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Health Services Advisory Group, Inc. –1– How Sharing Best Practices Inspires Innovation Jo Ann Bukovinsky, RN, MBA, LCHRM, RACCT Quality Improvement Specialist, HSAG Gazelle Zeya, MS, MBA, RACCT Quality Improvement Specialist, HSAG July 1, 2015 Objectives Review the Centers for Medicare & Medicaid Services (CMS) national initiatives related to the Quality Improvement Program Understand the aims and benefits of joining the National Nursing Home Quality Care Collaborative (NNHQCC) in Florida Provide an overview of Quality Assurance and Performance Improvement (QAPI) Discuss the next steps 7/1/2015 2 Health Services Advisory Group (HSAG) 3

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Health Services Advisory Group, Inc.–1–

How Sharing Best Practices Inspires Innovation

Jo Ann Bukovinsky, RN, MBA, LCHRM, RAC‐CT

Quality Improvement Specialist, HSAG

Gazelle Zeya, MS, MBA, RAC‐CT

Quality Improvement Specialist, HSAG

July 1, 2015

Objectives

• Review the Centers for Medicare & MedicaidServices (CMS) national initiatives related tothe Quality Improvement Program

• Understand the aims and benefits of joiningthe National Nursing Home Quality CareCollaborative (NNHQCC) in Florida

• Provide an overview of  Quality Assurance andPerformance Improvement (QAPI)

• Discuss the next steps

7/1/20152

Health Services Advisory Group (HSAG) 

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About HSAG

• Committed to improving the quality of healthcarefor more than 35 years

• Provides quality expertise to those who deliver careand those who receive care

• Engages healthcare providers, stakeholders,Medicare beneficiaries, families, and caregivers

• Provides technical assistance, convenes learning andaction networks (LANs), and analyzes data for improvement

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The Quality Improvement Organization (QIO) Program

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QIO Program

• Funded by the CMS, the QIO program is the largest federalprogram dedicated to: – Improving individual patient care

– Improving health forpopulations and communities

– Integrating care forpopulations and communities

– Delivering beneficiary‐ andfamily‐centered care 

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QIO Program

• Brings together hospitals, nursing homes (NHs),physician, practices, and patient advocates– Quickens the pace and broadens the spread ofpositive change in health quality

• Medical case review• Supports national priorities

– Department of Health and Human Services’ NationalQuality Strategy

– CMS Quality Strategy– Partnership for Patients– Partnership to Improve Dementia Care– Advancing Excellence (AE) in America’s Nursing Home

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National Quality Initiative Crosswalk

NNHQCCPartnership   

to Improve  Dementia Care

AE in America’s Nursing Homes

American Health Care Association (AHCA)Quality Initiative

Antipsychotic Use

Consistent Assignments

Customer Satisfaction

Falls (Subsumed in AE resident mobility goals¹) 1

Healthcare ‐ssociated Infections (HAIs): CAUTI, MRSA, CDI

Hospital Readmissions

Pain

Person‐Centered Care/Planning and Decision Making

Pressure Ulcers

Resident Mobility

Physical Restraints

Staff Retention/Stability/Turnover

Influenza Vaccine

Target Setting

QAPI* 2

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* (All AE tools & materials have been created with the goal of meeting QAPI process requirements2)

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10 Scope of Work (SOW) QIO Program Success

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10 SOW Program Success

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QIO Program Changes

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QIO Program Changes

• Effective August 1, 2014, CMS separated medicalcase review from quality improvement workcreating two separate structures:– Medical case review now performed by Beneficiary & Family Centered Care‐Quality Improvement Organizations (BFCC‐QIOs) 2 BFCC‐QIOs (KePRO and Livanta) reorganized to cover the Nation

– Quality improvement and technical assistance nowperformed by Quality Innovation Network‐Quality Improvement Organizations (QIN‐QIOs) 14 regional QIN‐QIOs each covering 2–6 states 

• QIO contract cycle extended from 3 to 5 years

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HSAG: QIN‐QIO

• HSAG awarded new QIN‐QIO contract for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands

– Contract: August 1, 2014–July 31, 2019

– Serves nearly 25 percent of the nation’s Medicarebeneficiaries

– Previous state‐based QIO contracts held by:

Arizona: HSAG

California: HSAG of California

Florida: FMQAI (HSAG owned since 2003)

Ohio: KePRO

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11 SOW QIN‐QIO Map

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QIN‐QIO Framework

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Better Healthcare for Communities

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Reducing Healthcare‐Acquired Conditions (HACs) in NHs

Aligned with theNursing Home Action Plan:

Include residents and families inpeer-coaching groups

Support adoption of QAPI framework for quality improvement

Focus on systems issues that affectquality (e.g., consistent staffassignments) as well as specific issues such as increasing mobility

Reduce avoidable hospitalizations

Decrease HAIs

Recruit at least 75% of all nursing homes (512 in Florida) into

the NNHQCC

CMS emphasis on recruiting

“One-Star” NHsRecruit high

performing NHs (NHs in the top 10% of the

state with their Composite Score) as

“Peer Coaches”

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Recruitment for the NNHQCC

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NNHQCC in Florida

Collaborative I:

– Recruitment: 

October 2014–March 2015

– Learning and Action Network: April 2015–September 2016

Collaborative II: 

– Recruitment: 

October 2016–March 2017

– Learning and Action Network: April 2017–September 2018

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NNHQCC Aims

• Reduce HACs in NHs

– Support NNHQCC initiatives

– Achieve score of 6.0 or lower on the Nursing HomeQuality Composite Measure by January 2019

– Improve rates of mobility among long‐stay NHresidents

– Reduce use of unnecessary antipsychoticmedications in residents with dementia

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NNHQCC Aims

What are we trying to accomplish?

– Peer Coaches serving as mentors

– Residents/family involved in LANs and quality improvement

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Benefits From Participating in the NNHQCC

Through the five‐year NNHQCC NHs will receive: • Expert assistance to improve the 13 long‐stay quality 

measures, which comprise the CMS Nursing Home Composite Score

• Training on how to implement QAPI• Tools and principles to improve resident care• Opportunities to share successful practices to improve clinical

systems in the NH setting• Continuing education credits during LAN meetings• Opportunities to network and build meaningful relationships

with peers, key stakeholders, partner organizations, and nationally recognized experts in long‐term care

• Assistance with the Advancing Excellence in America’s NursingHome Campaign

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Learning and Action Networks

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LAN Objectives

• Focus on improving quality of care• Enhance consumer engagement• Support innovation and sharing of successfulpractices and strategies

• Convene stakeholders, providers, andimprovement experts in an “all teach, all learn”model

• Provide educational webinars and conferences,peer‐sharing, rapid testing of change ideasthrough the Plan‐Do‐Study‐Act (PDSA) cycle, andsupport for adopting and spreading successfulimprovements

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Measuring Success of the NNHQCC

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The Quality Measure Composite Score

The quality measure composite  score is comprised of 13 National Quality Forum (NQF) endorsed, long‐stay quality measures that represent larger systems within the long‐term care setting: 

1. Percent of residents with one or more falls with major injury 

2. Percent of residents with a urinary tract infection (UTI)

3. Percent of residents who self‐report moderate to severe pain 

4. Percent of high‐risk residents with pressure ulcers 

5. Percent of low‐risk residents with loss of bowels or bladder

6. Percent of residents with catheter inserted or left in bladder

7. Percent of residents who are physically restrained 

8. Percent of residents whose need for help with activities of daily living (ADL) has increased 

9. Percent of residents who lose too much weight 

10. Percent of residents who have depressive symptoms 

11. Percent of residents who received antipsychotic medications

12. Percent of residents assessed and appropriately given flu vaccine*

13. Percent of residents assessed and appropriately given pneumococcal vaccine**The direction of the two vaccination measures should be reversed because they are directionally opposite of the other measures. This is done by subtracting the numerator from the denominator to obtain a “new” numerator.

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Calculating the Quality Measure Composite Score

The composite score is calculated using a methodology based on the opportunity model. 

– Denominator represents the number ofopportunities to provide or reflect high quality care

– Numerator represents the number of times anopportunity was missed

Formula for Composite Score:

Numerator (# of missed opportunities) X 100 = Composite Score     Denominator (# of opportunities) 

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Calculating the Quality Measure Composite Using Real Data

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How is Florida Doing?

NNHQCC  QUALITY MEASURE COMPOSITE SCORE  Q2 2014    *Data Source: QIN‐QIO National Coordinating Center (NCC)

Num Den Rate

Percent of residents with one or more falls with major injury 1,499 57,485 2.61

Percent of residents with urinary tract infection (UTI) 3,312 56,493 5.86

Percent of residents who self‐report moderate to severe pain 2,828 41,033 6.89

Percent of high‐risk residents with pressure ulcers  2,651 43,427 6.10

Percent of  low‐risk residents with loss of bowels or bladder 10,433 21,278 49.03

Percent of residents with catheter inserted or left in bladder 1,929 54,308 3.55

Percent of residents physically who are  physically restrained 868 57,473 1.51

Percent of residents whose need for help with ADL has increased 6,179 45,120 13.69

Percent of residents who lose too much weight 4,184 56,195 7.45

Percent of residents who have depressive symptoms 1,174 53,117 2.21

Percent of residents who received antipsychotic medications 11,761 54,277 21.67

Residents assessed and appropriately given flu vaccine (*reversed) 3,261 57,011 6.07

Residents assessed and appropriately given pneumococcal vaccine (*reversed) 3,103 57,487 5.40

Overall Composite Score 53,182 654,704 8.12

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Quality Assurance and Performance Improvement 

(QAPI)

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Purpose of QAPI

• To provide person‐centered care – to focus onthe person living in the NH

• To enhance each NH’s systems and processesof assessing their quality of care and services

• Continually correct defects and improveperformance outcomes

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Background

• The QAPI program in NHs is required by theAffordable Care Act; enacted in March 2010

• Legislation requires CMS to establish QAPIprogram standards and provide technicalassistance to NHs

• QAPI is currently being written into theregulations to replace Quality Assurance (QA)

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Background

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Model for Improvement

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Sources: Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey‐Bass Publishers; 2009.

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NNHQCC Tools for QAPI Implementation 

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QAPI at a Glance• Step‐by‐step guide to implementing QAPI,

including the steps to write a written QAPI plan• Excellent problem solving models (e.g., root cause 

analysis) outlined in this resource

Change Package• Menu of strategies, change concepts, and 

actionable items that will be helpful in finding solutions to challenge areas

• Refer to document during QAPI PIP meetings when trying to problem solve and/or look for ideas

Both documents may be found here: CMS QAPI Webpage: http://go.cms.gov/Nhqapi  

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What is QAPI?

QUALITY ASSURANCE PERFORMANCE IMPROVEMENT

Focus Assure standards are consistently met Improve processes and systems; continually “raise the bar” on performance

Outlook Retrospective review and correction Proactive: identify processes or systems for improvement, then test, make, and measure changes 

GoalTo meet minimum standards, reduce variation, and reduce errors 

To exceed expectations and produce excellent outcomes

ResponsibilityAll, whenever there is a need to meet internal or external standards

All, interdisciplinary team (IDT)

MotivationTo get it “right;” often required by state and federal law

Continuous activity

FrequencyRegularly, in conjunction with goods of service delivery, or process implementation 

Continuous activity 

Begins withUnderstanding standards and examining  goods, services, or processes

Proactively selecting a process or system to measure and improve after collecting data

QA + PI = QAPI (Quality Assurance and Performance Improvement)

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The Five Elements of QAPI

Quality of Care, Quality of Life, Resident Choice

1. Design andScope

1. Design andScope

2. Governanceand Leadership2. Governanceand Leadership

3. Feedback,Data,

Monitoring

3. Feedback,Data,

Monitoring

4. Performance Improvement

Projects 

4. Performance Improvement

Projects 

5. Systematic Analysis and System Action

5. Systematic Analysis and System Action

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The Five Elements of QAPI

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Design and ScopeGovernance and 

Leadership

Feedback, Data Systems, and Monitoring

Performance ImprovementProjects (PIPs)

Systematic Analysis and 

Systemic Action

• Addresses clinicalcare, quality of life,resident choice,and care transitions

• Utilize best evidence to defineand measure goals

• Led byadministration

• Input from staff,residents, and family

• Setting expectationsaround resident safety, quality,rights, choice, andrespect

• Create anatmosphere wherestaff are comfortableidentifying andreporting qualityproblems as well as opportunities for improvement

• Systems to monitor care andservices

• Draws data frommultiple sources

• Facilitybenchmarks andperformance goals

• Conduct a PIP toexamine andimprove care or services in areas that the facilityidentifies as needing attention

• Use a systematic approach todetermine when anin‐depth analysis is needed

• Understand theproblem, causes,and implications ofchange

• Conduct a Root Cause Analysis (RCA)

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The QAPI Process

• Identify areas for improvement using data

• Prioritize

• Form a QAPI team

• Analyze data and set goals

• Analyze current process

• Complete RCA

• Develop and implement QI

• Monitor the QI plan to sustain theimprovement

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Example QAPI in Action: Reduction of the Use of Antipsychotic Medication 

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Performance Improvement Projects (PIPs)

Include:

• Data review (MDS 3.0 CASPER Reports)

• Specific, measureable, attainable, relevant,timely (SMART) Goals

• RCA

• Plan of Action

• PDSA Cycles

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SMART  Goal Example

Decrease the long‐stay antipsychotic quality measure rate at Golden Acres, with a concentration on the Memory Care Unit (MCU), from the baseline rate (Q3–Q4 2012) of 35.4 percent to the (Q3–Q4 2013) re‐measurement rate of 25.0 percent, based on the MDS 3.0 CASPER Reports. 

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Root Cause Analysis (RCA)

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Golden Acres has a 35.4 percent long‐stay antipsychotic quality‐measure rate, compared to the state (FL) average of 22.7 percent.

Root Cause Analysis: The Five Whys Method

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TaskResponsible 

PartyGoal Date

Completed Date

Visit a local best‐practice nursing home specializing in dementia care.

MCU Director 8/6/14 8/6/14

Implement bio sketches during advanced‐care‐plan meetings.

MCU Director 8/15/14 8/16/14

Train MCU staff members on “needs‐driven expressions.”

MCU Director 9/30/14 In progress.

Create “life stations” on MCU. Activities Director

10/15/14 In progress.

Plan  of Action 

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Task Responsible PartyGoal Date

Completed Date

Medical Director will educate all practitioners of the facility on FDAblack‐box warnings regarding antipsychotic medication use.

Medical Director,Director of Nursing (DON), MCU Director

8/30/14 8/23/14

All physician order requests for antipsychotic medications are reviewed by the DON prior to presenting to the attending physician.

DONMCU Director

8/6/14 8/6/14

All physician orders, new admission charts, incident reports and 24‐hour reports are reviewed by the IDT daily.

DONIDT Members

8/6/14 8/6/14

Plan of Action 

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What change can we make that will result in an improvement?

What are we trying to accomplish?

How will we know that change is an improvement?

PDSA Model for Improvement

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PDSA

• Plan– SMART Goal Setting, RCA, create a Plan of Action

• Do– Implement Plan of Action items

• Study– Measure results via MDS CASPER 3.0 Reports, medication administration records (MARs), 24‐hour reports, and incident reports 

• Act– Spread the results through peer‐to‐peer sharing

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QAPI: The Big Picture

• The ultimate goal is toprovide person‐centered care

• QAPI does not refer to aprogram; rather, this is a waywe do our work

• The ability to think, makedecisions and take action atthe system level is aprerequisite for QAPI success

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Next Steps

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Closing in Action

Complete the Participation Agreement and return to HSAGas soon as possible• Go to:  www.hsag.com/nhjoin to view the Participation 

Agreement and to obtain information about joining the NNHQCC

Form your interdisciplinary QAPI Team Initiate and annually update the QAPI Self‐Assessment Tool Set your aims in topic specific NNHQCC quality projects 

such as:• Improving quality measure composite scores• Reducing the use of antipsychotic medications in residents with 

dementia• Improving mobility• Reducing avoidable hospitalizations

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Closing in Action (cont.)

Utilize the Change Package to select a strategy and change concept based on your organization’s priorities

Implement small tests of change

Share your QAPI Self‐Assessment results and/orsuccessful practices at our LAN events!

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QAPI Resources

• Advancing Excellence in America’s Nursing Homes: www.nhqualitycampaign.org

• CMS QAPI Web site:http://go.cms.gov/Nhqapi

• Health Services Advisory Group (HSAG) http://hsag.com• INTERACT (Interventions to Reduce Acute Care Transfers) Version 

4.0: https://www.interact2.net• Institute for Healthcare Improvement www.ihi.org• Agency for Healthcare Research and Quality www.ahrq.gov• Pioneer Network www.pioneernetwork.net• QAPI Process Tool Framework: http://qio.ipro.org/wp‐

content/uploads/2013/03/QAPI‐ProcessToolFramework.pdf• The Institute for Health Care Improvement’s Model for 

Improvement: www.ihi.org/resources/Pages/HowtoImprove/default.aspx

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QAPI Process Tool Framework

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QAPI Resources

http://qioprogram.orghttp://hsag.com

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Thank you!Contact Information

Jo Ann Bukovinsky, RN, MBA, LCHRM, RAC‐CT

Quality Improvement Specialist, HSAG

813.865.3196 | [email protected]

Gazelle Zeya, MS, MBA, RAC‐CT

Quality Improvement Specialist, HSAG

813.865.3188 | [email protected]

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This material was prepared by Health Services Advisory Group, Inc., the Medicare Quality Improvement Organization for Florida, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. FL‐11SOW‐C.2‐04302015‐01