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Quality Improvement Training Checklist Curriculum for a QAPI Training Program Check / Included Comments Mission, Vision and Who We Are Important aspects and meaning of mission and vision What important services are provided (departmental and overall) Who are our key stakeholders Results of self-assessments Overall strategic plan Quality Improvement Program Review of organization’s program – what is routinely monitored, how, when and by whom What methodology this organization utilizes (PDSA, or other) Importance of program Quality Improvement teams and overall staff roles and responsibilities Quality Improvement committee roles and responsibilities Quality Improvement Principles and Components A review of organization’s QI methodology – how it works (PDSA, or other) Definitions review Data collection – how to audit and collect data Systems vs. processes How to analyze data & Root Cause Analysis Action Plans Communication How we communicate quality improvement results and action plans Overall roles and responsibilities Where to find information What is a fair and just organizational culture What are our current Quality Improvement projects How to communicate about quality and to whom Other items identified as important to the nursing home Special programs Rewards Other Training includes Ethics and Compliance Training is delivered as part of orientation at all levels including to the quality improvement committee and at a corporate level Training is delivered annually

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Quality Improvement Training Checklist

Curriculum for a QAPI Training Program Check /

Included Comments

Mission, Vision and Who We Are • Important aspects and meaning of mission and vision • What important services are provided (departmental and

overall) • Who are our key stakeholders • Results of self-assessments • Overall strategic plan

Quality Improvement Program • Review of organization’s program – what is routinely

monitored, how, when and by whom • What methodology this organization utilizes (PDSA, or other) • Importance of program • Quality Improvement teams and overall staff roles and

responsibilities • Quality Improvement committee roles and responsibilities

Quality Improvement Principles and Components • A review of organization’s QI methodology – how it works

(PDSA, or other) • Definitions review • Data collection – how to audit and collect data • Systems vs. processes • How to analyze data & Root Cause Analysis • Action Plans

Communication • How we communicate quality improvement results and

action plans • Overall roles and responsibilities • Where to find information • What is a fair and just organizational culture • What are our current Quality Improvement projects • How to communicate about quality and to whom

Other items identified as important to the nursing home • Special programs • Rewards • Other

Training includes Ethics and Compliance Training is delivered as part of orientation at all levels including to the quality improvement committee and at a corporate level

Training is delivered annually

Quality Improvement Standards / Policies / Procedures Checklist

Quality Standards Check /

Included Comments

Include Overall Objectives of the Program, such as: • Improvement of services & prevention of adverse events • Regulatory compliance • Customer Satisfaction • Alignment with Organizational Profile, Vision and Mission

and Strategic Plan

Include Quality Improvement Committee information: • Overall Roles and Responsibilities • Meeting Schedule and Agenda • Reports

Include Training: • What will be included in training? • Who will be responsible for training? • Who will complete training (all staff, committee members,

other)? • When and where will training be performed? • How will training be budgeted?

Include Quality Improvement Teams: • Overall Roles and Responsibilities • Meeting Schedule • Meeting Agenda • Reports

Include what data will be routinely monitored based on services that are important to the organization:

• Key services provided and processes to deliver those services – including sentinel and adverse events

• Regulatory compliance • Customer satisfaction • Staff competencies • Finance

Include goals / benchmarks / measures for data to be routinely monitored as well as additional information about data:

• What methods will be utilized to collect data? • How will data be measured and when? • Who will be responsible?

Include overall QAPI methodology to be utilized in analysis of data & implementation of action plans (e.g., PDSA, DMAIC, or other)

Include communication of Quality Activities • All nursing home staff, Corporate, Governing Body, others • How, when, where and who is responsible

Page 16 QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT – V.1.0 – SECTION E

Case Study 1: Fall Reduction

OverviewSunshine Nursing home had been tracking the number of falls per month for the last five months as part of a restraint reduction program. This was one of its Advancing Excellence goals for 2009. Results had shown a consistent increase in the fall rate. Staff seemed discouraged and believed some residents may need restraints. The administrator and the director of nursing were committed to their Advancing Excellence goal of reducing restraint use, while also decreasing falls and continuing to protect the residents from injury. After discussion with the Quality Assessment and Assurance (QA & A) committee, the director of nursing decided to create a team of staff from multiple departments to analyze the problem, and develop and implement an improvement plan. The FOCUS-PDCA Model, Figure 1, was used to assist the team in developing and implementing a plan for improvement.

FindAn opportunity exists to improve the fall reduction process, beginning with the initial assessment of resident fall risk and ending with the evaluation of the effectiveness of the actions taken to prevent falls for a given resident. OrganizeThe QA&A committee convened a quality improvement performance (QIP) team composed of staff from multiple departments that include nursing, dietary, pharmacy, and rehabilitation services.

ClarifyWhile the team knew the overall goal was to decrease falls, members believed they did not have enough information to know what was needed to improve. Therefore, the team collected data and information on how the fall assessment process currently occurred. As part of this effort, the team conducted an analysis of falls over the last quarter. The team trended the

number of falls and grouped them according to the wings where the falls occurred; the types of falls (i.e., from a chair or bed); occurrence times; repeat falls; and specific locations of falls (i.e., in the bathroom or in the hallway). The team identified that the total number of falls included a significant number of repeat falls. The total number of falls and repeat falls are graphed on the run chart in Figure 2.

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Figure 1. FOCUS PDCA

Page 17 QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT – V.1.0 – SECTION E

Figure 2. Facility Total and Repeat Falls

In reviewing the current process, the team found that the investigative and assessment process used to identify the causes of a fall did not provide comprehensive information; therefore, it was difficult to identify realistic interventions to prevent subsequent falls.

UnderstandUsing a root cause analysis, the team kept asking themselves ‘Why’ events occurred until they reached the underlying cause for the falls. They determined first that there was incomplete information for good follow up after a fall. The team felt that this was because some of the information that they needed to correct the cause of the fall was often missing. They then determined that the information was missing due to the lack of a systematic, comprehensive process to determine the root causes of falls. This lack of a comprehensive process to obtain pertinent information adversely affected the facility’s ability to maintain an effective fall prevention program. The team agreed that this was the root or underlying cause of their repeat falls finding, and that addressing this gap was essential.

SelectThe team reached out to its state’s Patient Safety Commission and with the commission’s assistance, and again decided to use a root cause analysis (RCA) quality improvement process, but this time to evaluate every fall.

PlanThe team’s plan was to test the implementation of a RCA for each fall. They decided to first pilot test on one wing to evaluate if the new process decreased the number of repeat falls.

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Page 18 QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT – V.1.0 – SECTION E

The team identified three initial goals for this project: 1. Decrease overall fall rate to 10 per month by first quarter 2010, which represented an

overall decrease of 50%;2. Decrease repeat falls to five per month by last quarter of 2009, which represented an

overall decrease of 50%; and3. Maintain, if not decrease, the number of residents in physical restraints. The team

included this third goal to ensure that physical restraint use did not increase as an unintended consequence, as falls were decreased.

4. The team developed an action plan that included involving a number of additional staff to help with the development of the new assessment and investigative tool for capturing critical information when a fall occurred. The team wanted to be sure that all staff members were educated on the use of these new tools. Once the tools were developed and staff was educated, the team decided to pilot test the new tools on the wing with the greatest number of repeat falls.

The team developed an action plan that included involving a number of additional staff to develop new assessment and investigative documentation tools. The team assisted with education of staff on the use of these new tools. Once the tools were developed and staff was educated, the team decided to test the new tools on the wing with the greatest number of repeat falls.

Fall Reduction Action Plan

TASKS WHO WILL COMPLETE BY WHEN COMMENTS

Develop new tools to assess and investigate all falls using the Safety Commission’s RCA tools

QIP team with interdepartmental staff

June 2009 Team to meet weekly in May and June 2009

In-service licensed and unlicensed staff on new tools and RCA process

QIP team June 2009

Implement new investigation and assessment tools on chosen wing for 2 month trial;Monitor for any problems that occur along the way; take action to address any significant problems before they escalate

QIP team with leaders

July 2009 Ensure daily review of documentation related to falls

Collect falls and physical restraint use data on run charts

Leaders and QIP team

Ongoing

Meet to discuss with floor staff & other departments: How did it all go? Any changes needed?

QIP team September 2009

Report results to QA & A Committee

Educate all staff and ensure program now included in resident & employee orientation program

QIP team October 2009

Page 19 QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT – V.1.0 – SECTION E

TASKS WHO WILL COMPLETE BY WHEN COMMENTS

Implement new investigation and assessment tools across entire facility

QIP team with leaders

October 2009

Reevaluate effectiveness of new process and report to QA & A committee

QIP team December 2009

Continue monitoring monthly in 2010 – Determine additional plans to set and achieve stretch goals (higher performance)

QA & A committee with QIP team

Ongoing Monthly

Team to discuss how process worked and determine future changes to continue to improve goal

The team involved floor staff on the selected wing to implement the pilot by communicating the rationale and purpose of the program, as well as the new process. The process change was then tested over a two-month period.

Do

The team and other staff members implemented the program as planned, maintaining the deadlines. Each team member completed tasks as defined in the plan. The team collected and graphed data on the number of total falls, the number of repeat falls, and the number of residents in physical restraints.

The following is an example of an investigation, assessment, and root cause analysis the team and floor staff performed on a resident who had multiple falls. This fall example was identified by the facility as a sentinel event that required further investigation and root cause analysis even though the resident was discharged.

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Page 20 QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT – V.1.0 – SECTION E

Example

A resident fell on the evening shift. This was the third fall this resident had since admission four months prior. The resident sustained a pelvic fracture and was transported to the hospital. At the time of the latest fall, the previously developed care plan interventions included:

1. Reminder to use call light in room and when on toilet for transfer assist, 2. Place non-slip rug by bedside, 3. Implement toileting program listed as every two-hour toileting, and 4. Use stand-by transfer assist of one staff member.

The resident was found on the bathroom floor sitting upright in front of the toilet. Staff members were summoned to her room when they heard her yelling.

Gathering first impressions

The resident was alert and well-oriented and stated, “I slipped on the water on the floor, while trying to get back to my bed.” There was a large amount of water on the floor, which was flowing from the bathroom sink. A staff member who was assigned to the care of this resident stated she had assisted the resident to the bathroom approximately 10 minutes earlier. The resident requested to be left alone and to turn the water on as this assisted her with voiding. The staff member stated she reminded the resident to use the call light and told the resident she would return in a few minutes to assist her back to bed. The charge nurse determined the care plan had been followed.

Environmental factors and underlying medical conditions• The floor was wet. • The sink was overflowing.• The resident was alert and fairly well oriented; however, the MDS showed some

short-term memory issues.• The resident chose to do things by herself, without assistance.• She was looking forward to discharge back to her independent living facility.• At the time of the fall, the resident was wearing slippers.• The call light was in good working order.• The resident stated she did not call for help as “I know they are so busy on the

evening shift.”

Medication issues

None identified.

Page 21 QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT – V.1.0 – SECTION E

Filling in the gaps

The team evaluated this resident’s past falls for trends and patterns and found thather falls had all occurred on the evening shift and were associated with toileting. While the resident often used the call light during day shift, the resident’s cognitive functions tended to decline towards evenings. The resident was progressing well with therapy and a discharge plan was in place.

Root cause analysis (RCA)

The team identified a number of causes that required further investigation using RCA and the 5-Whys (See Figure 3).

TIP: Using sticky notes to identify items in a

Root Cause Analysis allows the team to easily

reorder or add ideas during the process as

the team asks themselves why something

happened or occurred.

Page 22 QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT – V.1.0 – SECTION E

Figure 3. RCA/Casual Tree/5-Whys Diagram

Page 23 QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT – V.1.0 – SECTION E

Action Plan Development & Evaluation

The team developed an action plan using Plan Do Check and Act that included staff education, updating assessment tools, and implementing a new communication system for maintenance repairs. Staff researched the web and found a SBAR tool (Situation-Background-Assessment-Recommendation) to enhance communication. Staff also identified additional residents with similar issues and developed a plan for those residents.

Check

After the two-month pilot, the team reviewed fall and restraint data and discussed findings with staff. Progress toward the goal to reduce repeat falls was good. However, the overall fall rates remained above the facility’s goal on the pilot wing, as well as in other areas of the facility (see Figure 4 for pilot wing data). Review of their physical restraints data showed the number of residents in restraints did not increase and had actually declined during the pilot (Figure 5).

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TIP: Better performance can be achieved at

a faster pace if an improvement team rapidly

recognizes and tries new interventions when

the data that are being monitored to evaluate

change does not show improvement.

Page 24 QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT – V.1.0 – SECTION E

Figure 4. Pilot Wing Total and Repeat Falls

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Figure 5. Resident Restraint Data

At this point, the team decided to continue with full implementation throughout the facility and added an action plan item related to admission assessments and overall fall risks. A new fall evaluation tool was developed that included risk factors and interview questions. This was used to complete a care plan within four hours of admission. A report went to the QA & A committee, which approved full implementation.

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Restraint use did not increase above previous levels during pilot July-

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Pilot implementedPrevious max

Page 25 QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT – V.1.0 – SECTION E

Act

The new process was implemented throughout the facility. The team continued to collect data. Good results were noted in the area of repeat falls. By first quarter of 2010, the number of falls improved, but the overall goal of 50% fewer falls was not achieved. The team continued to evaluate and refine processes, using a Rapid Cycle PDCA process. The facility tested small changes to their fall system of care with frequent monitoring and evaluations until their overall goal was obtained. Follow up monitoring allowed the facility to recognize that their changes had been sustained over time, moving them into higher performance.

Figure 6. Facility Total and Repeat Falls

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CQI Agenda Sample

I. Review minutes of past meeting

II. Review Current action plans

III. Clinical Review:

a. Quality Scorecard review (review of complete scorecard); benchmark against other facilities; need for process improvement team; action plan. Includes Quality metrics and/or Quality Indicators.

b. Other Care system or clinical reviews c. Infection control

IV. Health, Safety and Environment

a. Fall review b. Other Safety issue review c. Environmental reviews (includes kitchen)

V. Dietary Management

VI. Rehabilitation

VII. Pharmacy

a. Pharmacy review b. Medication Administration or other issues

VIII. Resident and Employee Quality of Life

a. Complaint / compliment review b. Resident and Employee satisfaction issues c. Activities d. Other Psychosocial issues

IX. Survey Management and POC review as needed

X. Quality Project Review

Measure Definition

Care Area / Measure Date/Year

Definition

Threshold / Goal

Data Source

Sample Size

Schedule / Frequency

Responsible person(s)

Numerator Denominator

Exclusions

Notes / Comments

Measure Definition

Care Area / Measure Date/Year

Definition

Threshold / Goal

Data Source

Sample Size

Schedule / Frequency

Responsible person(s)

Numerator Denominator

Exclusions

Notes / Comments

Quality Assessment and Assurance Minutes

Date Committee Members Present:

Committee Members Absent:

All identified negative trends as compared to thresholds and benchmarks require action plans.

Agenda Item Findings Comments & Discussion No Trend Identified (NT):

Trend Identified (TI): See action plan Action in Progress (AP): See action plan

No Trend Identified (NT): Trend Identified (TI): See action plan Action in Progress (AP): See action plan

No Trend Identified (NT): Trend Identified (TI): See action plan Action in Progress (AP): See action plan

No Trend Identified (NT): Trend Identified (TI): See action plan Action in Progress (AP): See action plan

No Trend Identified (NT): Trend Identified (TI): See action plan Action in Progress (AP): See action plan

No Trend Identified (NT): Trend Identified (TI): See action plan Action in Progress (AP): See action plan

No Trend Identified (NT): Trend Identified (TI): See action plan Action in Progress (AP): See action plan

No Trend Identified (NT): Trend Identified (TI): See action plan Action in Progress (AP): See action plan

Agenda Item Findings Comments & Discussion No Trend Identified (NT):

Trend Identified (TI): See action plan Action in Progress (AP): See action plan

No Trend Identified (NT): Trend Identified (TI): See action plan Action in Progress (AP): See action plan

No Trend Identified (NT): Trend Identified (TI): See action plan Action in Progress (AP): See action plan

No Trend Identified (NT): Trend Identified (TI): See action plan Action in Progress (AP): See action plan

No Trend Identified (NT): Trend Identified (TI): See action plan Action in Progress (AP): See action plan

No Trend Identified (NT): Trend Identified (TI): See action plan Action in Progress (AP): See action plan

No Trend Identified (NT): Trend Identified (TI): See action plan Action in Progress (AP): See action plan

No Trend Identified (NT): Trend Identified (TI): See action plan Action in Progress (AP): See action plan

No Trend Identified (NT): Trend Identified (TI): See action plan Action in Progress (AP): See action plan

Quality Action Plan

Action Plan for (issue, trend, analysis)

Process Improvement Team Members

Action Step Responsible person (s) Target Date Outcome

Action Plan Page two

Action Step Responsible person (s) Target Date Outcome

QI Calendar 2011 EXAMPLE ONLY

Item Goal / Threshold Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Resident Satisfaction Privacy No reported allegations X X X Self-Med Assessments 98% compliance – residents who self-med have

assessment, care plan and phy. order X X X

Resident / family satisfaction Using QIS interviews

No abuse allegations – all will be investigated Dignity – 90% satisfaction Dining – 90% satisfaction Met Needs – 90% satisfaction Privacy – 90% satisfaction Activities – 90% satisfaction

X X X X

Tubes, IV’s, Implants 98% compliance - residents who have these are assessed, care planned & documentation of needs

X X

Wander Guard alarm audits All alarms checked and documented weekly – 95% threshold

X X

Care Planning All needs identified / match in-room care plan – 90% threshold

X X

Nurse competencies – new hires

Just a report of how many hired, tested & trained. In June, establish turnover goal for all staff & report quarterly

X X X X X X X X

Discharge audits 98% compliance – D/C have evidence of discharge assessment, care plan and review with resident / family on discharge

X X X

Incidents / Accidents & Sentinel events = Fall with major injury (FX, Head); Unexpected death; Substantiated abuse; Med errors with harm; Equipment failures leading to harm; Elopements; Burns;

No neglect or abuse – all investigated Falls no greater than 8% = Number of falls divided by total care days X 1000 Repeat falls no greater than 2% = Number of residents with repeat falls divided by total care days X 1000

X X X X X X X X X X X X

Pressure Ulcers House acquired - No neglect causes – all investigated Total no greater than 8% = Number of PU at any stage on the last day of month divided by census X100; House acquired no greater than 2% = same as above # divided by census X 100

X X X X X X X X X X X X

Item Goal Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Infections Monthly report of suites or other trends

Total # of Health Care Associated Infections (HAI) no greater than 15% = Total number divided by total care days X 1000

X X X X X X X X X X X X

Weight Loss No greater than 5% = Total number of unplanned significant losses (5%, 7.5%, 10%) divided by total care days X 1000

X X X X X X X X X X X X

Kitchen Monthly review - 95% compliance with selected items from audit tool:

X X X X X X X X X X X X

Environmental Monthly review - 95% compliance with selected items from audit tool:

X X X X X X X X X X X X

Pharmacy Pharmacy reports monthly – need to identify one or two goal items: Psychoactive Meds;

X X X X X X X X X X X X

One QA project annually Team to choose and implement one QA project annually to improve care and services – reported to QA committee at start and end of project

X

Policy review and update

Report to committee new policies & reviews X X X X X

Resident Care audits

Random audits to ensure care plan followed and standards followed – need to choose thresholds for a number of areas.

X X X