Choosing a Performance Improvement Project NNHQCC Learning Session #1

Webinar 2 of 4

Donna Beebe

Quality Improvement Coordinator

LSQIN

May 2015

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Objectives

• Identify how to utilize Quality Assurance Performance Improvement (QAPI) resources to assist in choosing a Performance Improvement Project (PIP)

• Describe how to use the National Nursing Home Quality Care Collaborative (NNHQCC) Change Package as a resource and foundation for quality initiatives

• Identify how to develop PIP teams with specific “charters”

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Lead with Purpose

Focus on systems for change

• Proactively look for opportunities to improve the

system

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What is a Performance Improvement Project (PIP)?

• A Performance Improvement Project (PIP) is a concentrated

effort on a particular problem in one area of the facility or

facility wide

• It involves gathering information systematically to clarify

issues or problems, and intervening for improvements

• The facility conducts PIPs to examine and improve care or

services in areas that the facility identifies as needing

attention

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Getting Started

All identified problems need attention—and usually

from more than one person, but they do not all

require PIPs

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Getting Started

Two important components of your QAPI (PIP) plan will be setting priorities and chartering PIP teams

• Everyone should have an opportunity to participate in these activities

• Support staff in being effective PIP team members. Use tools that support effective teamwork

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Getting Started

Convey the message that any and every caregiver is

expected to raise quality concerns, that it is safe to

do so, and that everyone is encouraged to think

about systems

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Additional factors to take into account

1. What existing standards or guidelines are available

to provide direction for this initiative?

2. What measures can be used to monitor progress?

3. Is the topic publicly reported on Nursing Home

Compare and/or is it a goal of the Advancing

Excellence in America’s Nursing Homes

campaign?

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Additional factors to take into account

3. Which type of changes primarily will be involved

(i.e., system changes, environmental changes,

staffing changes)?

4. Which staff will be most affected by the initiative?

What training needs will this initiative present?

5. Is there an identified champion(s) for this initiative?

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Implementing a Performance Improvement Project

• Involve the people directly working in a process in

order to improve that process

• It is crucial to focus on organization-wide inclusion,

not for the sake of inclusion, but to truly understand

what is going on in any given process

• Residents’ perspectives need to be considered in

setting QAPI priorities

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Communicate with Residents & Families

• Ask residents and family members to tell you about

their quality concerns

• Focus on topics that are meaningful and address

the needs of residents and staff

• Make sure all residents and families know that their

views are sought, valued, and considered in facility

decision-making and process improvements

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Prioritization Tool

Purpose: objectively prioritize which projects you

want to work on

Who uses it? The QAPI team

When is it used? Depends on how many projects are

ongoing and how many improvement opportunities

exist

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Prioritization Worksheet for Performance Improvement Projects

http://www.cms.gov/Medicare/

Provider-Enrollment-and-

Certification/QAPI/downloads/

PIPPriorWkshtdebedits.pdf

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Prioritization Tool – Tips

• Should be completed by a team, representing

multiple disciplines

• Don’t be overly concerned about the rating scale

• Team discussion is most important

• Be as specific as possible in how you describe PI

opportunities

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Potential Sources of Data

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Dashboard

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QAPI Relies on Teamwork: Your PIP Team

• Task-oriented teams may be specially formed to look into a particular problem and their work may be limited and focused

• PIP teams are formed for longer-term work on an issue

• PIP teams need to plan for sufficient communication—including face-to-face meetings to get to know each other and plan the work

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Why Teams?

• No one works alone in health care

• No one of us are as smart as we are when we

come together

• Each team member becomes an owner of the

change

• Everyone learns, everyone teaches

• Teamwork begins to break down walls and

barriers between departments

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Create a Performance Improvement Project Charter

http://www.cms.gov/Medicare/Provid

er-Enrollment-and-

Certification/QAPI/downloads/PIPCh

arterWkshtdebedits.pdf

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Prioritize Quality Opportunities and Charter PIPs

As you continue to implement QAPI, you and your team

will:

• Prioritize opportunities for more intensive improvement

work

• Choose problems or issues that you consider important

(consider if the issue is high risk, high frequency, and/or

problem prone)

• Consider which problems will become the focus for a

PIP

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Additional CMS QAPI Tools for

Performance Improvement

Projects

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PIP Launch Check List

http://www.cms.gov/Medicare/

Provider-Enrollment-and-

Certification/QAPI/downloads/

PIPLaunchChecklistdebedits.

pdf

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Resources

Resources to assist you in your QAPI efforts to choose a PIP:

• CMS QAPI website: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/qapitools.html

• A Process Tool Framework: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/ProcessToolFramework.pdf

• QAPI at a Glance: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/QAPIAtaGlance.pdf

• NNHQCC Change Package: http://www.qioprogram.org/resources/content/nnhqcc-nursing-home-change-package

• Guide for Developing a QAPI Plan: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/QAPIPlan.pdf

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OPEN CALL

We will have an Open Call for Q & A and assistance

after nursing homes have reviewed both Webinar 1

and 2 recorded webinars, and completed their

activities, on 05/19/15, 1-2 PM CT, 2-3 PM ET

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Contact the Lake Superior Quality Innovation Network

Michigan: MPRO

Donna Beebe

248-465-7354 dbeebe@mpro.org

Minnesota: Stratis Health

Kristi Wergin

952-583-8561 kwergin@stratishealth.org

Wisconsin: MetaStar

Liz Dominguez

608-441-8266 ldomingu@metastar.com

For information on how to join the NNHQCC go to:

https://www.lsqin.org/initiatives/nursing-home-quality/join/

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Thank you.