QAPI – Performace Improvement for Long Term Care.

QAPI – Performace Improvement for Long

Term Care

Why does this matter in long term care?

Office of Inspector General Findings

• 1:3 Skilled Nursing Facility residents were harmed by an adverse event or temporary harm event within first 35 days of their stay– 60% were preventable– 79% resulted in an extended nursing home stay or

required hospital transfer• 50% of those were re-hospitalized costing Medicare

$208 million dollars

…in one month!

Adverse Events

37% Medication Related37% Care Related

26% Infection Related

F-520 Regulation

• QAA: Quality Assessment and Assurance regulation– Quarterly meetings to include the director of nursing, a physician, and three other staff

members– The committee identifies quality deficiencies and develops and implements plans of action to

correct with quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the action plans

– Root cause identification with corrective action plans

• Survey – Facility is not required to release the records of QAA committees related to being an internal

process– If facility does release information, the topics discussed in QAA committees may not be used

to cite deficiencies not identified prior to QAA review that are unrelated to the QAA regulation– Staff members will be interviewed about the QAA team and how they would bring up

concerns to be investigated for improvement

QA—Quality AssurancePI—Performance Improvement

What is QAPI?

QA vs PIQuality Assurance (QA) • QA is a process of meeting quality standards and assuring that care

reaches an acceptable level. Nursing homes typically set QA thresholds to comply with regulations. They may also create standards that go beyond regulations. QA is a reactive, retrospective effort to examine why a facility failed to meet certain standards. QA activities do improve quality, but efforts frequently end once the standard is met.

Performance Improvement (PI) • 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. PI in nursing homes aims to improve processes involved in health care delivery and resident quality of life. PI can make good quality even better.

What???• QAPI is a data-driven, proactive approach to improving the

quality of life, care, and services in nursing homes. The activities of QAPI involve members at all levels of the organization to:

1) identify opportunities for improvement; 2) address gaps in systems or processes; 3) develop and implement an improvement, or corrective plan;4) and, continuously monitor effectiveness of interventions.

5 Elements of QAPI

1. Leadership and Governance2. Design and Scope3. Feedback, Data Systems, and Monitoring4. Performance Improvement Projects5. Systematic Analysis and Systematic Action

12 Action Steps to QAPI1. Leadership Responsibility and Accountability2. Develop a Deliberate Approach to Teamwork3. Take your QAPI Pulse with a Self Assessment4. Identify Your Organization's Guiding Principles5. Develop your QAPI Plan6. Conduct a QAPI Awareness Campaign7. Develop a strategy for Collecting and Using QAPI Data8. Identify your Gaps and Opportunities9. Prioritize Opportunities and Charter PIPs10. Plan, Conduct, and Document PIPs11. Getting to the Root of the Problem12. Take a Systematic Action

Baldrige Framework and QAPI

AS1, AS2, AS4, AS6, E1

AS3, AS7, AS8, E3

AS4, AS5, AS9, AS10, E2

AS9, AS10, AS11, AS12, E4, E5

AS2, AS9, AS10, AS11

Deming restated

“The single greatest impediment to error prevention in the medical industry is that we

punish people for making mistakes.”--

Dr. Lucian Leape, Professor at Harvard School of Public Health

Need for a Just Culture

• Long term care is heavily regulated by state and federal government

• Immediate intervention of a disciplinary action needed as part of the corrective action

• Error reporting by employees is not accurate for fear of reprisal

• Managing not Leading• Scapegoats used frequently

https://www.youtube.com/watch?feature=player_detailpage&v=4r2r0Cfs8DI

Strong Leadership Needed

http://www.ted.com/talks/derek_sivers_how_to_start_a_movement

Meeting Improvement• Going through the “meeting motion” accomplishes nothing

• Problem Statements• Root Cause Analysis—asking why, why, why, why…• Sharing action plans• Monitoring results—data driven

The goal changes from showing motion i.e. having an action plan, to making a measureable improvement

• Holds your leadership accountable to have impact to a culture change

High Reliability Organization (HRO)

An organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity

……the hallmark of an HRO is not that is error free, but the errors do not disable it

HRO Characteristics

• Leaders at all levels know how to timeline events

• Front line staff and get engaged in finding errors in the system

• Culture that is highly aware of risks

HRO Focus

• Look at system failures from a multiple cause of events approach; it is not just what is happening at the time of the event that leads to the failure

• An accident, no matter how minor, is a failure in the system

QAPI—Think Outside the Box

http://www.ted.com/talks/derek_sivers_weird_or_just_different

How are you leading?

Questions?

• Lauren Hartlaub• Director of Quality

Assurance and Risk Management

• [email protected]

• Tedd Snyder• Snyder Consulting &

Associates• [email protected]

Resources

• http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2015-03-10-Presentation.pdf

• http://go.cms.gov/Nhqapi

Centers for Medicare & Medicaid Services (CMS)

• Section 6102 (c) of the Affordable Act provide the opportunity for CMS to mobilize some of the best practices in nursing home QAPI– Tools and resources• Advancing Excellence in American’s Nursing Homes• Agency for Healthcare Research and Quality

– Training Materials• Lean Goddess Video Series• Donna’s Diary