1 Clinical Indicator Goals Project: Developing QAPI Without Fear Svetlana (Lana) Kacherova, QI Director Lisle Mukai, QI Coordinator ESRD Network 18 November 19, 2008 2 Special Acknowledgement for Content Contributions: Laura Adams, President and CEO Rhode Island Quality Institute & Quality Improvement Directors & Quality Improvement Directors From other ESRD Networks! Session Objectives Project Description Project Description Increase understanding of Quality Principles Increase understanding of Quality Principles Use the Basic Quality Tools Use the Basic Quality Tools Apply PDSA cycle and project steps Apply PDSA cycle and project steps Learn something new Learn something new Have some fun Have some fun 3 4 V626 QAPI Condition Statement The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team... The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team... The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS 5 Condition : Quality Assessment and Performance Improvement Project ( QAPI) Condition : Quality Assessment and Performance Improvement Project ( QAPI) Interdisciplinary team (IDT) Interdisciplinary team (IDT) Must report problems to Medical Director and Quality Improvement committee Must report problems to Medical Director and Quality Improvement committee Outcome- focused Outcome- focused Process continuous & on-going Process continuous & on-going Use community accepted standards as targets Use community accepted standards as targets Include patient satisfaction, infection control, medical injuries & medication errors Include patient satisfaction, infection control, medical injuries & medication errors Plan/Do/Study/Act: Close the loop! Plan/Do/Study/Act: Close the loop! 6 Monitoring Performance Improvement (V638) The facility must: Continuously monitor its performance Continuously monitor its performance Take actions that result in performance improvement Take actions that result in performance improvement Track to assure improvements are sustained over time Track to assure improvements are sustained over time 7 Interdisciplinary Team: Show Me The Progress: 8 Performance Measures: include but not limit to: (V629) AdequacyKt/V, URR (V630) NutritionAlbumin, body weight (V631) Bone diseasePTH, Ca+, Phos (V632) AnemiaHgb, Ferritin (V633)Vascular access Fistula, catheter rate (V634) Medical errors Frequency of specific errors V635) Reuse Adverse outcomes (V636) Pt satisfaction Survey scores (V637) Infection control Infections, vaccination status Clinical Indicator Goals Project: Inclusion Criteria for Participating Facilities Not meeting Network goals on at least 2 of 3 clinical indicators (N=63) Not meeting Network goals on at least 2 of 3 clinical indicators (N=63) - Anemia - Anemia - Dialysis Adequacy - Dialysis Adequacy - Albumin - Albumin IMPORTANT: IMPORTANT: Anemia and Adequacy information is available on the Dialysis Facility Compare website atAnemia and Adequacy information is available on the Dialysis Facility Compare website at9 Project Goal: Project Goal: All participating facilities will perform a Root-Cause Analysis (RCA) and develop QAPI to meet clinical indicator goals All participating facilities will perform a Root-Cause Analysis (RCA) and develop QAPI to meet clinical indicator goals 65% of facilities (N- 40) will show improvement from baseline in at least 2 of 3 clinical indicators between October 2008 and March % of facilities (N- 40) will show improvement from baseline in at least 2 of 3 clinical indicators between October 2008 and March 2009 Goals are set per MRBs suggestion based on the historical clinical indicator monitoring processes Goals are set per MRBs suggestion based on the historical clinical indicator monitoring processes 10 Reasons for Anemia Goals => 11.0 g/dl Network Goal 85% patients with Hgb => 11.0 g/dl Network Goal 85% patients with Hgb => 11.0 g/dl CPM study looks at the % of patients => 11.0 g/dl and Network goals are determined upon CPM results CPM study looks at the % of patients => 11.0 g/dl and Network goals are determined upon CPM results Hgb lower and upper limits discussion Hgb lower and upper limits discussion MRB suggested no more than 15% of patients with Hgb 13.0 g/dl MRB suggested no more than 15% of patients with Hgb 13.0 g/dl 11 Important: If your facility anemia goals are different from the Network goal (upper and lower limits for Hgb or Hct) provide the Network with your policy on Anemia goals If your facility anemia goals are different from the Network goal (upper and lower limits for Hgb or Hct) provide the Network with your policy on Anemia goals Identify your goal on the Anemia Monitoring Run Chart when submitting data to the Network Identify your goal on the Anemia Monitoring Run Chart when submitting data to the Network Same applies to other clinical indicator goals (for adequacy and nutrition) Same applies to other clinical indicator goals (for adequacy and nutrition) 12 13 14 15 What is QAPI and why do we need it: Quality Assessment and Performance Improvement Project/Program Previously known as a CQI (Continuous Quality Improvement) 16 Information that Duels the Growing Emphasis on Quality Two million documents will be lost by the IRS this year Two million documents will be lost by the IRS this year 18,322 pieces of mail will be mishandled in the next hour 18,322 pieces of mail will be mishandled in the next hour 20,000 incorrect drug prescriptions will be written in the next 12 months 20,000 incorrect drug prescriptions will be written in the next 12 months Data from the early 1990s 17 Quality in Healthcare Rather then just meeting fixed standards, a never ending search for ways to improve patient outcomes Rather then just meeting fixed standards, a never ending search for ways to improve patient outcomes Focus on outcomes and the process that produce those outcomes Focus on outcomes and the process that produce those outcomes Focus on systems of care not individual cases Focus on systems of care not individual cases Improve the average and the outliers will improve too Improve the average and the outliers will improve too 18 Institute of Medicine Aims for Health Care: Institute of Medicine Aims for Health Care: 1. Evidence-based 2. Patient centered 3. Outcome improvement driven 4. Systems/team oriented 5. Six aims of health care: Safe Effective Patient centered Timely Efficient Equitable 19 What is the cost of Poor Quality? No show rates? No show rates? Lost charts? Lost charts? Lost labs? Lost labs? Train wreck visits? Train wreck visits? Lost revenue improper billing? Lost revenue improper billing? Staff turnover? Staff turnover? 20 Basic Principles of Quality Improvement Focus on improving work processes Focus on improving work processes A systems orientation to service delivery A systems orientation to service delivery Services or products tailored to customers needs Services or products tailored to customers needs Staff involvement Staff involvement Emphasis on design and improvement of products/services Emphasis on design and improvement of products/services A focus on continuously improving A focus on continuously improving 21 Introducing the Quality Tools 22 Basic Quality Tools: Process Analysis Process Analysis Flow Chart Flow Chart Brainstorming Brainstorming Fishbone Diagram (Cause and Effect) Fishbone Diagram (Cause and Effect) Check Sheet Check Sheet Histogram or Pareto Diagram Histogram or Pareto Diagram Run Chart Run Chart Communication Communication 23 Process Analysis: Basic Components or major Steps in a Process Wake-up Get Dresses Breakfast Go to Work 24 Use Process Analysis to: Defines and evaluate the overall process Defines and evaluate the overall process Each box placed in order of occurrence, represents a key part of the process being examined Each box placed in order of occurrence, represents a key part of the process being examined The amount of time could be added as it could be important for improvement The amount of time could be added as it could be important for improvement Once identified which part of the process needs improvement, the box could be further broken down into specific steps using a flow chart Once identified which part of the process needs improvement, the box could be further broken down into specific steps using a flow chart 25 Flow Chart 26 Use a Flow Chart to: Define specific steps in a process including choices and decision points Define specific steps in a process including choices and decision points If there is a decision to be made and no specific choices this is a source of variation and a potential problem! If there is a decision to be made and no specific choices this is a source of variation and a potential problem! Every process should have a clearly defined beginning and end (all team members must agree on steps) Every process should have a clearly defined beginning and end (all team members must agree on steps) 27 Brainstorming Tool for gathering ideas, particularly about problem causes and solutions Tool for gathering ideas, particularly about problem causes and solutions 28 Rules of Brainstorming Dont criticize Dont criticize Be creative Be creative Go for quantity not quality Go for quantity not quality Suspend judgment & evaluation Suspend judgment & evaluation Piggyback on others ideas Piggyback on others ideas Record all ideas Record all ideas Encourage others Encourage others 29 Fishbone Diagram Also called Ishikawa Diagram in honor of the man who developed this tool Also called Ishikawa Diagram in honor of the man who developed this tool Also called the Cause & Effect Diagram because its primary use is to assist in determining the root-cause of a problem Also called the Cause & Effect Diagram because its primary use is to assist in determining the root-cause of a problem Use this tool (bone by bone) to identify a major source and drill down to the level where action can be taken Use this tool (bone by bone) to identify a major source and drill down to the level where action can be taken 30 Fishbone Diagram (cont). Fishbone Diagram (cont). Determine the problem and create a problem statement (effect). Write it at the right center of the chart Determine the problem and create a problem statement (effect). Write it at the right center of the chart Brainstorm the major categories of causes of the problem. Write them as the main branches steaming from the center line Brainstorm the major categories of causes of the problem. Write them as the main branches steaming from the center line Brainstorm all possible causes of the problem. Ask Why did this happen? about each cause. Brainstorm all possible causes of the problem. Ask Why did this happen? about each cause. Fishbone Diagram (cont). Write sub-causes stemming from the category of causes Write sub-causes stemming from the category of causes Collect data to confirm root-cause Collect data to confirm root-cause If no further causes can be identified, then you found the root causes of the problem If no further causes can be identified, then you found the root causes of the problem Check Sheet 34 Check Sheet: Tracking Form 35 36 Check sheet Used when several possible problem causes are identified, but there is no information on the largest cause Used when several possible problem causes are identified, but there is no information on the largest cause Designed to collect data on the number of times that those causes occur Designed to collect data on the number of times that those causes occur Collect data and evaluate action taken Collect data and evaluate action taken The results allow action to be focused in on main causes The results allow action to be focused in on main causes 37 Run Chart 38 Use Run Chart to: Follow performance (Y) over time (X) (plotting the dots) Follow performance (Y) over time (X) (plotting the dots) Allow you to visualize how the process is performing and helps you to identify trends (good or bad) Allow you to visualize how the process is performing and helps you to identify trends (good or bad) Reveals the impact of improvement actions Reveals the impact of improvement actions Add the goals to the chart to see progress toward achieving the goal Add the goals to the chart to see progress toward achieving the goal 39 Using Run Charts to track AVF Rates in the Late Adopter Facilities 40 Using Run Charts as a Tracking Tool Where have you been? Where have you been? Where is the data going? Where is the data going? Please plot the dots Please plot the dots A word about variation A word about variation - normal variation - normal variation - special cause variation - special cause variation 41 Using Run Charts as an Evaluation Tool Compare performance before and after change Compare performance before and after change Calculate % change between old and new level Calculate % change between old and new level 42 The Danger of Comparing Two Data Points! July 05 July 06 Average = 3.5% 5.9 % 1.1 % Peritonitis Episodes/Year Facility A: Peritonitis Episodes Per Year Peritonitis Episodes Per Year (%) Facility B: Peritonitis Episodes Per Year Peritonitis Episodes Per Year (%) Facility C: Peritonitis Episodes Per Year Peritonitis Episodes Per Year (%) Improvement in Wait Time (Team A) Change Implemented Improvement in Wait Time (Team B) Change Implemented Get more from the Data Segment or stratify Segment or stratify - by day - by day - by shift - by shift - by machine - by machine - by staff, surgeon, physician - by staff, surgeon, physician Use comparative data Use comparative data 51 Pareto Diagram A histogram charted in descending order of frequency A histogram charted in descending order of frequency Visually displays the contribution of each cause to the overall problem Visually displays the contribution of each cause to the overall problem This part of problem analysis helps to focus action and resources on main causes This part of problem analysis helps to focus action and resources on main causes 52 Identifying Major Issues based on Pareto Diagrams/Check sheets 53 Communication Communicate organizational quality definition Communicate organizational quality definition Communicate customer/supplier needs Communicate customer/supplier needs Discuss problems (opportunities for improvement) Discuss problems (opportunities for improvement) Report team progress & project results Report team progress & project results Exchange information Exchange information 54 Communication Critical in quality improvement but often ignored tool! Critical in quality improvement but often ignored tool! For best results must be frequent and accurate communication among all involved For best results must be frequent and accurate communication among all involved Communication facilitates buy-in Communication facilitates buy-in Let others know what improvement project is going on Let others know what improvement project is going on Gather input, report progress, celebrate results Gather input, report progress, celebrate results 55 Listen to Your DATA What does the data say? 56 Aims to Action: Conducting QAPI utilizing Rapid-Cycle Improvement What is Rapid Cycle Improvement? Variant of process improvement that: Variant of process improvement that: relies on existing knowledge dramatically shortens discovery process works on rapid trial & learn method relies heavily on action 59 PDCA /PDSA Methodology PLAN DOCHECK /STUDY ACT Plan-Do-Study-Act Plan Identify Opportunity and plan for change Plan Identify Opportunity and plan for change Do Implement the Change on a small scale Do Implement the Change on a small scale Study Use data to analyze for the change and determine whether it made a difference Study Use data to analyze for the change and determine whether it made a difference Act If the change was successful, implement the plan and continuously monitor results. If the change did not work start the process again. Act If the change was successful, implement the plan and continuously monitor results. If the change did not work start the process again. 61 Root Cause Analysis Caution: Avoid the quick fix Caution: Avoid the quick fix Find and fix the root cause of the problem Find and fix the root cause of the problem 62 What is Root-Cause Analysis? Finding the basic cause Finding the basic cause Use brainstorming Use brainstorming Use the fishbone diagram Use the fishbone diagram Collect data if you need to Collect data if you need to Get down to an actionable level Get down to an actionable level Ask WHY? 3-5 times! Ask WHY? 3-5 times! 63 Model for Improvement What changes can we make that will result in an improvement? What are we trying to accomplish? How will we know that a change is an improvement? ActPlan Stud y Do Goal Developing Your Goal Write a clear statement of aim--make the target for improvement unambiguous Include numeric goals Set stretch goals Focus on issues that are important to your organization - choose appropriate goals Developing Your Goal Improvement relies on intention to improve Senior leaders set & align goal with strategic goals (involve Medical Director!) Agreement on goal is critical Include a specific time frame for accomplishing your goal Network Goals for Monitored Clinical Indicators: Clinical Indicators CMS GoalNetwork Goal Facility Anemia % pts with mean HGB => %85% Adequacy Mean Kt/V => 1.2 Mean URR => 65% 80%88% Nutrition (Albumin) Mean albumin => 3.5/3.2 (BCG/BCP) 80%84% 67 Examples of Goals At least 88% of patients will have Albumin > 3.5 by May At least 88% of patients will have Albumin > 3.5 by May To increase the number of patients meeting the Network goal for anemia by 10 percentage points between baseline and January 2009 (from 75% to 85%) To increase the number of patients meeting the Network goal for anemia by 10 percentage points between baseline and January 2009 (from 75% to 85%) Model for Improvement What changes can we make that will result in an improvement? What are we trying to accomplish? How will we know that a change is an improvement? ActPlan Stud y Do Measure Measurement Guidelines The key measures should clarify the goal and make it tangible The key measures should clarify the goal and make it tangible Use outcome and process measures Use outcome and process measures Integrate measurement into the daily routine Integrate measurement into the daily routine Use qualitative as well as quantitative data Use qualitative as well as quantitative data Seek usefulness, not perfection Seek usefulness, not perfection Measures: Process: Process: Identify patients with Kt/V < 1.2 Identify patients with Kt/V < 1.2 Dialysis Prescription assessment Dialysis Prescription assessment Vascular access assessment Vascular access assessment Dietary assessment Dietary assessment Communication of IDT members are essential! Communication of IDT members are essential! Outcome: >88% patients in the facility have Kt/V > Model for Improvement What changes can we make that will result in an improvement? What are we trying to accomplish? How will we know that a change is an improvement? ActPlan Stud y Do Select Changes Selecting Changes Blatantly steal: Use the literature, the experience of others, hunches and theories (FFBI suggestions) Blatantly steal: Use the literature, the experience of others, hunches and theories (FFBI suggestions) Be strategic: Set priorities based on the aim, known problems, and feasibility Be strategic: Set priorities based on the aim, known problems, and feasibility Objective of the Test: Change or No Change? Probably Change TestRedesignEliminateReduceDeliverImplement Probably No Change Recruit Distribute Continue Examine Discuss Teach To Be Considered a Real Test Test was planned, including a plan for collecting data. Test was planned, including a plan for collecting data. Plan was attempted and data was collected. Plan was attempted and data was collected. Time was set aside to analyze data and study the results. Time was set aside to analyze data and study the results. Action was taken, based on what was learned. Action was taken, based on what was learned. Small scale small change Small scale small change Success (or failure) in one PDSA cycle success or failure of the project Success (or failure) in one PDSA cycle success or failure of the project Two Key Points Clinical Indicator Goals Project: Network Responsibilities: Project Leader (change agent) Project Leader (change agent) Supply the templates for RCA & PDSA Supply the templates for RCA & PDSA Supply facilities with tools and knowledge Supply facilities with tools and knowledge Periodic monitoring and feedback Periodic monitoring and feedback Conduct phone interviews to obtain facility-specific data Conduct phone interviews to obtain facility-specific data Facility site visits for strugglers Facility site visits for strugglers 77 Facilities Responsibilities: Return agreement letter (signed by MD) Return agreement letter (signed by MD) RCA & PDSA due to the Network by December 12, 2008 RCA & PDSA due to the Network by December 12, 2008 Run Charts for October-December 2008 are due to the Network by January 9, Run Charts for October-December 2008 are due to the Network by January 9, Follow the project timelines Follow the project timelines 78 79 QUESTIONS? QUESTIONS? For questions please contact: Svetlana (Lana) Kacherova, RN, MPH, CPHQ Quality Improvement Director ESRD Network 18