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Driving 5-Star & RoP ImplementationThrough a QAPI Approach

SNF QAPI Fundamentals

Objectives

• Describe the fundamentals of QAPI programs and the similarities and differences between a QAPI program and the facilities current QAA work required by F520

• Understand the 5 elements of QAPI for nursing facilities

• Establish a framework for the written SNF QAPI plan that meets CMS QAPI Design and Scope requirements

• Describe a process for establishing priority QAPI goals based on the facility specific assessment.

• Understand the governing body and administrative role in development and sustenance of a QAPI culture and maintaining accountability for safety and quality in balance with resident rights and choice.

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Quality Assurance Performance Improvement (QAPI) Regulations

• Patient Protection & Affordable Care Act of 2010 requires nursing homes to have an acceptable QAPI plan within a year of the announcement of a QAPI regulation

• 42 CFR §483.75 published Federal Register October 4, 2016 outlining requirements for facilities to develop, implement and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life

• The QAPI plan is to be presented to the state agency at the first annual survey that occurs at least one year after the effective date of the regulation and at each annual recertification survey and upon request during any other survey and to CMS upon request.

QAPI in Action

QA = Quality Assurance

• Reactive process of meeting quality standards & ensuring care reaches acceptable level

PI = Performance Improvement

• Proactive continuous study of processes with intent of preventing or decreasing problems

• Data Driven

• Systems Thinking

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What is QAPI?

QA + PI = QAPI

QA PI

Motivation Measuring compliancewith standards

Continuously improving processes to meet standards

Means Inspection Prevention

Attitude Required, reactive Chosen, proactive

Focus Outliers, “bad apples”, individuals

Processes or systems

Scope Medical provider Resident care

Responsibility Few All

Source CMS, 2013c,p.2

Quality Assessment and Assurance (QAA) F520

§483.75(g) Quality assessment and assurance. §483.75(g)(1)(i)-(iii) Phase 1 Implementation 11/28/2016

• (1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:

• (i) The director of nursing services;

• (ii) The Medical Director or his/her designee;

• (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and

• (iv) The infection control and prevention officer.

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Quality Assessment & Assurance (QAA) F520

§483.75(g) Quality assessment and assurance.

(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

• (i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary

• (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;

• (iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.

Quality Assessment and Assurance (QAA) F520

§483.75(h) Disclosure of information. • A State or the Secretary may not require disclosure of the

records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section.

§483.75(i) Sanctions. • Good faith attempts by the committee to identify and correct

quality deficiencies will not be used as a basis for sanctions.

• §483.75(h)(i))will be implemented beginning November 28, 2016 (Phase 1)

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Examples of QAA non-compliance

• Facility failed to ensure a Quality Assurance meeting was held on a quarterly basis to identify issues with respect to quality assessment and assurance activities.

• Facility failed to ensure the Quality Improvement (QI) Committee developed, implemented, and monitored appropriate plans of action to correct identified deficiencies

• Failed to report unsafe water temperatures to the QAA committee

• Failed to identify quality issues

• Failed to ensure Medical Director attended quarterly

F520 Citation Example

• Based on observation, interview, and record review, it was determined the facility failed to maintain a Quality Assessment and Assurance Program that developed and implemented appropriate plans of action to correct quality deficiencies. This was evidenced by repeated deficiencies related to the facility's failure to ensure the Comprehensive Plan of Care was revised, and failure to ensure there was an effective Infection Control Program.

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QAPI + QAA

• F520 QAA provides little instruction on achieving compliance

• Proposed QAPI regulations are in addition to QAA requirements, as CMS has not found QAA to be sufficient

• QAPI expands a quality focus & provides a framework for driving high quality of care & reduced risk of survey tags & penalties

• QAA activity that continues:• Systems for care & compliance

with regulations• Tracking, investigating,

prevention of adverse events• Investigating complaints• Obtaining feedback from

residents and staff• Establishing quality targets• Setting goals for QM

improvement• Comparing facility quality to

peers• Survey preparation• Safety promotion• Activities to improve person

centered, individualized care

Case Study Example

• Mr. Lambert was found by his CNA, Terri to have a new Stage 2 pressure ulcer on the right hip. Terri reported this to the charge nurse who investigated and found that the pressure ulcer was not present on 3-11 the day before. The evidence indicated the pressure ulcer developed on night shift, when Beth was the assigned CNA. Interview with Beth found that she had not changed the resident’s position every 1.5 hours as care planned. Beth apologized and said she was having difficulty getting everything done.

Source: AANAC QAPI Series Manual One p. 24

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Case study cont.

QA Approach

• Beth was counseled, instructed to view an online video on pressure ulcer prevention and given a warning that this was not to happen again

QAPI Approach

• Nursing supervisor recognized the need to determine if there were issues with the pressure ulcer (PU) prevention care system in the facility

• She assessed PU data and found a trend of slowly increasing facility acquired PU.

• She reviewed Beth’s assignments and found she was assigned 20 residents on her shift with complex needs

• PIP initiated to analyze PU prevention resident care systems

• Changes implemented based on substantive, quantifiable findings regarding resident needs and standards of care for PU prevention.

Source: AANAC QAPI Series Manual One p. 24

OVERVIEW OF THE FUNDAMENTALS

Understanding QAPI

You can practice shooting eight hours a day, but if your technique is wrong, then all you become is very good at shooting the wrong way. Get the fundamentals down and the level of everything you do will rise.

---Michael Jordan

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QAPI in Action: 5 Elements

QAPI

Element 1:

Design and Scope

Element 2: Governance

& Leadership

Element 3:

Feedback, Data

Systems, & Monitoring

Element 4:

Performance Improvement

Projects (PIPS)

Element 5: Systemic

Analysis & Systemic

Action

Program Design and Scope

§483.75(b) Program design and scope. • A facility must design its QAPI program to be ongoing,

comprehensive, and to address the full range of care and services provided by the facility. It must:

• (1) Address all systems of care and management practices;

• (2) Include clinical care, quality of life, and resident choice;

• (3) Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a SNF or NF.

• (4) Reflect the complexities, unique care, and services that the facility provides.

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Design and scope• The QAPI program must be ongoing and comprehensively

address all care and services provided including

Clinical Care

Quality of Life

Resident Choice

12 Action Steps to QAPI Design & Implementation source Ohio QIO http://ohiokepro.com/shopping/pdfs/8772.pdf

1. Leadership Responsibility& Accountability

Develop a steering committeeProvide resources including training, equipmentEstablish climate of open communication & respectUnderstand current culture & how it will promote PI

2. Develop a deliberate approach to teamwork

Assess teamwork effectivenessDiscuss how PIP teams will work to address goalsDetermine how staff, residents & families can be involvedReview communication format

3. Self Assessment Complete self assessment by people with specific knowledge in their areas of responsibility. Set date for reassessment.

4. Identify Guiding Principles

Develop/enhance vision, mission, purpose statement and guiding principles. Combine with the written scope of care/services into the preamble document.

5. Develop QAPI plan Print QAPI at a glance Guide For Developing a QAPI Plan tool. Assign due dates and responsibilities for writing the QAPI plan and final review.

6. QAPI Self Awareness Campaign

Inform staff, residents, consultants, families, ancillary providers about QAPI plan. Provide education. Establish a communication plan.

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12 Action Steps to QAPI Design & Implementation

continued

7. Develop Data Collection & Use Strategy

Determine what data to monitor routinely, set performance targets, identify benchmarks. Develop data collection plan including who will collect, who will review, frequency and reporting.

8. Identify Gaps & Opportunities

Review information for gaps in systems of care or improvement opportunities. Discuss emerging themes. Identify successes. Set priorities for improvement.

9. Prioritize Opportunities &Charter PIPs

Prioritize which problems will become the focus of PIPs. Charter PIP teams. Define leaders, mission, timeline and budget. Set specific goals using the Goal Setting Worksheet.

10. PIPs Determine information needed, request needed supplies, select/create measurement tools, prepare & present results, use problem solving model, report to steering committee

11. Get to the Root of Problems

Use a methodical approach, determine root causes, define controllable factors, ensure the PSDA cycle addresses root causes

12. Take Systemic Action

Implement changes, target root causes with strong interventions, pilot test large scale change prior to launching facility wide

Governance and Leadership

§483.75(f) Governance and leadership. The governing body and/or executive leadership (or organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that:

• (1) An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities.

• (2) The QAPI program is sustained during transitions in leadership and staffing;

• (3) The QAPI program is adequately resourced, including ensuring staff time, equipment, and technical training as needed;

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Governance and Leadership

§483.75(f) Governance and leadership. The governing body and/or executive leadership (or organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that:

• (4) The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information.

• (5) Corrective actions address gaps in systems, and are evaluated for effectiveness; and

• (6) Clear expectations are set around safety, quality, rights, choice, and respect.

Governance and Leadership• Administration and/or the governing body promotes a

QAPI culture that includes continually seeking input related to quality and opportunities for improvement while holding staff accountable for QAPI

• Designated leader(s) accountable for QAPI program

• QAPI training to develop leaders and facility wide staff

• Resources allocated for the program

• Policies and procedures which ensure QAPI is sustained despite staff turnover

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Policies and Procedures• How leaders identify, collect, and use data from all departments

including how the info would be used to identify high risk, high volume or problem prone areas.

• A description of methodology and frequency for developing, monitoring and evaluating performance indicators

• The process for identification, reporting, analysis and prevention of adverse events or near misses.

• How facility leaders use a systematic approach (e.g. Root Cause Analysis) to determine underlying causes of problems impacting larger systems

• Development of corrective actions designed to effect change at the systems level and explain how the facility staff will monitor the effectiveness of performance improvement activities to ensure improvements were sustained (§483.75 (C) (2).

QAPI Policy/Procedures details:

• How accountability of top leadership is integrated into QAPI

• Who is the designated leader/coordinator

• A plan for facility wide QAPI training for new and current employees including who is responsible for training

• How front line workers will be trained to be proficient in PI and how proficiency will be measured

• A plan that ensures adequate resources such as staff time, training, equipment, supplies and meeting space

• Proposed structure for reporting QAPI findings and efforts

• Format and frequency of meetings

• Expectations for periodic self assessment and progress comparison

• Documentation and dissemination plan for meeting topics

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More details…

• Communication processes

• Guidelines for chartering PIPs

• PIP process

• Suggested methods of data gathering and analysis

• Tools available for measuring/displaying findings

• Audit topics, tools, and frequency

• Process for evaluating QAPI outcomes

• Periodic review of QAPI plan and program, with updates

Source: AANAC QAPI Manual Two Governance and Leadership for SNF p. 11

Program Feedback, Data Systems, and Monitoring§483.75(c) Program feedback, data systems and monitoring. A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following: • (1) Facility maintenance of effective systems to obtain and

use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

• (2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators.

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Program Feedback, Data Systems, and Monitoring§483.75(c) Program feedback, data systems and monitoring. A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

• (3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

• (4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

Feedback, Data Systems, & Monitoring

• Obtain and use feedback to facilitate improvement • Residents• Families/Representatives• Staff including direct care

workers

• Process for data collection and use from all departments

• Method for using data to determine high volume, problem prone or high risk areas

• Policies and procedures which describe the method and frequency for developing, monitoring and evaluating performance indicators

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Program Activities

§483.75(e) Program activities.

• (1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

Program Activities

§483.75(e) Program activities.

• (2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

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Program Activities

§483.75(e) Program activities.

• (3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section

Performance Improvement Projects (PIPs)• Concentrated effort on a problem area

• Systematic approach to clarify issues and intervene for improvement

• PIPs are conducted in individual facility priority areas

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Program Systematic Analysis and Systemic Action

§483.75 (d) Program systematic analysis and systemic action

• (1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

Program Systematic Analysis and Systemic Action

§483.75 (d)Program systematic analysis and systemic action• (2) The facility will develop and implement policies

addressing:

• (i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;

• (ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and

• (iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

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Systematic Analysis & Systemic Action

• Systematic, highly structured approach to problems review

• Policies and procedures on the use of Root Cause Analysis

• Comprehensive review across all involved systems to prevent future events

• Promotes sustained improvement

• Focuses on continual learning and continuous improvement

DEVELOPING THE QAPI PROGRAM

Transitioning from QAA to QAPI

Leadership sets long term view

Foundational Document Development

SelfAssessment

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QAPI Program

§483.75(a) Quality assurance and performance improvement (QAPI) program. • Each LTC facility, including a facility that is part of a

multiunit chain, must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life.

QAPI Program

§483.75(a) Quality assurance and performance improvement (QAPI) program. The facility must:

• (1) Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities;

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QAPI Program

§483.75(a) Quality assurance and performance improvement (QAPI) program. The facility must:

• (2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation; [§483.75(a)(2) will be implemented beginning November 28, 2017 (Phase 2)]

• (3) Present its QAPI plan to a State Survey Agency or Federal surveyor at each annual recertification survey and upon request during any other survey and to CMS upon request; and

• (4) Present documentation and evidence of its ongoing QAPI program's implementation and the facility's compliance with requirements to a State Survey Agency, Federal surveyor or CMS upon request.

QAPI Plan Preamble: Foundational Documents

1. Vision Statement

2. Mission Statement

3. Purpose Statement

4. Guiding Principles

5. Scope

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CMS foundational document examples:CMS Vision statement example:

The vision of the Good Samaritan Society is to create an environment where people are loved, valued and at peace.

CMS Mission statement example:Meadowlark Hills is each resident’s home. We are committed to enhancing the quality of life by nurturing individuality and independence. We are growing a value-driven community while leading the way in honoring inherent senior rights and building strong and meaningful relationships with all whose lives we touch.

CMS Purpose statement example:

The purpose of QAPI in our organization is to take a proactive approach to continually improving the way we care for and engage with our residents, caregivers, and other partners so that we may realize our vision to (reference aspects of vision statement here). To do this, all employees will participate in ongoing QAPI efforts, which support our mission by (reference aspects of mission statement here).

CMS guiding principles examples

• QAPI has a prominent role in our management and board functions, on par with monitoring reimbursement and maximizing revenue.

• Our organization uses QAPI to make decisions and guide our day to day operations.

• The outcome of QAPI in our organization is the quality of care and the quality of life of our residents.

• In our organization, QAPI includes all employees, all departments and all services provided.

• QAPI focuses on systems and processes, rather than individuals. The emphasis is on identifying system gaps rather than on blaming individuals.

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CMS guiding principles examples-cont.• Our organization makes decisions based on data, which

includes the input and experience of caregivers, residents, health care practitioners, families and other stakeholders.

• Our organization sets goals for performance and measures progress toward those goals.

• Our organization supports performance improvement by encouraging our employees to support each other as well as be accountable for their own professional performance and practice.

• Our organization has a culture that encourages, rather than punishes employees who identify errors or system breakdowns

Source: CMS, 2013b, p.2

Define the scope

• QAPI at a glance defines the scope as “an outline of what types of care and services are provided by the organization that impact clinical care, quality of life, resident choice, and care transitions (CMS, 2013c, p.33)

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Scope of Care & Services- Sample Listing

Care and Service Area Representative

Nursing short stay care Mary Reynolds, RN, DON

Nursing long term care Beth Simms, RN, Unit Manager

Nursing Memory Care Jonathan Lipscomb, RN, Unit Manager

Specialty Clinical Services• Wound care• Dialysis• Respiratory Care• Medication Management• Hospice• Restorative Nursing

Mary Reynolds, RN, DON

Therapy Services Robert Walker, DPT, Dept. Manager

Dietary Services Brenda Grissom, Dietary Manager

Nutrition Services Janine Bartle, RD

Environmental Services Jack Smythe

Physician Services Anne Parsons, MD, Medical Director

Social Services Jane Bartholomew, MSW, Director

Activities Debbie Sleziak, Director

source: AANAC QAPI design and scope for SNF manual one p.35

Vision

Mission

Purpose Statement

Guiding Principles

Scope

The QAPI Preamble Document

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QAPI Self Assessment

• Review existing QAA program to determine strengths and weaknesses

• CMS tool for self assessment at the start of QAPI

• Team input into self assessment to reflect organization’s awareness and involvement in QAPI

• Recommended to reassess annually to measure progress

• Self assessment reviews content from all five elements

CMS Self Assessment Tool

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/QAPISelfAssessment.pdf

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Developing Written QAPI PlanSTEP

1 QAPI goals Develop goals the plan will strive to achieve.

2 Scope Describe how QAPI is integrated into all care/service areas with focus on clinical care, quality of life & resident choice.

3 Guidelines for Leadership

Accountability of leaders, designated coordinator, resources, QAPI structure, training & proficiency measures

4 Feedback, Data, Monitoring

Data collection, analysis, reports, communication strategies, who receives information

5 PIPs Process for assigning topics, prioritization, chartering a PIP, team formation, reporting, documentation of findings

6 Systematic Analysis, Systemic Action

Detail systematic approach and the systemic action that will be implemented in response to findings, method for responding to unintended consequences, process of root cause analysis, monitoring implementation & effectiveness

7 Communications Formal process that includes: method, frequency, audience

8 Evaluation Frequency of self assessment, purpose of evaluation

9 Establish Plan Implementation date, revision plan/date at least annually

Written QAPI Plan-Step 1 QAPI Goals

• Specific goals based on QAPI preamble content

• Specific

• Measurable

• Actionable

• Relevant

• Timeline for completion

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QAPI Written Plan-Step 2 Scope

• Span or expanse of services the program will cover

• How QAPI is integrated into the areas of care and services provided by the facility

• Describe how the plan will address:

• Clinical Care

• Quality of Life

• Resident Choice

QAPI Written Plan-Step 3 Guidelines for Governance and Leadership• How responsibilities & accountabilities of top-level

leadership are integrated into QAPI• Plan to ensure QAPI activities receive adequate

resources• Description of organizations proposed QAPI

structure• Format & frequency of meetings• Communication processes• Documentation process• Designated leader• Training plans

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QAPI Written Plan-Step 4 Feedback, Data Systems, & Monitoring• Describe how team will identify sources of data

it will monitor

• Describe in detail:

• How data will be collected

• How data will be analyzed

• Type of reports that will be developed

• Process for communicating what is learned

• Who will receive information

QAPI Written Plan-Step 5 Performance Improvement Projects • Determination process for assigning PIP topics

• Criteria for prioritizing and selecting PIPS

• Procedure for chartering a PIP

• PIP team formation

• PIP report format

• Documentation of PIP activity and findings

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QAPI Written Plan-Step 6 Systematic Analysis & Systemic Action• Demonstrate difference between the systematic

approach and the systemic action that will occur based on what is learned

• Guidance on how to recognize and responded to unintended consequences

• Process for identifying root causes

• Monitoring plan

QAPI Written Plan-Step 7 Communication

• Provide details of formal communication process

• Frequency of communications

• Designation of intended audience

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QAPI Written Plan-Step 8 Evaluation

• Desired frequency of self-assessments

• Using data from self-assessment to evaluate success

• Purpose of evaluation

QAPI Written Plan-Step 9 Establishment of Plan

• Ensure every step included in plan

• Establish implementation date

• Begin following the plan

• Establish date for revisiting and revising plan if needed

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QAPI Team

• Committee selection based on experience and knowledge needed for the task at hand

• Select members from a variety of disciplines

• Senior administration as well as those with skills to develop the written plan and oversee QAPI implementation

• PIP specific sub-committees may be developed with members that hold special insight into the specific problem area being addressed

• E.g. Antipsychotic reduction PIP sub-committee may include the pharmacist

Training & Communication

• Establish a written QAPI communication plan• Format and frequency of meetings

• Method of communication between meetings

• Documentation and tracking of QAPI discussion topics

• Reporting to the governing body

• QAPI awareness campaign with plan for informing staff, residents, consultants, families, ancillary providers about the facility QAPI plan.

• A plan for general and technical training must be detailed in each facility’s written QAPI plan which includes:• How the leadership team will be educated on QAPI

• How facility wide training will prepare staff to participate

• Other training topics:• PIPs, effective team communication skills, problem solving techniques

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Identify Gaps & Opportunities

• Adverse Events

• Previous Survey Citations

• Quality Measures

• Infection Control Data

• Medications

• Complaints

• Satisfaction Surveys

• Rehospitalization Rates

• Consultant Reports

• Incident Reports

• Audits

Prioritizing Improvement• Frequency at which issue arises in the organizationPrevalence

• Level to which the issue poses a risk to the well-being of the residentsRisk

• Cost incurred by the organization each time the issue occursCost

• Extent to which addressing the issue would affect resident quality of life and/or quality of careRelevance

• Likelihood an initiative on this issue would address a need expressed by residents, family, and/or staffResponsiveness

• Ability of the organization to implement a PIP on the issue, given current resourcesFeasibility

• Level to which an initiative on the issue would support the organizational goals and prioritiesContinuity

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Collect and Review QAPI Data

• To help understand the process

• To make educated decisions based on facts

• To identify and prioritize improvement opportunities

• To analyze root causes

• To create baseline to monitor process improvements

• To predict future behaviors, detect process changes, & share information

• Identify and set benchmarks for comparison

• Establish performance indicators to assess progress

• Determine specifics of data monitoring activity

(Office of Quality Improvement University of Wisconsin Madison, 2007).

Presenting Data

(National Research Report, 2013 & AHCA, 2015)

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PIP Charter

• Creates the focus the QAPI team expects the PIP team to use in conducting improvement efforts

• Provides detailed information about expectations of the QAPI team

• Demonstrates the project has been well thought through and developed

• Guides selection of team members

• Directs team to work towards the outcomes they are asked to achieve

• See sample tools

Model for Improvement1. What are we trying to accomplish?2. How will we know the change is an improvement?3. What change can we make that will result in an improvement?

(CMS, 2014)

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Sustaining Improvement

Systems People

Environment Measurement

Root Cause Analysis

• Structured facilitated team process to identify root causes of an event that resulted in an undesired outcome & develop corrective actions.

• Purpose is to find out what happened, why it happened, & what changes need to be made

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Sustaining Improvement• Target elimination of the root causes

• Offer long-term solutions to the problem

• Achievable, objective, and measurable actions

(CMS, n.d.)

Strong Actions Intermediate Actions Weaker Actions

Change PhysicalSurroundings

Usability testing ofdevices beforepurchasing

Engineering controls intosystem (forcing functionswhich force the use tocomplete an action)

Simplify process andremove unnecessarysteps

Standardize equipmentor process

Tangible involvement and action by leadership in support of resident safety;i.e., leaders are seen and heard making or supporting the change

Increasestaffing/decrease in workload

Softwareenhancements/modifications

Eliminate/reducedistractions

Checklist/cognitive aide Eliminate look alike

and sound alike terms “Read back” to assure

clear communication Enhance

documentation/communication

Double checks Warnings and labels New procedure/ memo/

policy Training Additional study/analysis

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Achieving Change Success

• Visible leadership who are enthusiastic about the change

• Multidisciplinary approach

• Focus on human side of change

Next session in this series:Driving Five Star & RoP Implementation through a QAPI Approach:

Health Inspections: Analyzing 5-Star Data and Applying QAPI Principles to

Improve 5-Star Survey Results

scheduled for March 15, 2017

Please register to join us through your state association.

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Questions

Thank you for joining us ! Ask questions using the options on the right of your screen to either “raise your hand” for your phone line to be unmuted OR type your question

Please follow your state association guidance for obtaining CE credit. Inquiries related to certificates should be directed to the association with which you registered for this webinar. A recording of this session will be available for purchasethrough your association or www.proactivemedicalreview.com

Shelly Maffia, RN, MSN, HFA, MBA, QCP Amie Martin, OTR/L, CHC, RAC-CTsmaffia@proactivemedicalreview.com amartin@proactivemedicalreview.comProactive partners with providers for regulatory compliance, training, & medical review solutions.

Resources• CMS QAPI Resources

• https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/qapiresources.html

• IN & KY QIO-ATOM Alliance: Embracing QAPI

http://atomalliance.org/initiatives/reducing-healthcare-acquired-conditions/qapi/

• University of Wisconsin Facilitator Toolkit

http://oqi.wisc.edu/ resourcelibrary/uploads/ resources/ Facilitator%20Tool%20Kit.pdf

• Federal Register QAPI Proposed Regulation July 2015

http://www.gpo.gov/fdsys/pkg/FR-2015-07-16/pdf/2015-17207.pdf

• National Nursing Home Quality Care Collaborative Change Package

https://www.nhqualitycampaign.org/files/NH_ChangePackage_V2.0_03-26-2015_Final.pdf

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References• CMS. (2014). Guidance for performing root cause analysis (RCA) with

performance improvement projects (PIPs). Retrieved from https://www.cms.gov/ Medicare /Provider-Enrollment-and-Certification /QAPI/ downloads /GuidanceforRCA.pdf

• CMS. (n.d.). QAPI At A Glance. Retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/QAPIAtaGlance.pdf

• Office of Quality Improvement University of Wisconsin Madison. (2007). Facilitator Toolkit: A Guide For Helping Groups Get Results. Retrieved from http://oqi.wisc.edu/ resourcelibrary/uploads/resources/Facilitator%20Tool%20Kit.pdf

• Ohio KEPRO QIO The CMS QAPI Guide: What You Need To Know A Companion Guide to QAPI at a Glance. Retrieved 1/10/16 from http://ohiokepro.com/shopping/pdfs/8772.pdf

• AANAC. (2015) QCP Candidate Handbook: QAPI for Long Term Care.

• NADONA CMS Proposed QAPI Rule: What You Need to Know. Retrieved 1/11/15 from http://www.nadona.org/uploadIMG/moxie/CMS%20Releases%20Proposed%20Rule%20on%20QAPI.pdf