quality assurance performance improvement: 12 steps to excellence!

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Provisions set forth in the Affordable Care Act (ACA) require the Centers for Medicare and Medicaid Services (CMS) to broaden quality improvement activities in nursing homes. Although the mandatory implementation date for nursing homes to provide evidence of a systematic Quality Assurance and Performance Improvement (QAPI) program has been delayed, but facilities should not delay in implementing a detailed and well-documented QAPI program. This presentation moves beyond the five elements of a QAPI and begins to drill down to practical concepts for beefing up an existing Quality Improvement program to meet QAPI standards. Learn how to objectively assess where your facility is in the QAPI journey, and gain a deeper insight into how practical implementation of QAPI activities can be a part of the culture of excellence that is part of all successful nursing homes. 1. Learn to detail the five elements of QAPI and correlate the five elements to the twelve step action plan for QAPI implementation. 2. Learn to articulate the steps to evaluating their facilities progress in QAPI efforts. 3. Understand Performance Improvement Projects (PIPs). 4. Learn the five steps of Root Cause Analysis (RCA) and learn how to apply the RCA process to adverse events in their facility routinely.

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  • 1.Quality Assurance Performance Improvement: 12 Steps To Excellence! Harmony University The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Beckie Dow, RN, RAC-MT Director of MDS and Nursing Education & Training

2. Speaker Bio Over 20 Years Experience in Long-term Care Clinical and Reimbursement Accuracy in Assessments Quality Assurance Activities Interrelation between MDS, Care Planning, QA, and Clinical Excellence at the Bedside AANAC Master Teacher Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 2 3. Quality Assurance Performance Improvement: 12 Steps to Excellence Disclosures: The planners and presenter of this educational activity have no relationship with commercial entities or conflicts of interest to disclose Planners: Elisa Bovee, MS, OTR/L Diane Buckley, BSN, RN, RAC-CT Beckie Dow, RN, RAC-MT Presenter: Beckie Dow, RN, RAC-MT Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 3 4. Harmony Healthcare International, Inc. Criteria for Successful Completion Complete Sign-in and Sign-Out on Attendance Form Attendance for entire session Completion and submission of speaker evaluation form Copyright 2013 All Rights Reserved 4 5. Program Objectives Detail the five elements of QAPI and relate the five elements to the twelve action steps of QAPI Discuss the QAPI demonstration project Articulate how existing quality improvement programs in SNFs and other settings can benefit from the QAPI materials Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 5 6. Program Objectives Discuss problem solving models, including Root Cause Analysis, Directed Plan of Correction, Plan Do Study Act List three tools that the facility can use to prepare for the implementation of QAPI Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 6 7. Dont judge each day by the harvest you reap, but by the seeds you plant -Robert Louis Stevenson Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 7 8. The CMS Nursing Home Action Plan: A Three Part Aim Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 8 9. The CMS Nursing Home Action Plan: Five Approaches Enhance consumer engagement Strengthen survey processes, standards, and enforcement Promote quality improvement Create strategic approaches through partnerships Advance quality through innovation and demonstration Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 9 10. F520 - Quality Assessment and Assurance (QAA) The facility has an ongoing QAA committee that includes designated key members and that meets at least quarterly; and The committee identifies quality deficiencies and develops and implements plans of action to correct these quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the action plans Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 10 11. QAPI Timeline March 2010Affordable Care Act passed April 2011QAPI announced September 2011prototype QAPI program launched to test QAPI tools and resources May 2012QAPI questionnaire July 2012Panel of experts assembled to discuss the prototype tools and questionnaire results Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 11 12. QAPI Timeline December 2012QAPI at a Glance guide introduced in draft form June 2013Final version of QAPI at a Glance published June 2013Announced that wave one NHQI questionnaire results would be available in the near future TBDwave two of the NHQI questionnaire Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 12 13. The QAPI Elevator Speech QAPI is a comprehensive program by which an organization identifies problems or issues early on, develops a plan to address the root causes of problems and prevent adverse events throughout the system, and involves the entire team in using data to understand quality and work to improve performance Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 13 14. What is QAPI? The merger of two complimentary approaches to quality management: Quality Assessment determining where things are going well and where opportunity to improve exists Performance Improvement the reaction to the opportunity to improve Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 14 15. What is QAPI? Quality Assurance Performance Improvement Motivation Measuring compliance with 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 Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 15 16. What is QAPI? QAPI is about critical thinking. It involves figuring out what is causing certain problems, and implementing interventions and solutions that address the root causes of the problems, rather than just the symptoms Karen Schoeneman Past Technical Director, CMS Division of Nursing Homes Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 16 17. The Challenge Not all change is improvement, but all improvement is change Donald Berwick, MD Former CMS Administrator Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 17 18. The Goal of QAPI and/or Other Quality Improvement Models The Goal: Meet or exceed the expectations of our customers Meeting customer expectations = meeting the mission! Who are the customers? External customers: The reason the organization exists Internal customers: Anyone within the organization Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 18 19. The Goal of QAPI and/or Other Quality Improvement Models Nursing homes are in the best position to assess, evaluate, and improve their care and services, because each home has first-hand knowledge of their own organizational systems, culture, and history Effective QAPI leverages this knowledge to maximize the return on investments made in care improvement Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 19 20. The Goal of QAPI and/or Other Quality Improvement Models QAPI will take many nursing homes into a new realm in quality: Systematic Comprehensive Data-driven Proactive Performance Management and Improvement Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 20 21. The Goal of QAPI and/or Other Quality Improvement Models When nursing home leaders promote the QAPI philosophy the results may: Prevent adverse events Promote safety and quality Reduce risk for residents Reduce risk for caregivers Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 21 22. The Goal of QAPI and/or Other Quality Improvement Models The goal of QAPI is not to merely meet minimum standardsit is about continually aiming HIGHER! Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 22 23. A Culture of Caring I take care of my staff, and they take care of the patients, said one DON. If I treat them badly, they will treat the patients badly. Source: Beyond Unloving Care by Susan Eaton, June 2000 Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 23 24. Are You Already Doing QAPI? QAPI principles are not new to healthcare QAPI builds on our existing QAA regulations Your facility may already be participating in QAPI activities, and can use existing activities as a foundation for QAPI Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 24 25. Are You Already Doing QAPI? Does your facility Create systems to provide care and achieve compliance with nursing home regulation? Investigate problems and try to prevent their recurrence? Track and report adverse events? Compare the quality of your home to that of other homes in your state or company? Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 25 26. Are You Already Doing QAPI? Does your facility Receive and investigate complaints? Seek feedback from residents and front-line caregivers? Set targets for quality? Strive to achieve improvement in specific goals related to pressure ulcers, falls, restraints, or permanent caregiver assignment, or other areas (Advancing Excellence campaign) Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 26 27. Are You Already Doing QAPI? Does your facility Have a commitment to balancing a safe environment with resident choice? Strive for deficiency-free surveys? All of these activities are part of QAPI Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 27 28. Are You Already Doing QAPIBut Could Take it to the Next Level? Some QAPI components are new for many nursing homes QAPI emphasizes quality care for residents and an improved work environment for caregivers QAPI uses a systems approach to actively pursue quality, not just respond to external requirements Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 28 29. Are You Already Doing QAPIBut Could Take it to the Next Level? Use data to identify quality problems, opportunities for improvement, and setting priorities for action Building on residents own goals for health, quality of life, and daily activities Building meaningful resident and family voices into setting goals and evaluating progress Copyright 2013 All Rights Reserved Harmony Healthcare International, Inc. 29 30. Are You Already Doing QAPIBut Could Take it to the Next Level? Incorporating caregivers broadly in a shared QAPI mission Developing Performance Improvement Project (PIP) teams with specific charters Performing a Root Cause Analysis (RCA) to get to the heart of the reason for a problem Copyright 2013 All Rights Reserved Harmony H

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