organization. For example, it would be evident from meeting minutes of the board or other leadership meetings that they are informed of what is being learned from the data, and they provide input on what initiatives should be considered. Other examples would be having leadership (board or executive leadership) representation on performance improvement projects or teams, and providing resources to support QAPI.

Notes:

Thank you for completing the CMS QAPI self-assessment and submitting to Primaris, CMS’ designated quality improvement organization for Missouri. We will maintain your assessment in strictest confidence.

Primaris staff is available to consult with you during the preparation of the assessment of after completion. To arrange assistance or review, please call Deborah Finley at 573-817-8300 ext 133.

Please return this assessment tool to a Primaris staff member or in the attached postage paid envelope.

Nursing Home Name: _____________________________________________________________________________________________________

Nursing Home Address: ___________________________________________________________________________________________________

Name and Title of Person Completing Assessment: _____________________________________________________________________________

Email Address and Phone Number: __________________________________________________________________________________________

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Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor does its completion ensure regulatory compliance.

QAPI Self-Assessment Tool

Directions: Use this tool as you begin work on QAPI and then for annual or semiannual evaluation of your organization’s progress with QAPI. This tool should be completed with input from the entire QAPI team and organizational leadership. This is meant to be an honest reflection of your progress with QAPI. The results of this assessment will direct you to areas you need to work on in order to establish QAPI in your organization. You may find it helpful to add notes under each item as to why you rated yourself a certain way.

Date of Review: Next review scheduled for:

Rate how closely each statement fits your organization Not started

Just starting

On our way

Almost there

Doing great

Our organization has developed principles guiding how QAPI will be incorporated into our culture and built into how we do our work. For example, we can say that QAPI is a method for approaching decision making and problem solving rather than considered as a separate program.

Notes:

Our organization has identified how all service lines and departments will utilize and be engaged in QAPI to plan and do their work. For example, we can say that all service lines and departments use data to make decisions and drive improvements, and use measurement to determine if improvement efforts were successful.

Notes:

Our organization has developed a written QAPI plan that contains the steps that the organization takes to identify, implement and sustain continuous improvements in all departments; and is revised on an ongoing basis. For example, a written plan that is done purely for compliance and not referenced would not meet the intent of a QAPI plan.

Notes:

Our board of directors and trustees (if applicable) are engaged in and supportive of the performance improvement work being done in our organization. For example, it would be evident from meeting minutes of the board or other leadership meetings that they are informed of what is being learned from the data, and they provide input on what initiatives should be considered. Other examples would be having leadership (board or executive leadership) representation on performance improvement projects or teams, and providing resources to support QAPI.

Notes:

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Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor does its completion ensure regulatory compliance.

Rate how closely each statement fits your organization Not started

Just starting

On our way

Almost there

Doing great

QAPI is considered a priority in our organization. For example, there is a process for covering caregivers who are asked to spend time on improvement teams.

Notes:

QAPI is an integral component of new caregiver orientation and training. For example, new caregivers understand and can describe their role in identifying opportunities for improvement. Another example is that new caregivers expect that they will be active participants on improvement teams.

Notes:

Training is available to all caregivers on performance improvement strategies and tools.

Notes:

When conducting performance improvement projects, we make a small change and measure the effect of that change before implementing more broadly. An example of a small change is pilot testing and measuring with one nurse, one resident, on one day, or one unit, and then expanding the testing based on the results.

Notes:

When addressing performance improvement opportunities, our organization focuses on making changes to systems and processes rather than focusing on addressing individual behaviors. For example, we avoid assuming that education or training of an individual is the problem, instead, we focus on what was going on at the time that allowed a problem to occur and look for opportunities to change the process in order to minimize the chance of the problem recurring.

Notes:

Our organization has established a culture in which caregivers are held accountable for their performance, but not punished for errors and do not fear retaliation for reporting quality concerns. For example, we have a process in place to distinguish between unintentional errors and intentional reckless behavior and only the latter is addressed through disciplinary actions.

Notes:

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Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor does its completion ensure regulatory compliance.

Rate how closely each statement fits your organization Not started

Just starting

On our way

Almost there

Doing great

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. For example, the administrator can clearly describe the current performance improvement initiatives, or projects, and how the work is guided by caregivers involved in the topic as well as input from residents and families.

Notes:

Our organization has identified all of our sources of data and information relevant to our organization to use for QAPI. This includes data that reflects measures of clinical care; input from caregivers, residents, families, and stakeholders, and other data that reflects the services provided by our organization. For example, we have listed all available measures, indicators or sources of data and carefully selected those that are relevant to our organization that we will use for decision making. Likewise, we have excluded measures that are not currently relevant and that we are not actively using in our decision making process.

Notes:

For the relevant sources of data we identify, our organization sets targets or goals for desired performance, as well as thresholds for minimum performance. For example, our goal for resident ratings for recommending our facility to family and friends is 100% and our threshold is 85% (meaning we will revise the strategy we are using to reach our goal if we fall below this level).

Notes:

We have a system to effectively collect, analyze, and display our data to identify opportunities for our organization to make improvements. This includes comparing the results of the data to benchmarks or to our internal performance targets or goals. For example, performance improvement projects or initiatives are selected based on facility performance as compared to national benchmarks, identified best practice, or applicable clinical guidelines.

Notes:

Our organization has, or supports the development of, employees who have skill in analyzing and interpreting data to assess our performance and support our improvement initiatives. For example, our organization provides opportunities for training and education on data collection and measurement methodology to caregivers involved in QAPI.

Notes:

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Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor does its completion ensure regulatory compliance.

Rate how closely each statement fits your organization Not started

Just starting

On our way

Almost there

Doing great

From our identified opportunities for improvement, we have a systematic and objective way to prioritize the opportunities in order to determine what we will work on. This process takes into consideration input from multiple disciplines, residents and families. This process identifies problems that pose a high risk to residents or caregivers, is frequent in nature, or otherwise impact the safety and quality of life of the residents.

Notes:

When a performance improvement opportunity is identified as a priority, we have a process in place to charter a project. This charter describes the scope and objectives of the project so the team working on it has a clear understanding of what they are being asked to accomplish.

Notes:

For our Performance Improvement Projects, we have a process in place for documenting what we have done, including highlights, progress, and lessons learned. For example, we have project documentation templates that are consistently used and filed electronically in a standardized fashion for future reference.

Notes:

For every Performance Improvement Project, we use measurement to determine if changes to systems and process have been effective. We utilize both process measures and outcome measures to assess impact on resident care and quality of life. For example, if making a change, we measure whether the change has actually occurred and also whether it has had the desired impact on the residents.

Notes:

Our organization uses a structured process for identifying underlying causes of problems, such as Root Cause Analysis.

Notes:

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Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor does its completion ensure regulatory compliance.

Rate how closely each statement fits your organization Not started

Just starting

On our way

Almost there

Doing great

When using Root Cause Analysis to investigate an event or problem, our organization identifies system and process breakdowns and avoids focus on individual performance. For example, if an error occurs, we focus on the process and look for what allowed the error to occur in order to prevent the same situation from happening with another caregiver and another resident.

Notes:

When systems and process breakdowns have been identified, we consistently link corrective actions with the system and process breakdown, rather than having our default action focus on training education, or asking caregivers to be more careful, or remember a step. We look for ways to assure that change can be sustained. For example, if a policy or procedure was not followed due to distraction or lack of caregivers, the corrective action focuses on eliminating distraction or making changes to staffing levels.

Notes:

When corrective actions have been identified, our organization puts both process and outcome measures in place in order to determine if the change is happening as expected and that the change has resulted in the desired impact to resident care. For example, when making a change to care practices around fall prevention there is a measure looking at whether the change is being carried out and a measure looking at the impact on fall rate.

Notes:

When an intervention has been put in place and determined to be successful, our organization measures whether the change has been sustained. For example, if a change is made to the process of medication administration, there is a plan to measure both whether the change is in place, and having the desired impact (this is commonly done at 6 or 12 months).

Notes:

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Share Your Success StoryDate:________________

Name:____________________________________ Title:_______________________

Organization:____________________________________________________________

Address:__________________________________________________________________

Email Address:_____________________________ Phone:_____________________

Please share your story below. Keep in mind the following questions, but write as little or as much as you wish, adding another sheet if necessary.

• How did you know there was a problem?• What did you do to address it?• Who was involved in the improvement project?• What results have you seen? Do you have any data to show?• How has this improved resident care?• What advice would you offer to other homes?

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I hereby grant permission to Primaris to disclose our relationship with them in quality improvement projects and to use and/or publish information regarding this organization’s quality improvement efforts, including interventions, literature, documents, images, graphs, or other materials, for the purpose of furthering the advancement of healthcare quality. This is to include print, electronic, visual,verbal,weband/orvariousmediaforanindefiniteperiodoftime.Thisreleaseandconsent is made without compensation and no compensation is required or anticipated.

Signature:________________________________________

Please submit this page to Primaris.Use an additional sheet if more space is needed. Fax all pages to Primaris at (573) 777-9003.