building a successful hospice qapi program
TRANSCRIPT
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HPS Alliance Members Only Hospice Webinar Series ‐ 2021
Presenter: Sharon M. Litwin RN, BSHS, MHA, HCS-D
Building a Successful Hospice QAPI Program
June 15, 2021
Objectives•Explain the benefits of having an effective QAPI plan
•Understand the hospice QAPI Condition of Participation (CoP)
•Describe the impact of HIS and CAHPS relative to QAPI
•Identify the steps involved in an agency self‐assessment
•Explain the difference between a Quality Indicator and a Process Improvement Project (PIP)
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Benefits of An Effective QAPI Program
•A Quality Program it is a key component of a well‐run organization
•It not only assists in being compliant to laws and regulations, but it:
o Minimizes Risk
o Improves Palliative Outcomes
o Improves Hospice Performance
o Lessens your Crises “Du Jour”
o Prevents future problems!
o Increase your Agency’s Quality and Efficiency
•A good QAPI program should be incorporated into everyday operations and involve ALL staff!
418.58–CONDITION OF PARTICIPATION
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Condition 418.58 ‐ QAPI
Standards :
Program Scope
Program Data
Program Activities
Performance Improvement Projects
Executive Responsibilities
Condition 418.58 – QAPI Standards
A. Program Scope –(1)The program must at least be capable of showing measurable improvement in indicators related to improved palliative outcomes and hospice services
(2)The hospice must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations
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Condition 418.58 – QAPI StandardsB. Program Data -
(1)The program must use quality indicator data, including patient care, and other relevant data, in the design of its program
(2) The hospice must use the data collected to do the following:(i)Monitor the effectiveness and safety of services and quality of care(ii)Identify opportunities and priorities for improvement
(3) The frequency and detail of the data collection must be approved by the hospice’s governing body
Condition 418.58 – QAPI StandardsC. Program Activities ‐(1) The hospice’s performance improvement activities must:
(i) Focus on high risk, high volume, or problem‐prone areas
(ii) Consider incidence, prevalence, and severity of problems in those areas
(iii) Affect palliative outcomes, patient safety, and quality of care
(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice
(3) The hospice must take actions aimed at performance improvement and, after implementing those actions, the hospice must measure its success and track performance to ensure that improvements are sustained
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Condition 418.58 – QAPI StandardsD. Performance Improvement Projects ‐ hospices must develop, implement and evaluate performance improvement projects
(1) The number and scope of distinct performance improvement projects conducted annually, based on the needs of the hospice’s population and internal organizational needs, must reflect the scope, complexity, and past performance of the hospice's services and operations
(2) The hospice must document what performance improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects
Condition 418.58 – QAPI StandardsE. Executive Responsibilities ‐
The Hospice's governing body is responsible for ensuring the following:
(1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually
(2) That the hospice‐wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness
(3) That one or more individual(s) who are responsible for operating the quality assessment and performance improvement program are designated
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QAPI
CONDITION
QAPI – Allows Flexibility in Program Development
But there are Some Rules:
Must reflect the complexity of its organization and services
Must involve all hospice services including those furnished under contract or arrangement
Must focus on indicators related to improved palliative outcomes
Must take actions to demonstrate improvement in hospice performance
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QAPI – Allows Flexibility in Program Development
Hospice QAPI should demonstrate, through the use of objective data, that improvements have taken place in:
• actual care outcomes
• processes of care
• patient/family satisfaction levels
• hospice operations
• other performance indicators
BUILDING A SUCCESSFUL
QAPI PROGRAM
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Where Do We Start?• CASPER Quality Measures Reports
• Care Compare (Hospice Compare)
• Self Assessment of Agency (Mock Survey)
• How to select the outcome measures to focus on
o What to do with the selected outcomes
• How to develop indicators and audit tools
• How to write action plans
• What if we aren’t improving
Understanding Hospice CASPER Quality Measure Reports
In the Certification and Survey Provider Enhanced Reporting (CASPER) application, two reports are available as Confidential Provider Feedback Reports:• Hospice‐Level Quality Measure Report
• Hospice Patient Stay‐Level Quality Measure Report
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Understanding Hospice CASPER Quality Measure Reports
These two reports fall under the class of CASPER reports known as “QM reports”
CASPER QM reports are intended to provide hospice providers with feedback on their quality measure scores, helping them to improve the quality of care delivered.
Incorporate Error Details in hospice QA program to monitor timeliness and proper HIS submission sequence
Understanding Hospice CASPER Quality Measure Reports
CASPER QM reports • View national average scores in a specific reporting period• View your own quality data at both the patient‐stay level and hospice level.
Reports are on‐demand • Can view and compare your performance to a national comparison group at any time and for a reporting period of their choice.
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Hospice HIS ‐What Measures are Reported & How Data is Collected
Hospices are required to submit the appropriate HIS record for each patient admission and discharge, regardless of the patient’s payer source, age, or location where the patient receives hospice services.
Hospices submit HIS data to CMS through the Quality Improvement and Evaluation System (QIES), Assessment Submission and Processing (ASAP) system.
HIS data are used to calculate 10 quality measures.
These quality measures are reported on both the Hospice‐Level Quality Measure Report and Hospice Patient Stay‐Level Quality Measure Report.
Quality Measures Reported on CASPER QM Reports
Measure Title Measure Description
Treatment Preferences The percentage of hospice patient stays with chart documentation that the hospice discussed (or attempted to discuss) preferences for life‐sustaining treatments
Beliefs/Values Addressed (if desired by the patient) The percentage of hospice patient stays with documentation of a discussion of spiritual and existential concerns or documentation that the patient and/or caregiver did not want to discuss
Pain Screening The percentage of hospice patient stays during which the patient was screened for pain during the initial nursing assessment
Pain Assessment The percentage of hospice patient stays during which the patient screened positive for pain and received a comprehensive assessment of pain within 1 day of screening
Dyspnea Screening The percentage of hospice patient stays during which the patient was screened for dyspnea during the initial nursing assessment
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Quality Measures Reported on CASPER QM Reports
Measure Title Measure Description
Dyspnea Treatment The percentage of hospice patient stays during which the patient screened positive for dyspnea and received treatment within 1 day of the screening
Patients Treated with an Opioid who are Given a Bowel Regimen The percentage of patient stays with vulnerable adults treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not needed
Hospice and Palliative Care Composite Process Measure: Comprehensive Assessment at Admission
The percentage of hospice stays during which patients received a comprehensive patient assessment at hospice admission
Hospice Visits When Death Is Imminent, last 3 days of life The percentage of patients receiving at least one visit from a registered nurse, a physician, a nurse practitioner, or a physician assistant in the last three days of life
Hospice Visits When Death Is Imminent, last 7 days of life The percentage of patients receiving at least two visits from a medical social worker, a chaplain or spiritual counselor, a licensed practical nurse, or a hospice aide in the last seven days of life
CASPER – Hospice‐Level Quality Measure Report
Quality measure scores ‐ Figure 1 illustrates how to read this report. • The report identifies which quality measures a hospice could develop quality improvement interventions to improve performance.
• Hospice providers can trend their quality measure results by comparing their quality measure scores and percentiles across multiple reporting periods, such as consecutive quarters.
• Trending the quality measure scores enables hospice providers to monitor the progress of the quality improvement interventions.
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CASPER – Hospice‐Level Quality Measure Report
* Because of the change to the HIS, the QM and Review and Correct reports display HVWDII measure scores only when hospice agencies select quarters before or including Q4 2020, after Q4 2020 the reports will display a dash for HVWDII.
Reference: CMS Getting Started with Hospice CASPER Quality Measure Reports: August 2019 Fact Sheet
CASPER – Hospice Patient Stay‐Level Quality Measure Report
Can review the quality measure outcomes for all patient stays during the reporting period.
The report shows whether each patient stay triggered each quality measure. Figure 2 illustrates how to read this report. • Along with the Hospice‐Level Quality Measure Report this report drills down to patient‐stay level information for each quality measure.
• This report can assist a hospice to quickly assess which patient stays contributed to the unfavorable results and then implement care processes to address the issues identified.
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CASPER – Hospice Patient Stay‐Level Quality Measure Report
• Use this report to assess quality of care concerns for specific patient populations based upon length of stay.
• Example: A hospice could review cases in which the admission and discharge date were within the same month and year and for which the patient did not achieve three or more of the quality measures, to determine if there are general quality of care concerns for patients with this length of stay.
• This report indicates when an admission record was not submitted with an HIS discharge record (Type 2 Stay). This information could assist hospice in identifying when a missing admission record should be submitted to the QIES ASAP system.
CASPER – Hospice Patient Stay‐Level Quality Measure Report
Reference: CMS Getting Started with Hospice CASPER Quality Measure Reports: August 2019 Fact Sheet
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How to Utilize Casper Reports for Quality Improvement
•Obtain Hospice‐ Level and Hospice Patient Stay‐Level Quality Measure Reports Monthly.
•Review hospice‐level report to determine which quality measures your hospice performs well, and which quality measures need improvement.
•Review hospice patient stay‐level report to determine which patient stays triggered a specific quality measure (i. e. met the numerator criteria) and those that did not trigger that quality measure.
How to Utilize Casper Reports for Quality Improvement
•The patient stays that did not trigger each quality measure are your agencies opportunities for quality improvement. o Audit a sample of these charts to determine where there are opportunities
to improve care and where defined care processes were not carried out as planned.
o Identify root causes of why the care process were not carried out as planned
• Look beyond the chart data
• Trends
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Identify and Prioritize•Identify how daily clinical practice and operations can impact responses and hospice outcomes
•Prioritize the areas that you are significantly below average firsto What needs your attention the most?
•Develop a top priority listo Often this will branch off into other areas to work on
•Spend the majority of your time on the biggest challenges
•Assign task force for bigger areas
Educate…Educate…Educate•Involve EVERYONE
•Educate staff on HIS and CAHPS and review the items/questionso Educate monthly in various ways:
• Staff meetings• Posters• Newsletters• Games• Quizzes
•Discuss the impact of HIS and CAHPS and Hospice Quality Reporting has on agency outcomes
•At admission, educate patient, families and/or caregivers
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Have a Meaningful QAPI Plan•Ensure program is designed to help you
•Incorporate HIS items and Hospice CAHPS survey results into your QAPI program
•Collect data
•Trend
•Analyzeo Root cause analysis
•Develop action plans
•Evaluate plan
HIS ACCURACY&
CONSISTENCY
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HIS AccuracyIf lacking, your work on improving outcomes will not be successful!
Steps:
• HIS Audit of all of your clinicians completing HIS Admission and HIS Discharge
• Trend results‐ identify if common problem or individuals
• Develop Education Plan‐ Tailored educationo Ex: if common problem with 3 quality measures, educate all HIS clinicians on those;
o Ex: if individuals that don’t understand HIS‐ do full education
HIS AccuracyIf lacking, your work on improving outcomes will not be successful!
Steps:
• Recommend a FULL HIS training class at least annually !oUpdate on CMS Q&A’s, etc.
oReview CMS HIS MANUAL chapter 2 Item Specific Instructions and HIS Item Completion Conventions – as many clinicians forget all of the caveats that can assist in increasing outcomes!
• Audit Again!
• Drop frequency and amount of Best Performers
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Hospice Comprehensive Assessment Measure
This one measure is based on 7 HIS measures
• This measure helps ensure all hospice patients receive a holistic comprehensive assessment at admission, although it does not replace a comprehensive assessment.
• To achieve the measure, you must complete all 7 HIS measures for each patient.
• The Comprehensive Assessment Measure Includes:
o Treatment Preferences
o Beliefs values addressed (if desired by the patient)
o Pain screening during the initial nursing assessment
o Pain assessment received within 1 day of screening, if screening is positive for pain
o Dyspnea screening during the initial nursing assessment
o Dyspnea assessment received within 1 day of screening, if screening is positive for dyspnea
o Patients treated with an opioid who are given a bowel regimen
Hospice Comprehensive Assessment Measure
Why should your agency focus on meeting this measure• Leads to compliance and appropriate patient centered care.
• Supports the plan of care by determining a patient’s pain and symptom management needs.
• May avoid one of the top deficiencies cited in hospice care.
• Can prevent denials.• Can improve CAHPS scores by meeting patient goals and outcomes.
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HQRP – PROPOSED RULE – REMOVAL OF THE SEVEN HIS PROCESS MEASURES
•As part of the CY 2022 Proposed Rule, CMS is Proposing:
o To remove the seven individual Hospice Item Set (HIS) measures from HQRP beginning FY 2022 and also to remove the “7 measures that make up the HIS Comprehensive Assessment Measure” section of Care Compare, but continue to have it publicly available in the data catalogue
o To make these changes removing the seven HIS process measures as individual measures from HQRP no earlier than May 2022.
•The proposal is to remove the 7 individual HIS process measures, but it does not propose any changes to the requirement to submit the HIS admission assessment.
•Hospices that do not report HIS data used for the HIS Comprehensive Assessment Measure will not meet the requirements for compliance with the HQRP.
HQRP – PROPOSED RULE – HOSPICE CARE INDEX MEASURE ‐ HCI
•CMS is proposing A new measure to the HQRP called the Hospice Care Index. This single measure includes 10 indicators of quality that are calculated from claims data.
1. Continuous Home Care (CHC) or General Inpatient (GIP) Provided2. Gaps in Nursing Visits3. Early Live Discharges4. Late Live Discharges5. Burdensome Transitions (Type 1) ‐ Live Discharges from Hospice Followed by Hospitalization and Subsequent Hospice Readmission
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HQRP – PROPOSED RULE – HOSPICE CARE INDEX MEASURE ‐ HCI
6. Burdensome Transitions (Type 2) ‐ Live Discharges from Hospice Followed by Hospitalization with the Patient Dying in the Hospital
7. Per‐beneficiary Medicare Spending
8. Nurse Care Minutes per Routine Home Care (RHC) Day
9. Skilled Nursing Minutes on Weekends
10. Visits Near Death
HQRP – PROPOSED RULE – HCI MEASURE•Each indicator equally affects the HCI score, reflecting the equal importance of each aspect of care delivered from admission to discharge.
•A hospice is awarded a point for meeting each criterion for each of the 10 indicators.
•The sum of the points earned from meeting the criterion of each indictor results in the hospice’s HCI score, with10 as the highest hospice score.
•The indicators represent different aspects of hospice care and aim to convey a comprehensive characterization of the quality of care furnished by a hospice.
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HQRP – PROPOSED RULE – HCI MEASURE•The HCI will help to identify whether hospices have aggregate performance trends that indicate higher or lower quality of care relative to other hospices.
•CMS will revise the QM report to include claims‐based measure scores, including agency and national rates through the Certification and Survey Provider Enhanced Reports (CASPER) or replacement system.
•The QM report will also include results of the individual indicators used to calculate the single HCI score and provide details on the indicators and HCI overall score.
•If finalized, this measure would be publicly reported no earlier than May 2022.
Hospice Visits in Last Days of Life (HVLDL)
•As of January 1, 2021, the Hospice Visits in the Last Days of Life claims‐ based measure replaces the information previously collected in Section O of the HIS‐Discharge.
•This is a re‐specified, claims‐based version of the Hospice Visits when Death is Imminent (HVWDII) measure pair.
•HVLDL indicates the hospice provider’s proportion of patients who have received visits from a RN or MSW (non‐telephonically) on at least two out of the final three days of the patient’s life.
•The calculation of the last three days remains unchanged from the last three days documented in Section O.
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HVLDL Measure•Hospice Visits in the Last Days of Life (HVLDL) Measure
•The new HVLDL measure achieves:
o Improved ability to differentiate higher from lower quality hospices
o Quality rankings more consistent with those produced with other quality measures in the HQRP
o Alignment with the Service Intensity Add‐On (SIA), CMS’s payment policy initiative implemented in 2016 which seeks to incentivize visits by registered nurses and medical social workers when patients are near death
o Reliance solely on existing administrative data for calculation, removing the need for data collection through clinician assessment
HQRP Measures
•All HQRP measures in the past included data for all hospice patients regardless of payor however, because claims-based data available to CMS is only for Medicare hospice patients, Patient Visit Data in the last days of life for non-Medicare hospice patients will not be used in the HQRP after January 1, 2021.
•All HQRP measures that are not claims based will continue to be used for all hospice patients regardless of the payor.
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HOSPICECAHPS
Hospice CAHPS•The CAHPS Hospice Survey is a national survey of family members or friends who cared for a patient who died while under hospice care.
•The survey is conducted monthly.
•The questionnaire contains 47 questions covering topics of interest to family caregivers and hospice patients.
•Survey results are displayed publicly on Care Compare
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Hospice CAHPS•Impacts Paymento CAHPS Hospice Survey Compliance in CY 2020 affects FY 2022 Annual Payment Update (APU)
•Goalso Improve transparency through public reporting
o Create incentives for quality improvement
•Hospices report 2 types of data as part of the Hospice Quality Reporting Program (HQRP)1. Quality of patient care
2. Results of family survey of experiences with hospice care ‐ CAHPS
Hospice CAHPS•Eight Quality Measures Publicly Reported
o Composite Measures:
Communication with family (Hospice Team Communication)
Getting timely help (Getting Timely Care)
Treating patient with respect (Treating Family Member With Respect)
Emotional and spiritual support (Getting Emotional And Religious Support)
Help for pain and symptoms (Getting Help For Symptoms)
Training family to care for patient (Getting Hospice Care Training)
o Global Measures:
Rating of the hospice (Rating of Hospice)
Willing to recommend this hospice (Willingness To Recommend)
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Care Compare
•Reports information on hospices across the nation and allows patients, family members, and health care providers to get a snapshot of the quality of care each hospice provides.
•Compare hospices based on a national survey that rates family members’ experiences with hospice care or on important indicators of quality
◦ https://www.medicare.gov/care‐compare/#search
Other than Casper Reports, Where Else Do We Find High Volume/High
Risk/Problem Prone Indicators to Monitor?
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Self‐Assessment/Mock Survey•Another valuable tool to help select areas to monitor in your QAPI program.
•Best way to ensure that you are in a state of continued survey readiness.
•Must assign qualified employees (often managers or QAPI staff) from your agency or another location if multi–site.
•If no one is qualified to be able to ‘survey’ your agency internally, consider engaging a consultant with appropriate survey expertise.
•Even if your own staff is performing the mock survey, do it formally as a surveyor would.
Self‐Assessment/Mock Survey‐Items to Review
•Previous regulatory survey reports & the agency’s approved plan of correctionoProbably will be included as a QAPI indicator
o Important to avoid repeat deficiencies.
A standard level deficiency, if repeated, is vulnerable to escalating to a condition level deficiency.
oOngoing monitoring in the QAPI program can help your agency to avoid repeat deficiencies and Conditions!
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Self‐Assessment/Mock Survey‐Items to Review
•Complaints, incidents including falls, and infection surveillance o Ensure that there is resolution documented for all complaints.
o Trend complaints to see red flags early. Trends may become QAPI indicators.
Ex: increasing falls for patients without therapy services, complaints regarding staff competency, and increasing numbers of UTI’s
•In‐service, Orientation and Competency programs, Human Resource files
Mock Survey/Home Visits•Home visits – VERY important to do during a mock survey oDo the approximate number a surveyor would do
Number of unduplicated admissions 12 months prior
to the survey
Minimum number of record review only (No home visit)
Minimum number of record review with home
visit
Total survey sample
Less than 150 8 3 11
150 ‐ 750 10 3 13
751 ‐ 1250 12 4 16
1251 or more 15 5 20
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Mock Survey•Home Visits:oChoose a variety:
Disciplines / diagnoses / various length of stays / patient setting
oPrior to home visit
Review the clinical record
Interview clinician
oCheck the clinician's car set up and supplies
Mock Survey•During the home visit:o Locate and review the home folder
o Observe if POC is being followed
o Observe infection control/ bag technique/ hand hygiene
o Do NOT intervene unless see safety issue
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Mock Survey•Home Visits:oAt the end of the visit:
• Interview the patient and/or representative/caregiver/family
• Ask questions like a surveyor would:Any complaints
Access to after hoursCommunication – arrival times of staff
Teaching – medications, infection control, pain management, etc.
• Day after visit: Check clinician's documentation
Clinical Record Reviews
•From Home Visits note what was non‐compliant to physician orders, medications, patient rights, infection control, aide care plan, etc. o Ensure the audit tool is appropriate to capture all regulations.
o Ensure auditor understands what to look for on both clinical record reviews and home visits.
o Train staff on how to perform these key areas of a mock survey.
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Clinical Record Reviews•Look for commonly seen deficiencies, such as: o Plan of Care
• Goals/interven ons not specific or measurable
• Not updated when problems or changes occur
o Coordina on of services
• Within IDG and/or in visit notes
o Aides not following aide care plans, and untimely supervisory visits
o Physician orders:
• Visit frequencies, interventions, medications, treatments
Analyzing, Trending & Developing Action Plans
Many agencies perform a lot of audits, gather a lot of data, but
then don’t do the most important steps in a QAPI
program.
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Analyze Results
Examples:• Low patient outcomes and poor customer satisfaction
• Low pain quality measures, CAHPS say patients didn’t receive much help with pain
• Low number of visits, CAHPS say caregivers didn’t get the help they needed from the hospice team during evenings, weekends, or holidays
What did you find from your assessment
Where are your vulnerable areas
Do any areas tie together
Development of the QAPI Plan•Prioritize the topics that you have found from the CASPER Quality Measures Reports and the Self Assessment/Mock Survey deficiencies.
o Separate into items you can address and resolve immediately, and those that require more review and auditing.
o Focus on the high volume, high risk, problem‐prone areas in your agency.
o These will be your QAPI Indicators for the plan!
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Development of the QAPI Plan•Audit Tools must be developed for each indicator.
o There are many variations to audit tools and tracking o Make certain that criteria are objective in order to ensure accurate
results o Measure for each criteria, for total per patient, and total for all Ex: Interim orders written for med changes ‐ one criteria or 20 – but
this one is 60%• This criteria may become a separate quality indicator!• Overall Quality Indicator percent is 90% but can't ignore the interim
orders!o Drill Down – Identify if documentation issue, knowledge deficit or care
issue
Action Plans•Ensure that your Action Plans are specific with findings
•Drill down to the items that you will perform during this time period in order to improve and sustain.
•Action items may include: o Staff Education
o Process change
o Policy Change
o QAPI Monitoring
o PIP Project
•Whenever an indicator is lower than the goal or has significantly varied over the time periods of collection, it is important to revise the action plan.
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PERFORMANCEIMPROVEMENT
PROJECTS
Performance Improvement Project•You may find that a deficiency is widespread, effecting many services as well as office and field staff. This would become then a PI project!
•Remember PIP – Performance Improvement Project oMost of us in healthcare have done many PIPs!
o The QAPI condition requires this
o If you find a deficiency and/or problem area that is critical to patient care, safety and/or outcomes, develop and initiate a PIP
oRemember project‐ this is what separates a PIP from a Quality Indicator.
• Complex, multiple issues and people to interact with ,etc.
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Performance Improvement Projects
The projects will often involve performing a root cause analysis or Fish Bone Analysis, where a task force of stakeholders reviews the deficient area, and then drills down to all the various facets that are involved. • Often communication is key – between clinicians, office staff, physicians and patients / caregivers.
• Very often processes and policies need to be revised.
• Several ongoing QAPI indicators may need to be developed as a result as well.
QAPI SUCCESSGet Everyone in your Agency Involved!
Having a large QAPI team and rotating them every six months to a year is a great way to get all staff involved.
• The team will brain‐storm on action plans, indicators, audit tools, etc.
• Assign team members to parts of the action plan, examples include clinical record reviews, education, and process development.
Your agency will improve in many ways when your staff is involved in QAPI!
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QAPI Never Stops!
Indicators may be able to be discontinued once you find sustained and complete
improvement . . .
but the evaluation must continue!
Casper Mock Survey
High Volume High Risk
Problem Prone
Indicators
Collect Data
AnalyzeTrends
Action Plan
Evaluate
Repeat
A QAPI program is not just busy work that must be done because of the CoPs, but is a true tool to enhance an agency’s outcomes, quality, and operation
Checklist:
• Ensure you review CASPER Quality Management Reports
• Perform an agency self‐assessment (mock survey)
• Action plan of Findings from above reports and survey
• Develop QAPI indicators and audit tools
• Collect the data
• Review/analyze and trend the data
• Revise action plans for improvement and sustained improvement.
• Involve all your agency staff for improved performance!
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QAPI Indicator Examples
QAPI‐ Results
Indicator Freq Goal Jan Feb Mar
Clinical Record Review q 90% 78% 90% 82%
Home Visits q 90% 85% 87% 90%
Infection Surveillance q <10% 2% 3% 8%
Comprehensive Pain Assessment q <10% 15% 8% 9%
Human Resource File ‐ Audit annual 90% 95%
Medication Errors q <2% 0% 1% 1%
It is important to improve results in an indicator being monitored and then sustain that improvement
An annual QAPI calendar is an easy way to track results over a year.
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QAPI Indicator Pain Assessment Completed
•A primary goal of having a patient receive hospice services is pain management.
•Agency goal is to have greater than 95% (based on Agency CASPER Quality Management Reports) of our patients screened, assessed, and treated for pain.
•The QAPI coordinator or designee will review 25% of patient admission records for screening, assessment, and treatment of pain. The goal is for a 95% compliance to the audit criteria.
Pain AuditThe QAPI coordinator or designee will audit 25% of admission records for completion of a comprehensive pain assessment to criteria with expected threshold 95%.
Criteria for Audit Tool:• Was comprehensive pain assessment completed on admission?• Was a standardized pain tool used for pain assessment?
• If the patient experienced pain on admission, were the 7 characteristics of a comprehensive pain assessment clearly documented and did they accurately reflect the patient’s pain?
• Was physician notified for signs and symptoms of uncontrolled pain ?• Was pain education documented ?• Was understanding of education by patient/caregiver documented? • Did the patient /cg contact the Hospice with reports of uncontrolled pain? • If yes, did the nurse call the physician and / or make a visit• Was there anything the Hospice could have done to proactively manage the patient’s uncontrolled pain ?
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Criteria Pt Pt
Pain
Did the pain assessment correlate with the J items for pain on HIS Admission?
Was a standardized pain tool used for pain assessment?
If the patient experienced pain on admission, were the 7 characteristics of a comprehensive pain assessment clearly documented and did they
accurately reflect the patient’s pain?
Was physician notified for signs and symptoms of uncontrolled pain ?
Was pain education documented ?
Was understanding of education by patient/caregiver documented?
Not Scored‐ Did the patient /cg contact the Hospice with reports of uncontrolled pain?
If yes, did the nurse call the physician and / or make a visit?
Was there anything the Hospice could have done to proactively manage the patient’s uncontrolled pain ?
Total per patient:
Total compliance : ________
Pain Audit Tool
QAPI Indicator Dyspnea Screening, Assessment, and Treatment Completed
A primary goal of having a patient receive hospice services is dyspnea management.
•Agency goal is to have greater than 95% (based on Agency CASPER Quality Management Reports) of our patients screened, assessed, and treated for dyspnea.
•The QAPI coordinator or designee will review 25% of patient admission records for screening, assessment, and treatment of dyspnea. The goal is for a 95% compliance to the audit criteria.
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Dyspnea AuditThe QAPI coordinator or designee will audit 25% of admission records for screening of Dyspnea to criteria with expected threshold 95%.
Criteria for Audit Tool:• Does patient have respiratory diagnosis?
• Did the respiratory assessment correlate with the J items for dyspnea?
• Was HIS J2030 response correct?
• If HIS J2030C answered 1 – Yes, was J2040 answered correctly?
• Was physician notified for dyspnea signs and symptoms?
• Were treatment interventions effective?
• Was there documentation of patient/ caregiver dyspnea education?
• Was understanding of education by patient/caregiver documented?
Criteria Pt Pt Pt Pt Pt
Respiratory:
Not scored – does patient have respiratory diagnosis?
Did the respiratory assessment correlate with the J items for dyspnea?
Was HIS J2030 response correct?
If HIS J2030C answered 1 – Yes, was J2040 answered correctly?
Was physician notified for dyspnea signs and symptoms?
Were treatment interventions effective?
Was there documentation of patient/caregiver dyspnea education?
Was understanding of education by patient/caregiver documented?
Total per patient:
Total compliance : ________
Dyspnea Audit Tool
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Conclusion•Review your current QAPI Program- Plan, Indicators, Audit Tools, Action Plans, Improvement
•Review CASPER Quality Measures Reports
•Identify vulnerabilities to the Conditions / Standards through Mock Survey/ Self-Assessment
•Develop QAPI indicators and PIPs relevant to your high risk, high volume, problem prone areas
•EDUCATION ….. On-Going!
•Task Forces to include field staff are excellent ways to improve both programs!
•Involve ALL Staff
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HPS Alliance Members Receive 10% Off NAHC FMC!
Code: HPS10PERCENT
Thank You For Participating!
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