s6 szumlinski & o'neill - qapi in al - home - hcam szumlinski & o'neill -...

9/10/2015

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Quality Assurance Performance Improvement in Assisted LivingTake Action ‐ Improve Care

©Evolucent All Rights Reserved

EvolucentLisa M. O’Neill, CALD, CDP, BS

Angie Szumlinski, LNHA, RN‐BC, RAC‐CT, BS


LEARNER OBJECTIVES

• Define Quality Assurance Performance Improvement

• Report on the 5 Elements of QAPI

• Define Root Cause Analysis


• Organize a QAPI Committee

• Develop a Performance Improvement Project

QAPI IN ASSISTED LIVING

• Quality Assurance in Assisted Living varies by state

• QA is required by some levels of assisted living and in some states

• Some states and licensing jurisdictions (or non


• Some states and licensing jurisdictions (or non‐licensed assisted living) have NO requirements

• Follow your State (or Federal) requirements

– Form AND Function makes QAPI “real”

• LEGAL COUNSEL review & assistance

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QAPI IN ASSISTED LIVING

CMS (Centers for Medicare & Medicaid Services) has spent a lot of time developing tools for SNFs

• Take what you need from these validated and reliable tools


• No need to reinvent the wheel

BEFORE YOU EMBARK

Your path may not be linear…


CREATE YOUR QAPI PROGRAM

• Resident and family satisfaction and feedback

• QA checklists for departments

• QAPI collaborated departmental reviews (i.e. having other departments audit)


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DECIDE HOW MUCH QA?

• Who

• What

• Where


• When

• WHY?

ORGANIZE A QAPI COMMITTEE

• Educate stakeholders

• Recruit a group of “champions”

• Meet regularly


• Focus on OUTCOMES not PROCESS

HOW TO USE THE QA COMMITTEE

• Planning meetings

• Policies & Procedures

• Calendar of areas for review


• “Wish list” for improvements

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ORGANIZE THE QAPI COMMITTEE

• Start small

• Set tangible, realistic goals

• Set benchmarks


• Establish methods for approach and deployment

• Establish an evaluation process

DEFINING QAPI

Quality Assurance (QA) and Performance Improvement (PI) are complementary approaches


DEFINING QAPI

• QA is a process of meeting quality standards and assuring that care reaches an acceptable level

• Quality Assurance thresholds are often set to comply with regulations and standards of practice


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DEFINING QAPI

• PI is a pro‐active and continuous study of processes with the intent to prevent or decrease the likelihood of problems

• PI identifies areas of opportunity and tests new


pp yapproaches to fix underlying causes of persistent/systemic problems

DEFINING QAPI

Quality Assurance Performance Improvement

MOTIVATION Measures compliance with the standards (regulations)

Continuously improving to meet standards (as defined by regulations, MISSION, VISION & Values)

MEANS I t i “ it ” P ti l i


MEANS Inspect, review, “monitor” Prevention, planning

FOCUS Outliers, “bad apples”, individuals, regulations/rules

Processes, systems (how we get there & keep it going)

SCOPE Silo model/individual providers

Systems for care delivery and quality of care

RESPONSIBILITY QA committee (few) All hands on deck –stakeholder involvement

QA VERSUS QAPI – WHAT DIFFERENCES?

Maybe nothing; it depends on your philosophy and actions


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• QA is a reactive process

• QAPI is intended to be proactive



QAPI expects teams to work on PIPs (performance improvement plans)


DEFINING QAPI

• QA + PI = QAPI

• A data‐driven, proactive approach to improving the quality of life, care, and services.


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DEFINING QAPI

Activities of QAPI involve members at all levels of the

organization


QAPI BUILDS ON QAA

• Committee structure

• Review complaints and concerns

• Conduct audits

• QAPI exceeds narrow QAA


QAPI exceeds narrow QAA

DEVELOPING PURPOSEGUIDING PRINCIPLES AND SCOPE FOR QAPI

• CMS rolled out QAPI tools

• They are available at: http://go.cms.gov/Nhqapi

• Great resources at the website!


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DEVELOPING PURPOSEGUIDING PRINCIPLES AND SCOPE FOR QAPI

1. Locate or develop organization’s vision statement.

2. Locate or develop organization’s mission statement.

3. Develop a purpose statement for QAPI.

4 Establish guiding principles


4. Establish guiding principles.

5. Define the scope of QAPI in your organization.

6. Assemble the document.

(Use the Guide for Developing Purpose, Guiding Principles, and Scope for QAPI

for step‐by‐step reference.)

VISION STATEMENT

A vision statement is sometimes called a picture of your organization in the future. It is your inspiration and the framework for your strategic planning. Consider involving staff in the development of your vision


statement, post it for everyone to view.

MISSION STATEMENT

A mission statement describes the purpose of your organization. The mission statement should guide the actions of the organization, spell out its overall goal, provide a path, and guide decision‐making. It provides


the framework or context within which the company’s strategies are formulated. As with the vision statement, get caregivers involved in establishing your organizations mission.

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PURPOSE STATEMENT

• A purpose statement describes how QAPI will support the overall vision and mission of the organization.

• If your organization does not have a vision and


y gmission statement, the purpose statement can still be written and would state what your organization intends to accomplish through QAPI

ESTABLISH GUIDING PRINCIPLES

Examples:

• Guiding Principle #1 – QAPI has a prominent role in our management and Board functions

• Guiding Principle #2 Our organization uses quality


• Guiding Principle #2 – Our organization uses quality assurance and performance improvement to make decisions and guide our day‐to‐day operations

• Guiding Principle #3 – The outcome of QAPI in our organization is the quality of care and the quality of life of our residents

DEFINE YOUR SCOPE OF QAPI

• The scope outlines what types of care and services are provided by the organization that impact clinical care, quality of life, resident choice and care transitions.

• Be sure to incorporate the care and services delivered


pby all departments.

• Once the list of care and service areas have been identified you can determine how each will use QAPI to assess, monitor and improve performance ongoing

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ASSEMBLE DOCUMENTS

• Once you have completed steps 1‐5, assemble the vision and mission statements, guiding principles and scope of QAPI into a separate document that may be used as a preamble to your QAPI plan.


• This document will help you articulate the goals and objectives of your organization; QAPI will help you get there. Consider posting this document for all to see.

DEVELOPING A QAPI PLAN

• The QAPI plan will guide your organization’s performance improvement efforts.

• This is a living document that you will continue to refine and revisit


• The plan should reflect input from caregivers representing all roles and disciplines within your organization

QAPI GOALS

• Based on the purpose, guiding principles and scope for QAPI, identify the QAPI goals that you plan to meet.

• Goals should be specific, measurable, actionable,


p , , ,relevant and have a time line for completion

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QAPI GOALS – SMART FORUMULA

Describe the business problem to be solved and use the SMART formula to develop a goal

• S – Specific – describe the goal in terms of 3 “W” questions:


q

– What do we want to accomplish

– Who will be involved/affected

– Where will it take place

QAPI GOALS – SMART FORMULA

M – Measurable – describe how you will know if the goal is reached:

• What is the measure you will use?

• What is the current data figure (count percent rate)


• What is the current data figure (count, percent, rate) for that measure?

• What do you want to increase/decrease that number to?


A – Attainable – defend the rationale for setting the goal measure above:

• Did you base the measure or figure you want to attain on a particular best practice/average


p p / gscore/benchmark?

• Is the goal measure set too low that it is not challenging enough?

• Does the goal measure require a stretch without being too unreasonable?

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R ‐ Relevant – briefly describe how the goal will address the business problem identified in the QAPI plan

T Time Bound Define the timeline for achieving the


T – Time Bound – Define the timeline for achieving the goal

GOAL STATEMENT

Write your goal statement based on the SMART elements. The goal should be descriptive yet concise enough that it can be easily communicated and remembered.


THE FIVE ELEMENTS FOR FRAMING QAPI

The 5 elements are your strategic framework for

developing, implementing and sustaining QAPI.


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THE FIVE ELEMENTS


ELEMENT 1: DESIGN & SCOPE

• A QAPI program should be ongoing and comprehensive, dealing with the full range of services offered by the facility and departments.

• When fully implemented, the program should address all systems of care and management practices

• The focus should be on resident safety and high quality with clinical


y g q yinterventions while emphasizing autonomy and choice in daily life for residents

• Utilize the best available evidence to define and measure goals.

ELEMENT 2: GOVERNANCE AND LEADERSHIP

• The leadership team develops and leads a QAPI program

• The governing body assures the QAPI program is adequately resourced to conduct its work including:

– Designating one or more persons to be accountable for the QAPI program;

Developing leadership and facility wide training;


– Developing leadership and facility‐wide training;

– Ensuring staff time, equipment, and technical training as needed.

• The governing body ensures accountability

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ELEMENT 2: GOVERNANCE AND LEADERSHIP

• The governing body is responsible for establishing policies to sustain the QAPI program.

• Setting priorities for the QAPI program and building on the principles.


• Also responsible for setting expectations.

ELEMENT 3: FEEDBACK, DATA SYSTEMS AND MONITORING

• Systems to monitor care and services, drawing data from multiple sources.

• Feedback systems incorporate input from all levels.

• Performance Indicators to monitor care processes and outcomes, and review and/or established targets.

T ki I ti ti d it i U l O d ti


• Tracking, Investigating, and monitoring Unusual Occurrences and action plans implemented to reduce likelihood of recurrences.

ELEMENT 4: PERFORMANCE IMPROVEMENT PROJECTS (PIPS)

• Performance Improvement Projects (PIPs) examine and improve care or services.

• PIPs are selected in areas important and meaningful.

• PIPs will vary depending on type of facility and scope of services.


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ELEMENT 5: SYSTEMATIC ANALYSIS AND SYSTEMATIC ACTION

• In‐depth analysis as needed to understand the problem, the cause of the problem and the implications of change

• Develop policies and procedures and use Root Cause Analysis.

• Comprehensive Systemic Actions to prevent future events and promote sustained improvement.


p

• This element includes a focus on continual learning and continuous improvement.

ACTIONS STEPS TO BUILD QAPI

STEP 1: Leadership Responsibility and Accountability

• Creating a culture to support QAPI efforts begins with leadership. • Support from the top is essential, and that support should foster the

active participation of every caregiver. • The administrator and senior leaders must create an environment that


promotes QAPI and involves all caregivers.

PERSONAL FACE

• Put a personal face on quality issues

• Leadership should give residents, family and staff the opportunity to meet board members and executive leaders to generate support for QAPI


g pp Q

• Tour the organization regularly, meet with residents and caregivers where they live and work

• Choose the person responsible to lead the QAPI

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STEP 2: Develop a Deliberate Approach to Teamwork

Teamwork is a core component of QAPI and too often it is taken for granted.



STEP 3: Take your QAPI “Pulse” with a Self‐Assessment

To establish QAPI, it is helpful to conduct a self‐assessment in your organization.


(Self‐Assessment Tool included at CMS.gov website or Appendix A of QAPI at a Glance)


STEP 4: Identify Your Organization’s Guiding Principles

Lay a foundation about what principles will guide decision making and help set priorities.


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STEP 5: Develop Your QAPI Plan

• Your plan will assist in achieving what you have identified as the purpose, guiding principles and scope for QAPI.

• This is a living document that you may revisit as your facility evolves.



STEP 6: Conduct a QAPI Awareness Campaign

Let everyone know about your QAPI plan often and in multiple ways.



STEP 7: Develop a Strategy for Collecting and Using QAPI Data (set targets &

benchmarks)

Your team will decide what data to monitor routinely.


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STEP 8: Identify Your Gaps and Opportunities

• This step involves reviewing your sources of information to determine if gaps or patterns exist in your systems of care that could result in quality problems.

• Are there opportunities to make improvements?



STEP 8: Identify Your Gaps and Opportunities

During this step, you may decide to spend more time discussing the quality themes you have identified with residents and caregivers.



STEP 9: Prioritize Quality Opportunities and Charter PIPs

Prioritizing opportunities for improvement is a key step in the process of translating data into action.


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STEP 10: Plan, Conduct and Document PIPs

• Careful planning of PIPs includes identifying areas to work on through your comprehensive data review which are meaningful and important to your residents.

• It is important to focus your PIPs


p y

by defining the scope so they

do not become overwhelming.


STEP 11: Getting to the “Root” of the Problem



STEP 12: Take Systemic Action

The goal is to make changes that will result in lasting improvement.


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STEP 12: Take Systemic Action

To be effective, interventions/corrective actions target

elimination of root causes, provide long term solutions and have

greater positive vs negative impact Interventions must be


greater positive vs. negative impact. Interventions must be

achievable, objective and measurable.

STEP 12: TAKE SYSTEMIC ACTION ‐ EXAMPLES

WEAK INTERMEDIATE STRONG

Double checks Decrease workload Physical changes

Warnings / labels Software enhance Forcing functions or constraints

New policies / procedures / Eliminate/reduce distraction Simplifying


New policies / procedures / memorandum

Eliminate/reduce distraction Simplifying

Training/education Checklists/cognitive aids/triggers/prompts

Build in redundancy

QAPI PRINCIPLES SUMMARIZED

• Starts at the top and includes the top management• Involve care partners• Continuously communicates QAPI throughout the

organization• Resident oriented perspectives


p p• Creates a record of QAPI activities• Sets priorities• Celebrates success!

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Performance Improvement Projects = PIPs


PERFORMANCE IMPROVEMENT PROJECTS = PIPs

• How will you decide on PIPs?

• Generally the RESIDENT’S NEEDS ARE HIGHEST PRIORITY.


ABCs OF PIPs

• CMS uses a lot of fancy words

• They say you should “draft a charter”

• This is a fancy way of saying “write a description of what you hope to accomplish”


what you hope to accomplish

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ABCs OF PIPs

Designate a CHAMPION or sponsor for each PIP


ABCs OF PIPs – SETTING THE AIM

What are you trying to accomplish?


ABCs OF PIPs

What changes can we make that will result in improvement?


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ABCs OF PIPs – TIPS FOR SETTING AIMS

1. State the aim clearly

2. Include numerical goals that require fundamental change to the system

3 Set goals


3. Set goals

4. Avoid aim drift

5. Be prepared to refocus the aim

ABCs OF PIPs ‐MEASUREMENTS

How will you know that change is an improvement?


ABCs OF PIPs ‐MEASUREMENTS

Measurement for Learning and Process Improvement

Purpose To bring new knowledge into daily practice

Tests/PDSA cycles Many sequential, observable tests/PDSA cycles


Biases Stabilize biases from test to test/PDSA cycles

Data Gather “just enough” data to learn and complete another cycle

Duration “Small tests of significant changes” accelerates the rate of improvement

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MEASURING PIPs

• How does the system impact the residents?

• Are you getting the results you wanted?


We Know About PIPs How Do We START?


METHODS FOR GOAL SETTING AND DETERMINING IMPROVEMENT

Different ways to develop and lay out plans for improvement; only a couple are discussed


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PLAN, DO, STUDY, ACT (PDSA)

Use the Plan‐Do‐Study‐Act (PDSA) Worksheet to help your team document a test of change.



PDSA CHECKLISTS ‐ DO

During this stage, the change is tested, followed by data

collection and preliminary data analysis.


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PDSA CHECKLISTS ‐ STUDY

How do the actual results compare to the predictions?


PDSA CHECKLISTS ‐ ACT

If the change was successful and will be expanded to other parts of the facility, how will we spread the change?


SMART FORMULA

Goal setting is important for any measurement related to performance improvement.


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SMART FORMULA – GOAL SETTING WORKSHEET

• SPECIFIC

• MEASURABLE

• ATTAINABLE

• RELEVANT


RELEVANT

• TIME‐BOUND

Root Cause Analysis


ROOT CAUSE ANALYSIS GETTING TO THE ROOT OF THE PROBLEM

It’s tempting to try to come up with a solution before we really understand what is causing the problem.


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ROOT CAUSE ANALYSISGETTING TO THE ROOT OF THE PROBLEM

Example:

Lost personal laundry is a common problem


ROOT CAUSE ANALYSIS GETTING TO THE ROOT OF THE PROBLEM

Another common concern in homes is “hoarding” of linens.


ROOT CAUSE ANALYSIS WAYS TO GET THERE ‐ LEAVE YOUR BOXES BEHIND

Think outside the box

It is extremely important, when doing this exercise, not to cut off the flow of ideas from participants


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ROOT CAUSE ANALYSISWAYS TO GET THERE

Flow ChartAlmost any service is the result of a series of tasks performed by several different departments.



• Root Cause Analysis (RCA) is a method of “drilling deeper” and asking WHY at each level.

• Consider this example:

– A resident fell while walking. WHY did she fall?

d l l f


• NOW develop a plan of action.


Many ways to conduct Root Cause Analysis


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SAMPLE QAPI PROJECT – FALL ANALYSIS

• Analysis reveals a peak in falls between 6:45 pm and 7:30 pm

• The second most common time for falls is 5:30 am –7:30 am.


• The evening falls are analyzed further and related to bathroom patterns and habits.

• The morning falls and people’s sleeping habits were further analyzed.

SAMPLE QAPI PROJECT – FALL ANALYSIS

• The home reviewed the hours employees worked

– In activities, dietary, and care assistance

– Shifted activity programming for more after dinner activity to provide care givers assistance with supervision


– Dietary began clearing tables 10 minutes later and bringing out dessert to slow down the dining process.

• Residents who woke early were provided newspapers, toast, and coffee in their rooms after being assisted (as needed) to use the bathroom.

QAPI SUMMARY

• QAPI allows you to take more credit and act more creatively

• Don’t get fixated on the small details

• If an intervention doesn’t work (or doesn’t work well


(enough), try, try again!

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FINAL THOUGHTS

• QAPI is a daily process and there should be daily work toward QAPI benchmarks

• QAPI doesn’t end when the meeting ends


Questions or Concerns?


REFERENCE

• Bolhack, S.M., Grant, S., Viggiano, B., Hector, P. How and Why Quality Improvement Programs Are Developing at a Growing Rate. Assisted Living Consult (November/December 2006).

• Golant, S.M., Hyde, J. The Assisted Living Residence: A Vision for the Future. (2008). Baltimore, Maryland: Johns Hopkins University.


• Nursing Home QAPI; CMS Webinar 2012

• QAPI at a Glance: A Step by Step Guide to Implementing Quality Assurance and Performance Improvement (QAPI) in Your Nursing Home. CMS 2012.

• Wyatt, A. Getting Better All The Time. (2010). Retrieved from: www.susanwehry.com/files/gettingbetterall‐the‐time.pdf

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RESOURCES

• Maryland Office of The Secretary of State; 10.07.14.13.htm Administration. http://www.dsd.state.md.us/comar/SubtitleSearch.aspx?search=10.07.14.*

• Washington State Legislature; RCW 18.20.390 Quality Assurance Committee. http://apps.leg.wa.gov/rcw/default.aspx?cite=18.20.390


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