PruittHealth QAPI Purpose - Healthcare Continuing … · Web viewPI (also called quality improvement--QI) is a pro-active and continuous study of processes with the intent to prevent

Quality Assurance Performance Improvement PlanPruittHealth 2015

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Quality Assurance and Performance Improvement is the merger of two complementary approaches to quality, Quality Assurance (QA) and Performance Improvement (PI). Both involve seeking and using information, but they differ in key ways:

QA is a process of meeting quality standards and assuring that care and services reach an acceptable level. The process includes the systematic monitoring and evaluation of the various aspects of a project, service, or center/office/agency operations to ensure that standards of quality are being met. Skilled nursing and rehabilitation centers (SNRC’s), hospice and home health set quality assurance thresholds to comply with internally developed standards of performance and; also, to comply with all applicable state and Federal regulations. QA activities are planned at specific intervals and are ongoing to always assure an acceptable level of performance.

PI (also called quality improvement--QI) is a pro-active and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems. Performance improvement in skilled nursing and rehabilitation centers (SNRC’s), hospice and home health aim to improve processes involved in health care delivery, patient safety and quality of life. Performance improvement can make good quality even better.

The merger of the two approaches creates Quality Assurance Performance Improvement. QAPI is a data-driven, proactive approach to improving the quality of life, care, and services in healthcare. The activities of QAPI involve members at all levels of the organization to: identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor effectiveness of interventions.QAPI utilizes systems thinking: an approach to problem solving, which views “problems” as parts of an overall system rather than reacting to specific parts, outcomes or events. “Systems’ thinking is not one thing but a set of habits or practices within a framework that is based on the belief that the component parts of a system can best be understood in the context of relationships with each other and with other systems, rather than in isolation.” Systems’ thinking enables understanding of a system, as well as, the desired or expected outcome by examining the linkages and interactions between the elements that compose the entirety of the system. (Wikipedia, the free encyclopedia)


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PruittHealth QAPI PurposeThe purpose of QAPI at PruittHealth is to continually take a proactive approach to assure and improve the way we provide care and engage with our patients, partners, and other stakeholders so that we may fully realize our vision, mission and commitment to caring pledge. Quality assurance performance improvement, quality assessment & assurance, performance improvement has been a long-standing practice in our company, beginning in 2015 we will implement a standardized QAPI program with consistent elements across all business lines which supports the PruittHealth Model of Care and cross-sector partnerships, including hospitals. In the implementation of QAPI we continue to be innovators and push the boundaries in the delivery of care in the post-acute and long-term care sector. In doing so we will be change agents who are relentless in making things happen; throughout our-organization of people, sites of care, and in the utilization of resources, including technology, to deliver health care services to meet the health needs of our target population.

Commitment to CaringAt PruittHealth Corporation, we recognize the inherent value of the individual. We are committed to providing the highest quality health care while fostering relationships grounded in respect, open communication and professionalism with our patients, residents, clients and communities. Our customers' loyalty speaks for itself as we exceed expectations at the highest level and develop enduring relationships.For our employee-partners, we commit to cherishing performance excellence through continuing professional development. We reward teamwork and empower those that advocate for and contribute to quality care and services.We commit to upholding a culture that continuously fosters caring, fairness and respect.

Our MissionOur family, your family, ONE FAMILY. Committed to loving, giving and caring. United in making a difference.

Our VisionTo be innovators in a seamless and superior health delivery system in the communities we serve.


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Core ValuesQuality of Expertise, Quality of Care, Quality of Services, Quality of Life

PruittHealth History

A Leader in Health CareFor over 45 years, PruittHealth has ensured the peace and mind of its patients, residents, clients and their families through its commitment to quality health care.

PruittHealth is a southeast regional leader in long-term health care. Since its inception in 1969 as the Toccoa Nursing Center, the PruittHealth community of services has grown to encompass more than 90 post-acute, skilled nursing and assisted living locations, as well as an array of supplementary resources, including home health care, end-of-life care, rehabilitation, veteran care and consultative pharmaceutical services. PruittHealth also offers a variety of business-to- business services.

At PruittHealth, we understand our customers' needs may change over time. To manage these changes, we have developed a continuum of services allowing patients to receive the care they need within the same family of providers. Using the knowledge and experience we've honed over four decades, we anticipate the needs of patients and have set in place best practices to ensure our patients receive the best quality care. Our staff provides the care, love and professionalism that have been part of PruittHealth since our beginning.

PruittHealth serves communities in Georgia, North Carolina, South Carolina and Florida, and our commitment to caring continues to expand in both care offerings and geographic regions.


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The five elements that serve as the core of QAPI. These elements interact with each other without firm lines or boundaries between them.

Design and Scope

Systematic Analysis and

Systemic Action

Governance and Leadership

Performance Improvement Projects (PIPs)

Feedback, Data Systems

and Monitoring

PruittHealth Guiding Principles QAPI PruittHealth mission, vision, and core values, creates the foundation for

organizational QAPI performance. PruittHealth uses quality assurance and performance improvement to make

decisions and guide our day-to-day operation. (In establishing the system we remain cognizant that QAPI is not a program; rather, it is the way we do our work.)

PruittHealth QAPI includes all business lines, partners, all departments and allservices.

QAPI is comprehensive regarding systems of care, management practices, and business practices.

PruittHealth QAPI is data-driven and is guided by our five performance improvement pillars: People, Service, Quality, Finance, and Growth and the respective business drivers in each performance improvement pillar.

PruittHealth QAPI decisions are based on data, which is collected in a systematic format in alignment with our infrastructure and aggregated on PruittHealth Connect Dashboard.


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PruittHealth sets annual goals for performance and measures progress toward these goals.

PruittHealth supports QAPI through the concept of team management, and encouraging our partners to support each other and be accountable for their professional performance and practice.

PruittHealth focuses on systems and processes, rather than individuals. The emphasis is on identifying system gaps and correcting them rather than on blaming individuals.

PruittHealth sets high expectations for ethical practice through the Code of Conduct and a rigorous compliance program.

I. Leadership Responsibility & Accountability


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It is the expectation of PruittHealth QAPI system that each business line will establish a QAPI process that guides and directs the operations of each center, office or agency. The executive leadership of each business line sets the expectation and provides the resources for implementation. Each business line establishes a QAPI committee (steering committee)—the steering committee has overall responsibility to develop and modify their respective QAPI plan, review information, and set priorities for performance improvement projects (PIPs). A QAPI committee will be established at each level of the business line—center/office/agency, region, division. The executive leadership team (ELT) of PruittHealth will act as the executive QAPI team. The steering committee charters teams to work on particular problems and/or implementation of new programs, initiative’s, projects. Essential to the success of each QAPI steering committee is the integration of information from stakeholders, at all levels of the organization.Stakeholders include employees/ partners, patients, families, physicians, and others as appropriate. The process also supports strong business-to-business related and non- related communications grounded in the PruittHealth Model of Care . QAPI information flow is a standardized process; information focuses on business practice, policies and procedures, business drivers and key performance indicators. Quality (QAPI) information flows up and down the organization in an organized format. PruittHealth culture supports the philosophy that, knowledge is shared and information flows freely. If you think an issue, statement, or concern should be communicated to the QAPI team/steering committee, then communicate and ask for assistance and/or guidance.


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II. ScopePruittHealth QAPI system is ongoing and comprehensive; all facets of care and services offered by the organization at each level of the organization (center, office, agency, region, division, and enterprise) including the full range of individual departments are included. QAPI addresses all systems of care and management practices and always includes our “core products”: clinical care, quality of life, patient choice and care transition. The scope of PruittHealth QAPI is further defined by the Five Performance Improvement Pillars of Excellence (adopted from HARDWIRING EXCELLENCE, author Quint Studer). The five Performance improvement pillars provide the foundation for setting PruittHealth goals for organization excellence.

Standards Committee (s)


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Service HHC Quality HHC People HHC

Finance HHC

Growth HHC

CustomerServices Calls

Customer Net Promoter Score

Patient Events Green Sweep Survey

Outcomes (Readiness, Annual, Complaints)

ResidentAssessment Instrument (RAI)

Data Integrity Assessment

Call BellMonitoring

New Policy Implementation

Care Ambassador Program Care Transitions Rehospitalizations Antipsychotics Quality Measures Five Star (survey, quality

metrics, staffing) Checklist/systems

overview/trends (Clinical, Environmental, Clinical Reimbursement, Operations, Pharmacy)

Abaqis/Quality of Life Process Measure

Turnover Partner Net

Promoter Score

RequiredTraining

StaffingTrends

24/7 RNCoverage

Consistent Assignments

Performance Net Income

Net Income Cash Velocity Medicaid

Pending DCG

Accounts Rate Analysis

FinancialResults (PNI)

CensusTrending (Total/Skilled/Quality)

Starts of Care Radar Review Competitive

Analysis


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Service HH Quality HH People HH Finance HH Growth HH

ImproveCustomer Net Promoter Score by 3%

AchieveBudgeted Quality Revenue by 3%

MaintainCompliance Score of 0%

Improve Home Health Readmissions by 5%

Increase Home Health Improvement in Ambulation by 5%

Oasis/POC data integrity

Improve Partner Net Promoter Score by 3%

ImproveTurnover Rate by 3%

Achieve 90% of Required Training

Administrator & DHS Turnover

RequiredTraining 90%

Achieve 100% of Budgeted Net Income

Achieve 100% of Budgeted Performance Net Income

Maintain Cash Velocity of 99.5%

Meet Total Budgeted Census of 100%

Meet Total Budgeted SOCs of 100%

Service Home First

Quality Home First

People Home First

Finance Home First

Growth Home First


AchieveBudgeted Quality Revenue 0f 57.51%

MaintainRevenue at Risk of 0%

Increase Level of Care Admissions and Re-Evaluation Approvals by 3%.

Process/Checklist Score above 90%








Increase Level of Care Admissions and Reevaluations Approvals

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Service Hospice

Quality Hospice

People Hospice

Finance Hospice

Growth Hospice


AchieveBudgeted Quality Revenue by 3%

MaintainCompliance Score of 0%

Improve Pain Management by 3%

Increase Percent of Community Patients Served by 3%

Point of Care Data Integrity

Hospice Item Set no office above national average

Quality Checklist 90%

AVP Checklist 90%




Administrator & DHS Turnover





Service Pharmacy

Quality Pharmacy

People Pharmacy

Finance Pharmacy

Growth Pharmacy

Off-labelAntipsychotics ST/LS Improve by 3%

Customer Net Promoter Score

Order Fulfillment Rate

Support HCC to achieve Process Score of 90%




Part A Rx PPD Costs

Recoupments Achieve 100% of

Budget Net Income

Achieve 100% PNI

Maintain Target Cash Velocity of 99.50%

Percent Quality Revenue—Achieve Budget of 94.62%

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The five performance improvement pillar model defines the standards and the respective goals in relation to performance excellence in each business line for the organization. The goals for performance are reset annually by the cross-functional standards teams/committee(s) of the organization.


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Pruitt Health’s QAPI steering committee model includes: a financial, clinical/operations and customer service cross-functional standards committee. The standards committee is one of most important components of the continuous improvement and continuous learning environment at PruittHealth. The committee acting, as a committee of the whole or as further sub-divided into functional areas, ensures that the organization is aware of changes in standards or regulations. The committee(s) may recommend performance standard changes in the form of additions, deletions, or enhancements to policies, procedures, guidelines, checklist/scoring guidelines.

Recommendations for new or modified performance standards embody PruittHealth vision, mission, core values and the philosophy of committed to caring. Any performance standard recommendations made by committee(s) must include a: statement of impact on the organization, desired goal of the standard and, if appropriate, how the standard will be measured. New or modified standards must include strategies for implementation, training of partners, and oversight protocol. The committee will also develop tools and roll out strategies to ensure the employee-partners fully understand and live by these standards.


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II. III. Feedback, Data Systems, and MonitoringPruittHealth QAPI utilizes a robust system of data collection, the data are collected and displayed on PruittHealth Connect, the data are updated daily at midnight---data sources are also updated as made available on a daily, weekly, monthly, annual basis specific to each data source. The dashboard is made available to key leaders within the organization, as part of their role on the QAPI committee, including administrators, directors of clinical services in each business line.


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The dashboard serves as a key source of data used for the monthly QAPI meeting. The data are analyzed against PruittHealth standards of performance and annual targets established for each metric. Standards are reviewed by the respective standards committees. Additional data collection includes in-depth review of unscheduled data sources such as annual and complaint surveys, committed to caring hotline calls, (calls are distributed to all key leaders when received for prompt service recovery and an in-depth review/analysis is completed monthly and distributed to leadership from the region level up to the executive management). Included as process measures on the PruittHealth Connect Dashboard are “checklist” completed quarterly by field support staff which support the individual business units.

Goals for systems checklist, which aggregates at the business unit, region, division and executive level, completion include:

o Ensuring consistent/predictable service delivery;o Serve as a check on quality, which flows from the business unit to the executive

team;o Assure ongoing compliance with regulatory requirements;o Supports a robust compliance program.

The checklist are used to collect and synthesize data which links to expected outcomes:o Clinical Outcomeso Customer Satisfactiono Company Standardso Revenue Growth/Stability

Additional benefits include:o Determine center, region, division, corporate trends;o Monitor and document service delivery trends;o Identification of improvement opportunities (OFI).


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Checklist Example


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Committed to Caring Hotline Calls Monthly Report Example


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PruittHealth Connect Dashboard Example


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IV. Systematic Analysis and Systemic ActionPruittHealth uses a systematic approach to determine when in-depth analysis is needed for identifying contributing causal factors that underlie variations in performance. This structured method of analysis is designed to get to the underlying cause of a problem— which then leads to identification of effective interventions to make improvements. It is the goal of the organization to use the many and various sources of data (PruittHealth Connect) to do early and ongoing review to proactively identify incremental change in expected outcomes. The goal of early intervention balanced against targeted goals and outcomes, ensures consistent delivery in care and business outcomes.Unexpected/unanticipated process failures or outcomes are evaluated to determine the “root cause” (RCA).

PruittHealth uses several different methods for root cause analysis. The fishbone diagram is used to explore and display the potential root causes of a specific problem or condition. When identifying possible root causes, it is helpful to ask why (Five Whys) each one exists. Asking “WHY” is necessary and recommended to discover the true root cause(s).Documenting causes on the diagram, is helpful to understand the


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underlying: gaps in systems or processes; and identify processes/systems that need improvement. Using the root cause(s) will determine procedures needed or systemic changes necessary to ensure that improvement is achieved.

V. Performance Improvement Projects (PIPs)Prioritizing opportunities for improvements is an important step in the process of data- driven management and of translating data into information used for action.

Pruitt Health’s implementation strategy uses our strategic framework, business drivers and key performance indicators and includes:

Identification of problems/opportunities for improvement (OFI) and/or issues that are considered important (consider is the issue high risk, high frequency).

Consideration of which problems should become the focus of a performance improvement project (PIP).

Consideration of all identified problems which need attention and correction—but do not need/require a PIP. (Just do it! Or Low Hanging Fruit)

Development of improvement project charter or scope of work. A perforamnce improvement project is more than a casual effort—it requires a specific written mission to look into the problem area. The PI team includes people in a position to explore the problem, including if appropriate, direct care givers.

o Developing the scope of work and chartering indicates that the team has a specific mission and that the team will report back to the steering committee at defined intervals. PruittHealth status reporting and blue sheet will be used for this step in the project (blue sheet for required decisions by the executive leadership team). This step adds strength, importance, and formality to the PruittHealth performance improvement process. The scope of work/charter includes:

Designation of team/project leader and team members; A description of the project and brief background –specify a new

program or in response to new standard, regulations, etc. and/or performance improvement project secondary to failure to meet expected outcomes or goals;

Project/PIP timeline.

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o Description of actual task which the project will require; Kickoff-List task Design Phase-List task Development Phase-List Task Project Timeline & Milestones Implementation Phase-List task Training Phase-List task Project Handoff/Closure-List Task

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ReferencesCenters for Medicare and Medicaid Service, StratisHealth, University of Minnesota, QAPI Technical Expert Panel, (2013) QAPI At A Glance & Guide for Developing a QAPI Plan.

American Health Care Association, Quality Cabinet, (2013) Implementing QAPI—The Twelve Action Steps.

Pelletier, L, Beaudin, C, ((2008) Essential Resources for the Healthcare Quality Professional, National Association for Healthcare Quality.

Studer, Q. (2003) Hardwiring Excellence, Studer Group.

Langley, G., Moen, R., Nolan, K., Nolan, T., Norman, C. Provost, L., (2009) The Improvement Guide, A Practical Approach to Enhancing Organizational Performance. Jossey-Bass

Wikipedia, the free encyclopedia, (2013) Systems Thinking, 1. The Concept of a System,2. The Systems Approach.

PruittHealth QAPI Purpose - Healthcare Continuing … · Web viewPI (also called quality improvement--QI) is a pro-active and continuous study of processes with the intent to prevent

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