Karyn P. Leible, RN, MD, CMD

Chief Medical Officer

Jewish Senior Life of Rochester, NY

Immediate Past President, AMDA

Quality Assurance and Process Improvement

Speaker Disclosures:

Dr. Leible has disclosed that she has no relevant financial relationships.

Learning Objectives:

By the end of the session, participants will be able to: 1) discuss the changes in nursing facility Quality

Assurance and Assessment (QA&A) as outlined in health care reform legislation

2) discuss tools and processes that are associated with best practices for quality assurance and process improvement

3) discuss the role of the facility medical director in the facility Quality Assurance Process Improvement program

Definitions

◦ Quality Assessment- is an evaluation of a process to determine if a defined standard of quality is being achieved.

◦ Quality Assurance- is the organizational structure, processes, and procedures designed to ensure that care practices are consistently applied

◦ Quality Improvement- (Process or Performance Improvement) is an ongoing interdisciplinary process that is designed to improve the delivery of services and resident outcomes.

Quality Assurance and Process Improvement

The Patient Protection and Affordable Care Act (ACA) Signed into law March 23, 2010

Many provisions for which CMS is responsible for implementing

Survey and Certification Group Section 6102

Establishment of standards relating to quality assurance and process improvement

Purpose of program is to strengthen current requirements and promote accountability for resident care

and safety by nursing facilities

Nursing Home QAPI: A Proactive Approach to Improving

Quality and Safety Transforming nursing homesthrough continuous attention toquality of care and quality of life

Quality Assurance and Performance Improvement (QAPI) Overview

Expands current regulations for QAA

Sets expectation for a sound, basic plan for QAPI that will support the systems of care and quality of life in every nursing home

A demonstration project is testing QAPI in 17 nursing homes, and preparing for national implementation

QAPI Nursing Home Demonstration

CMS contracted with University of Minnesota, with Stratis Health serving as a subcontractor, to develop the demo and early implementation strategies

CMS will support stakeholders, providers, consumer advocates, consumers, and surveyors through outreach and communication

Technical Expert Panel (TEP) is reviewing QAPI program materials

QAPI Nursing Home Demonstration

Two year demo began September 2011 Four states

- Florida - Massachusetts

- California - Minnesota Diversity of participating nursing homes Learning Collaborative based on IHI model Tools and resources being developed Extensive evaluation planned

Five Elements of QAPI

Design & Scope Governance & Leadership Feedback, Data Systems and

Monitoring Performance Improvement Projects

(PIPs) Systematic Analysis & Systemic

Action

5 Elements of QAPI

Design and Scope Comprehensive and ongoing plan Includes all departments and functions Addresses safety, quality of care, QOL, resident

choice, transitions Based on best available evidence QAPI plan

5 Elements of QAPI

Governance and Leadership Boards/owners and executive leadership

Buy in and support Training and organizational climate

Administration sees value Sufficient resources Sustainability

5 Elements of QAPI

Feedback, Data monitoring Systems, and Monitoring

Multiple sources, including resident and staff Benchmarking and targeting Adverse events

5 Elements of QAPI

Performance Improvement Projects Prioritized topics

Number of PIPs depend on the facility program Team Chartered PDSA Cycle

5 Elements of QAPI

Systematic Analysis and Systemic action Root cause analysis Systems thinking Systematic changes as needed

AMDA Position Paper

The Role of the medical director on the QA committee begins with an awareness of the current program in the facility. (March 2011)

Structure and process of the facility program Role of the IDT participants How issues are identified, addressed and

monitored

Case presentation

You are the medical director/ administrator/ director of nursing of a 100 bed facility just outside of Denver. During the facility QAA meeting it is brought to your attention that the facility use of antipsychotics is above the state average based on data just released from the CMS.

QAPI

The facility provided data through monitoring a potential problem is identified.

Next steps will be to evaluate if a true problem exists

look at root causes, analyze and interpret data and develop interventions.

Monitor and re-evaluate All part of an over all program to proactively

monitor facility processes of care in order to ensure the highest quality of care and quality of life

QAA Tools

Proprietary programs/ Corporate programs ABAQIS My InnerView

Facility reports Pressure ulcers Falls Accidents Infection Control

QI/QM data MDS derived

MDS 3.0 data

MDS 3.0

Opportunities to assess quality through the facility own data collection opportunities with 3.0

Assessments are done for OBRA Day 14 then quarterly Annual review Discharge

Assessments are done for PPS Days 5, 14, 30, 60, 90

Quality Measures

Short stay % of residents on a scheduled pain medication

regimen on admission who report a decrease in pain intensity or frequency

% of residents who self report moderate to severe pain

% of residents with pressure ulcers that are new or worsened

Quality Measures

Short stay % of residents assessed and given, appropriately,

the Seasonal Influenza vaccine % of residents assessed and given, appropriately,

the Pneumococcal Vaccine Long stay

% of residents assessed and given, appropriately, the Seasonal Influenza Vaccine

% of residents assessed and given, appropriately, the Pneumococcal Vaccine

Quality Measures

Long Stay % of residents experiencing one or more falls with

major injury % of residents who self report moderate to severe

pain % of high risk residents with pressure ulcers % of long stay residents with a urinary tract

infection % of long stay residents who lose control of

bowels and bladder

Quality Measures

Long Stay Residents who have/had a catheter inserted and

left in their bladder % of residents who were physically restrained % of residents who needed help with physical

activities has increased % of long stay residents who lose to much weight % of residents who have depressive symptoms

Quality Measures- Antipsychotics

June 2012 Public Reporting Short Stay Measure

Incidence of short stay residents that are given an antipsychotic medication after admission to the nursing home

Quality Measures- Antipsychotics

Long Stay Measure Percentage of long stay residents receiving an

antipsychotic who do not have a diagnosis of Tourette’s, Huntington's or Schizophrenia

Diagnosis of hallucinations, delusions or bipolar are no longer excluded

Reporting currently last quarters of 2011 and first 2 of 2012

Quality Measures-Antipsychotics

National average 23.9% (long stay) goal for 15% reduction would bring the national prevalence rate to 20.3%

MDS 3.0- Section N Medications

N0400. Medications Received.Check all medications the resident received at any time during the last 7 days or since admission/reentry if less than 7 days.

Antipsychotic.

Antianxiety.

Antidepressant.

Hypnotic.

Anticoagulant (warfarin, heparin, or low-molecular weight heparin).

Antibiotic.

Diuretic.

Z. None of the above were received.

MDS 3.0- Section I

In the past 7 days: Check all that apply Anxiety Disorder Depression (other than bipolar) Manic Depression (bipolar) Psychotic Disorder (other than

Schizophrenia) Schizophrenia (schizoaffective,

schizophreniform disorders) Post traumatic stress disorder

MDS 3.0

Potential areas for quality monitoring BIMS scores PHQ-9 scores Pain management Late loss ADL (toileting, eating, transfers, bed

mobility) Urinary incontinence Weight loss Prognosis (less than 6 months) Pressure ulcers

Quality Assurance and Assessment

Facility Reports Pressure ulcers Infection control Falls Antipsychotic use

Incidence

Number of new whateversAverage census x time

Average census x time = bed days of care

Assume stable census of 100 elder in month of September then BDOC= 3000

Multiply incidence by 1000 to get # per 1000 resident days

Incidence

In September Shady Pines had 5 facility acquired urinary tract infections. They had a stable census of 100 residents.

What is the incidence of facility acquired urinary tract infections?

Incidence

5_UTI X 1000 = 1.7

3000 (BDOC)

BDOC = 100 resident x 30 days

Prevalence

Prevalence is defined as the total number of cases of the disease in the population at a given time, or total number of cases in the population

Number of whatevers that exist

number at risk

Prevalence

Shady Pines has 4 residents with pressure ulcers. Non of the ulcers are new. What is the prevalence of pressure ulcers in the facility?

Prevalence

4 elders with pressure ulcers X 100

100 elders at risk

.04 X 100 = 4 %

Consider unit of measure

number of ulcers versus number of elders with ulcers

Prevalence

Sunny Acres has 100 long stay residents. 25 of those residents are receiving an antipsychotic. 2 residents are schizophrenic and one resident is bipolar. What is the prevalence of antipsychotic use in the facility?

What is the incidence?

Prevalence

23 residents are on antipsychotics without dx

100 long stay residents

.23 X 100 = 23 %

Incidence cannot be determined with the information given.

Run Charts

Control Chart

41

View a process over time

Give a visual description of what the process has done and is doing

If the process is in control, (random normal variation or random walk), you can predict how the process will perform over time

42

Example Facility Weight Loss > 5 lbs and Below IBW

10%

14%

18%

22%

26%

30%

34%

Mean

UCL

LCL

Control Chart

Process Improvement Projects

Performance Improvement Project (PIP) team to address a question

Involve staff working closest to the residents whenever possible

PIP team meets identifies potential root case Develops action plan/intervention Monitors and reports back to QAA

Root Cause: 5 Whys

Why is the resident screaming in her room? When she is in the dining room she was trying to

strike out at other residents Why is she trying to strike out at other residents?

She is fearful that someone is trying to take her food Why is she fearful that someone is trying to take

her food? The doctor cut back on her risperdone dose 2 days

ago

Root Cause: 5 Whys

Why is cutting back on the risperdone dose important?

She is more alert at meals and is afraid that someone is taking her food

Why is she afraid someone is taking her food?

She grew up in Germany at the end of world war 2 and Russian soldiers used to come through the village she lived in and steal food

facilityresidents

Policies and proceduresStaff

6 social workers for 362 residents

Independent consultant pharmacist

No monitoring of which residents are on meds

No GDR process

Multiple units all function independently

Geriatric nurse practitioner and psychiatrist round weekly

“Our patients are different”

Secured unit for dementia

Employed physician model

Interventions

Meet with attending physicians Identify barriers to GDR Monthly review of residents on antipsychotics and

GDR Meet with facility psychiatrist and geriatric

psych ANP Require nursing have MD consult request

Meet with pharmacy consultant Request monthly reports regarding psychoactive

medication usage

Interventions

Meet with Director of Nursing Identify potential barriers Address staff education opportunities

Meet with facility administrator Identify barriers Identify potential opportunities

Review of current policies and revise as indicated

Prevalence of Antipsychotic Use: Jan-Oct 2012

1 2 3 4 5 6 7 8 9 100

5

10

15

20

25

30

35

40

45

Series 1

Quality Improvement Process

Three fundamental questions What are we trying to accomplish?

Reduce inappropriate medication use Improve dementia care

How will we know that change is an improvement? There will be an appropriate reduction in medications There will not be an increase in incidents

What changes can we make that will result in improvement?

The Model for Continuous Improvement - PDCA

START

Plan

Do

Check

Act

QAA Meetings

Agenda Reports prepared in advance

Process Improvement Reports Facility reports

Manage the time of the meeting

QAPI Resource Library & Tools

Web-based Resource Library• Content-rich• User-friendly• Supports diversity of target audiences

Provides Consumers Regulators

• Easy links to tools and resources - relevant to nursing home QAPI

National Rollout: Timeline

By statute, nursing homes will be expected to have QAPI programs in place that meet a defined standard, one year after CMS issues a QAPI rule. CMS expects to issue a draft regulation for comment in 2012. A final rule is likely to be issued by the end of 2012 or early 2013.

QUESTIONS?