CREATING A CULTURE OF QUALITY:

Developing the Infrastructure to Meet Quality Improvement Requirements

 Identifying Facilities That Are Most At-Risk: Part I

Carolyn E. Latham, R.N., M.S.N., M.B.A., C.N.N.Corporate Vice President, Clinical Quality and UltraCare

Fresenius Medical Care North America

CCQCreating a Culture of

Quality

3/16/2011 A renal community collaboration

CCQCreating a Culture of

Quality

QAPI Impact on Facilities at Most Risk

QAPI

CMS QAPI Requirements• Program Scope• Data driven• Medical Director & IDTNetwork Relationships

Regulatory SurveysMonitoring & ReportingNetwork Relationships

QAPI: Structure, Processes & Oversight

3/16/2011 A renal community collaboration

CCQCreating a Culture of

Quality

QuestionThe most significant driver(s) of effective QAPI at

the local level?

a. Engaged Medical Directorb. Clinical Manager with skill in QAPIc. Team involvement in QId. Quality culturee. Management commitmentf. All of the aboveg. None of the above

3/16/2011 A renal community collaboration

CCQCreating a Culture of

Quality

3/16/2011 A renal community collaboration

FMCNA Facility-BasedQAPI

Quality Improvement, Certification,

& Recognition

Tools:Quality ReportsCalendarMeeting MinutesAction PlansTracking ToolsInterview GuidesAudits• Documentation• Observational

CCQCreating a Culture of

Quality

QuestionThe most common barrier(s) to effective QAPI at

the local level:

a. Insufficient knowledge & skill in QAPIb. Lack of a quality culturec. Inadequate QI tools and resourcesd. Lack of management commitmente. All of the abovef. None of the above

3/16/2011 A renal community collaboration

CCQCreating a Culture of

Quality

Identifying Facilities That Are Most At-Risk

Ongoing Measurement

Periodic Assessments

Ongoing Reporting & Tracking

3/16/2011 A renal community collaboration

CCQCreating a Culture of

Quality

Criteria Used to Identify Facilities That Are Most At-Risk

Poor clinical quality outcomes

• Low total and subtotal quality scores• Quality measures at action threshold• High standard mortality rates

Web-based results are visible to alllevels of organization

3/16/2011 A renal community collaboration

CCQCreating a Culture of

Quality

Criteria Used to Identify Facilities That Are Most At-Risk

Ineffective QAPI processes (internal)

Poor results on in-person audits,assessments, reviews (internal)

3/16/2011 A renal community collaboration

CCQCreating a Culture of

Quality

Criteria Used to Identify Facilities That Are Most At-Risk

Network reviews (external)

CMS condition-level deficiencies (external)

3/16/2011 A renal community collaboration

CCQCreating a Culture of

Quality

Criteria Used to Identify Facilities That Are Most At-Risk

Major Positions Unfilled• Governing Body• Interdisciplinary Care Team• QAI Team

Inadequate Medical Director Support

3/16/2011 A renal community collaboration

CCQCreating a Culture of

Quality

Criteria Used to Identify Facilities That Are Most At-Risk

Adverse Events• Concerns of reporting

(i.e. under or no reporting)• Unusual patterns

Serious Adverse Events

3/16/2011 A renal community collaboration

CCQCreating a Culture of

Quality

Criteria Used to Identify Facilities That Are Most At-Risk

Persistent Physical EnvironmentPlant Concerns

Biomedical Concerns

3/16/2011 A renal community collaboration

CCQCreating a Culture of

Quality

Criteria Used to Identify Facilities That Are Most At-Risk

Complaints or Grievances• Related to poor quality care, clinical performance, staffing, or physical plant issues

• Initiated by patients, patients’ significant others, staff, and/or physicians

3/16/2011 A renal community collaboration

CCQCreating a Culture of

Quality

QuestionThe most important determinant(s) of a facility

at-risk:

a. Poor clinical quality outcomesb. Higher mortality ratesc. Clinical Manager openingd. Ineffective QAPI processese. Lack of Medical Director leadershipf. All of the aboveg. None of the above

3/16/2011 A renal community collaboration