How to Direct and Produce a “BLOCKBUSTER”

QAPI Meeting

A learning and action webinar for

the South Dakota Nursing Home

Quality Care Collaborative

October 17, 2013

Presented by: Holly Beving, RN, hbeving@sdqio.sdps.org, 605-228-9594

Lori Hintz, RN, lhintz@sdqio.sdps.org, 605 354-3187

South Dakota Foundation for Medical Care

This material was prepared by SDFMC, the Medicare Quality Improvement Organization for South Dakota, under

contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health

and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-SD-C7-13-410

2

The Plot . . . “aka” the objectives

• Learn key strategies that will assist Quality Assurance

Performance Improvement (QAPI) meetings to be more

organized, more effective, and produce results.

• Share meeting agenda template designed specifically for QAPI

that incorporates an action and follow-up plan for EVERY

meeting.

• Learn when to form a PIP Team. Share PIP documentation tool.

• Familiarize participants with the “National Nursing Home Quality

Care Collaborative CHANGE Package” and “QAPI At A Glance”

document.

• Hear from three South Dakota DONs related to their QAPI best

practices.

3

The Backdrop: F520 Regulation 483.75(o) Quality Assessment and Assurance

1) A facility must maintain a quality assessment and

assurance committee consisting of: (i) the director of

nursing services; (ii) a physician designated by the facility,

and (iii) at least 3 other members of the facility’s staff.

2) . . . (i) Meets at least quarterly to identify issues with

respect to which quality assessment and assurance

activities are necessary; and (ii) develops and implements

appropriate plans of actions to correct identified quality

deficiencies.

The Long Term Care Survey Manual, AHCA, May 2013 Edition

4

F520 Regulation continued

3) A state or the Secretary may not require disclosure of the

records of such committee except insofar as such

disclosure is related to the compliance of such committee

with requirements of this section.

Surveyors will ask for a record of dates of your QAPI meetings and list

of attendee names and titles at each meeting. . .You do not have to

give them your notes unless you choose to do so.

4) Good faith attempts by the committee to identify and

correct quality deficiencies will not be used as a basis for

sanctions. The Long Term Care Survey Manual, AHCA, May 2013 Edition

5

F520 Guidance to Surveyors Section helpful

QA? QI? QAA? QAPI?

Technically have different meanings but are used

interchangeably. QAA is what is used in F520 now . . .

QAPI will probably be the term used in the sequel.

Root Cause Analysis mentioned frequently in the F520

Surveyor Guidance Section. Are you using this term in

your building with all staff and departments?

Action Plan and Follow Up mentioned frequently

6

Also Helpful: The Investigative Protocol Under Guidance to Surveyors in F520

Prior to the Survey Team visit they review:

• CASPER Quality Measure Reports

• 4 year history of the facilities’ deficiencies from past surveys,

revisits, and complaint surveys

• Look for repeat deficiencies

Survey Team will interview QAPI Committee Leader to

determine the PROCESS:

• How committee identifies current and ongoing issues

• Methods used to develop action plans

• How current action plans are being implemented

Survey Team will be looking that QAPI process is

demonstrated facility wide.

7

Behind the Scenes Get your cast and crew selected

Designate a leader for the QAPI Committee

• Need to BELIEVE in quality improvement

• Need to be organized

• Need to be given the time, resources, and equipment to do

the “behind the scenes” work

– Education, Long Term Care Survey Manual, CASPER QM

reports, computer, email

• Needs to be a good communicator with a hint of

outspokenness . . . Can he/she lead the Root Cause Analysis

(5 Why’s)?

• Needs to drive accountability

8

Behind the Scenes Get your cast and crew selected

• Director of Nursing

• Medical Director

• Administrator

• Board Member(s)

• Therapy

• Maintenance

• Laundry

• Housekeeping

• Social Services

• Activities

• Pharmacist

• MDS Coordinator

• Infection Control

Coordinator

Recommendation: Every

department is represented at

your QAPI Committee Meeting

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QAPI Committee Roles

• RESPECT - Each discipline brings a UNIQUE

perspective

• Each discipline is responsible for a focus area Review the federal and state regulations that pertain to

member’s focus area. Know what drives the data on the QM

report.

• Develops and modifies the QAPI plan

• Reviews data measures

• Sets benchmarks and goals

• Prioritizes focus areas and PIPs Target high volume, high risk, problem prone areas first

Not every focus area requires a PIP

10

Meeting Ground Rules

• Meetings start and end on time (may consider having a

timekeeper)

• Use a consistent agenda/format

• Set a regular time and place for meeting

• Recommend MONTHLY QAPI meetings • If need be, post meeting reminders/send members reminders

(email works great, create email data base so easy to send

the group notices)

• Avoid distractions and maintain active engagement

• Create safe environment to brainstorm and voice concerns

• Expectation that everyone is prepared for meeting

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Meeting Ground Rules continued . . . Best Practice Idea!

All members report on their focus areas in the

Agenda/Meeting Template PRIOR to QAPI meeting

Why?

• Saves time! Increases efficiency! Promotes action!

• Meeting time is reserved for real discussion of the facts, NOT to

enter the facts.

• Meeting minutes are essentially done with exception of QAPI

leader taking notes of attendance, action plans, and follow-up.

How?

• Put Agenda/Minutes Template on shared electronic drive – allows for easy

access for members to complete.

• QAPI Leader makes copies available for members at meeting.

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Action Plans and Follow Up are the star attractions

Making action plans and following up

on those action plans at EVERY meeting is

key to producing results.

“It is not what the latest software or technology does.

It’s what the user does.”

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The Script . . . QAPI Agenda Meeting Template

QAPI AGENDA/MEETING TEMPLATE

Making a difference in the lives we touch through quality assurance and performance improvement.

ATTENDING (List name and title; save on template) YES NO

MEDICAL DIRECTOR

ADMINISTRATOR

DIRECTOR OF NURSING

QAA COORDINATOR

ENVIRONMENTAL SERVICES

PHARMACY

RD/DM

SOCIAL SERVICES

ACTIVITIES

HUMAN RESOURCES

BOARD MEMBER

(INSERT ACTION PLAN TABLE FROM PREVIOUS MEETING)

MISSION STATEMENT: (Print and save on template)

DATE OF MEETING:

QAPI AGENDA/MEETING TEMPLATE

QUALITY OF LIFE/QUALITY OF CARE

ITEM SYSTEM

CHAMPION REPORT ACTION PIP

Quality Measures: Quality measures >

75% and identify trends/causes

ALL

Facility Focus: Antipsychotic

reduction Advancing

excellence Activities Call lights Enhancing resident

centered care Advanced care

planning Other

DON SS RD/DM ACT ALL ALL

Infection Control: Resident infection

rate Staff infection rate Trends by location

and organism

ICN

Mock Survey: Benchmark set/met

ALL

State Survey/Nursing Home Compare: Finds Barriers Survey readiness Benchmarks set/met Star rating

ALL

EMR: Totally rolled out? Accurate Reports being

utilized Case mix

ALL

Care Transitions Rehospitalization/ Discharges: 30 day discharge

benchmark and results

Follow up on residents discharged home

DON SS

Pilot Projects: Interact 3 Others

ALL

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The Script . . . QAPI Agenda Meeting Template Continued

QAPI AGENDA/MEETING TEMPLATE

ITEM SYSTEM

CHAMPION REPORT ACTION PIP

Daily Rounding: Items/areas

identified

ADM DON

Other:

ACTION PLAN

GOAL ACTION PROCESS CHAMPION

TARGET DATE

COMPLETION DATE

This material was prepared by SDFMC, the Medicare Quality

Improvement Organization for South Dakota, under contract with the

Centers for Medicare & Medicaid Services (CMS), an agency of the U.S.

Department of Health and Human Services. The contents presented do

not necessarily reflect CMS policy. 10SOW-SD-C7-13-XXX.

QAPI AGENDA/MEETING TEMPLATE

ITEM SYSTEM

CHAMPION REPORT ACTION PIP

Policies: Current ones

updated New ones

implemented

DON

Secured Unit: New programs Issues that need

attention

DON

Pharmacist Report: Physician response

to recommendations Tracking and

trending of medication

PHARM

Recruitment and Retention: Turnover rate by

department Efforts to recruit and

retain Trends of exit

interviews

HR

Staff Satisfaction: Progression of top

two areas identified in staff survey

ALL

Orientation/Training: # of new people

starting per department

ALL

Incident Reports/Safety: Trends and tracking Falls

benchmark/trends Reportable to the

State Work comp trends

Resident Council: Recommendation

from Council

Concern Forms: Tracking/trending of

staff and family issues

24-48 hour follow-up done?

SS

Family/Resident Survey: Progression of top

two areas identified

ADM

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Stunt Team aka “PIP Team”

erformance mprovement roject

Charter PIP teams with a specific mission to look into a

problem area. • Select those working closest to the challenge to explore the root cause and

problem solve (i.e. direct caregivers, dietary, housekeeping, even family

and residents in some cases).

• PIP team always includes one member from the QAPI Committee.

• PIP teams need to be given TIME to work on the issue. Give them a

timeline and a budget.

• Need a leader for the PIP team.

• Need to report back to the QAPI Committee.

• PIP teams must be considered VALUABLE and an important assignment.

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Easy to Use Documentation Tool for PIPs

PERFORMANCE IMPROVEMENT PROJECT (PIP) GUIDE

START DATE REVIEW DATE(S) COMPLETE DATE PIP SQUAD MEMBERS

9/1/13 9/15/13, 10/1/13 Projected 11/1/13

PROJECT LEADER:

Lori Hintz, QAPI Coordinator 1. Lori, QAPI Coordinator

2. Holly, ADM

3. Sarah. DON

KEY AREA FOR IMPROVEMENT:

Absence of a written QAPI plan. Incorporate QAPI principles with our current QI program.

4.

5.

6.

7.

GOAL:

Specific PIP Squad will have a draft of written QAPI plan to be presented to entire leadership team for their input and/ or approval by 11/1/13. .

Measureable

Action Oriented

Realistic

Time Bound

WHAT IS THE ROOT CAUSE(S) FOR THE PROBLEM? Ask “Why is this happening?” 5 times. If you removed this root cause, would the event have been prevented?

Don’t know where to start - Have attended several QAPI education webinars and have even downloaded CMS, “QAPI At a Glance” doc but haven’t actually read the doc – time constraints have prevented taking action – it wasn’t a facility priority until now.

BARRIERS:

CMS final regulations for having the written QAPI plan in place not finalized. However, CMS has provided tools for QAPI education and implementation.

BRAINSTORM POSSIBLE SOLUTIONS and START YOUR PDSA CYCLE (PLAN, DO, STUDY, ACT) – See page 2

17

PIP Documentation Tool Continued

PERFORMANCE IMPROVEMENT PROJECT (PIP) GUIDE

BRAINSTORM:

Read “QAPI At A Glance” . Solicit examples of QAPI plans from peers. Review current QI program. Know the current F520 QAA regs in the survey manual. Educate entire leadership team and then staff utilizing problem solving models (PDSA’s and RCA’s) .

PLAN DO STUDY AND ACT

LIST THE TASKS TO BE DONE RESPONSIBLE

MEMBER START DATE

ACTUAL COMPLETION

DATE

COMMENTS (RESULTS/LESSONS

LEANRED)

ADOPT/ADAPT/ABANDON (CHOOSE ONE)

Read QAPI At A Glance, current facility QI program and F520 reg, then discuss

Lori Holly Sarah

9/1/13 9/15/13 Current QI doesn’t incorp. QAPI principles; but does adhere to F520

Adapt QAPI principles in current QI program/policy

Review examples of QAPI plans (Avera Brady & Golden Living) then discuss

Lori Holly Sarah

9/15/13 9/30/13 Decided on format and key QAPI elements to include in current QI Plan

Adapt

Formulate written draft to be given to leadership team for input / approval

Lori 9/30/13 10/15/13 In leadership daily standup, PIP team informs progress & solicit ideas as plan written

STUDY AND ACT

BENCHMARKS/METRICS How will we measure progress

BASELINE FIRST

MEASUREMENT SECOND

MEASUREMENT FINAL

MEASUREMENT COMMENTS

DATE DATE DATE DATE

Facility QI program will be updated to incorporate QAPI principles in a written format

Written QI program only

1st draft done

9/1/13 10/15/13

This material was prepared by SDFMC, the Medicare Quality Improvement Organization for South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-SD-C7-13-405

18

National Nursing Home Quality Care Collaborative “CHANGE Package” and “QAPI At A Glance”

“CHANGE Package”

• Gives a menu of strategies, change

concepts, and actionable items that

will be helpful in finding solutions to

challenge areas.

• It is not the intent that nursing

homes try to attempt every change

concept at the same time.

• Prioritize the areas where you feel

change is needed.

• Have document available at QAPI/

PIP meetings. Refer to the

document when trying to problem

solve and/or looking for ideas.

“QAPI At A Glance”

• It is the “nuts and bolts” of QAPI.

• Step by step guide to

implementing QAPI, including the

steps to write a written QAPI plan.

• Excellent problem solving models

outlined in this resource.

• Have copies available.

Both the “Change Package” and

“QAPI At A Glance” can be found

on the CMS, SDFMC websites

(addresses on resource slide)

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Metric / Benchmark Formula

Date Chosen Measure

for Evaluation

# of Cases

Reviewed

(A)

# of Cases

w/Positive

Results (B)

(B) out of (A)

(B/A)

9/20/13 New admissions have

completed assessment

forms within 24 hours

10 7 7/10 =

.70 or 70%

9/20/13 Call lights received

response within 10

minutes

20 10 10/20 =

.50 or 50%

FYI: A Way to Calculate Falls

Falls will be calculated by taking the total number of falls that have occurred

for one month and dividing it by the total number of resident days for that

same month. This figure will then be multiplied by 1000 to give you the

average number of falls per 1000 resident days.

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Best Performances go to . . .

Jenkins Living Center, Watertown, SD - Shawn Gilman, DON

Forming a PIP Squad

Platte Care Center Avera, Platte, SD - Traci Harrington, DON

QAPI and Falls

Firesteel Healthcare Center, Mitchell, SD - Sarah Comp, DON

Using the Connecticut RCA Event Tool

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Credits “aka” resources

South Dakota Foundation for Medical Care:

http://www.sdfmc.org/PatientSafety/SDNursingHomeQualityCareCollaborative/SDNHQCCResources

/Index.cfm

CMS QAPI Webpage: http://go.cms.gov/Nhqapi

CMS QAPI AT A Glance document: http://cms.gov/Medicare/Provider-Enrollment-and-

Certification/QAPI/Downloads/QAPIAtaGlance.pdf

Advancing Excellence in America’s Nursing Homes: http://www.nhqualitycampaign.org/

Agency for Healthcare Research and Quality, STEPPS program:

http://www.ahrq/gov/professionals/education/curriculum-tools/teamstepps/ltc/index.html

Department of Veterans Affairs, Root Cause Analysis: http://www/patientsafety.gov/CogAids/RCA/

Getting Better All the Time: Working Together for Continuous Improvement:

http://www.susanwehrymd.com/files/gettingbetterall-the-time.pdf

InterAct: www.interact2.net

Oklahoma Foundation for Medical Quality: National Nursing Home Quality Care Collaborative CHANGE

Package: http://www.ofmq.com/nhtoolsandresources

Ohio KePro: Quality Improvement Workbook:

https://www.ohiokepro.com/shopping/pdfs/QualityImprovementWorkbook.pdf

The Long Term Care Survey, AHCA, May 2013 Edition

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Our Offer

Host Open Office Call

9:00 am MT/ 10:00 am CT

Thursday, January 30, 2014

* Purpose: Share how QI/QAPI meetings are going

What is working? What is not?

Contact Information:

Holly Beving: hbeving@sdqio.sdps.org 605-228-9594

Lori Hintz: lhintz@sdqio.sdps.org 605-354-3187