Joel Elsenbroek

Christ ina Matzke

LeadingAge MI

Annual Conference

2014

TRANSFORMING QUALITY IMPROVEMENT

Section 6102(c) of the Affordable Care Act requires CMS to establish regulations in Quality Assurance and Performance Improvement (QAPI) and provide technical assistance to nursing homes to help them develop best practices to comply with the forthcoming regulations

QAPI is the coordinated application of two mutually -reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, comprehensive, and data -driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving.

QAPI

CMS – QAPI at a Glance

QA is the specification of standards for quality of service and outcomes, and a process throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards. QA is on-going, both anticipatory and retrospective in its efforts to identify how the organization is performing, including where and why facility performance is at risk or has failed to meet standards.

PI (also called Quality Improvement - QI) is the continuous study

and improvement of processes with the intent to better services or outcomes, and prevent or decrease the likelihood of problems, by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems or barriers to improvement. PI in nursing homes aims to improve processes involved in health care delivery and resident quality of life. PI can make good quality even better.

QAPI

CMS – QAPI at a Glance

As a result, QAPI amounts to much more than a provision in Federal statute or regulation; it represents an ongoing, organized method of doing business to achieve optimum results, involving all

levels of an organization.

QAPI

CMS – QAPI at a Glance

HHS/CMS RIN: 0938-AR61 Publication ID: Fall 2013

Title: Reform of Requirements for Long-Term Care Facilities and Quality Assurance and Performance Improvement (QAPI) Program (CMS-3260-P)

Abstract: This proposed rule would reform the Medicare conditions of participation for long-term care facilities to reflect significant changes in the industry and remove obsolete or unnecessary provisions. In addition, under the Affordable Care Act, this rule would propose to expand the level and scope of required QAPI activities to ensure that facilities continuously identify and correct quality deficiencies as well as promote and sustain performance improvement.

Agency: Department of Health and Human Services(HHS)

Priority: Other Significant

RIN Status: Previously published in the Unified Agenda

Agenda Stage of Rulemaking: Proposed Rule Stage

Major: Undetermined Unfunded Mandates: Undetermined

CFR Citation: 42 CFR 483

Legal Authority: PL 111-148, sec 6102; secs 1102, 11281 and 1871 Social Security Act

Legal Deadline: None

Timetable:

Action Date FR Cite

NPRM 03/00/2014

Additional Information: Includes Retrospective Review under E.O. 13563.

Regulatory Flexibility Analysis Required: Undetermined

Government Levels Affected: State

Small Entities Affected: Businesses

Federalism: No

Included in the Regulatory Plan: No

PROPOSED RULE - CMS

www.reginfo.gov

Why change if you don’t have to?

(1) A facility must maintain a quality assessment and assurance committee consisting of--

(i) The director of nursing services;

(ii) A physician designated by the facility; and

(ii) At least 3 other members of the facility’s staff.

Intent §483.75(o)

The intent of this regulation is to ensure the facility has an established quality assurance

committee in the facility which identifies and addresses quality issues, and implements

corrective action plans as necessary.

F520 §483.75(O) QUALITY ASSESSMENT AND ASSURANCE

(2) The quality assessment and assurance committee -- (i) Meets at least quarterly to identify issues with respect to which

quality assessment and assurance activities are necessary; and

(ii) Develops and implements appropriate plans of action to correct identified quality deficiencies.

(3) A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section.

(4) Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

F521

Members were leadership only Met monthly, but physician and

pharmacy couldn’t meet monthly

Set additional quarterly QA meeting to satisfy the regulation of participation. And another quarterly corporate QA meeting to f inish the circle to executive leadership and the Board of Directors – l imited feedback

Long meeting – reporting on everything. Litt le to no collaboration

Data was reported, but questionable if processes were actually addressed

Majority didn’t know why we were reporting on what we were reporting on

No one outside of the meeting knew what QA was

No root cause analysis Redundant Nothing really ever came off

the l ist Each staff member made up

their own tools and data collection

Lots of paper to be f i led Many, many sub committee’s

that were QA related, but not contributing to the reports made at QA

TRADITIONAL QA SHORT COMINGS

Felt like we were meeting a regulated standard – but not accomplishing anything.

T

IME

& E

NE

RG

Y

DR

AIN

ED

Recognize this traditional QA format isn’t functional, or meaningful to the organization

Started talking about QAPI concepts at leadership meetings; sparking interest in change, allowed people to start thinking about the what if ’s…

what if we had less to audit but more useful results?

what if the staff on the floor had a way to contribute?

what if we could combine some of our meetings for one purpose?

PATHWAY TO CHANGE

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey -and-Cert-Letter-13-05.pdf

Determine do we want to do/need to do/should do from this.

Like everything else, weed out the unnecessary parts.

Don’t overwhelm your team with things they don’t necessarily need to know.

Complete self assessment tool as a team.

Gather input to priorities

QAPI AT A GLANCE

Be sure your measurements are justified:

Do you have to track this?

Do you want to track this?

Should you track this?

What are you going to do with this information?

Not all things tracked need to be discussed…

DEVELOPMENT OF TOOLS

Tracking Tool – data driven, uniformed, accessible, easy to use

Reporting Tool – basic trends & accountability

Use the data reported in the QAPI meetings to identify Problems or Opportunities that require a PIP.

Assemble your PIP team

Format & track your progress

PIP Meeting protocols

Trouble Shooting

Case Studies

PERFORMANCE IMPROVEMENT PROJECT

Players Faci l itator Owner(s) Front l ine staff (HR/Leadership support)

Who picks the team? Direct Supervisor Faci l itator DON/Administrator

Who do you need on your team? Good ones Bad ones Team Players

PIP TEAM

Team Charter Ensure Compliance

Get Buy-in

Set Structure

FORMAT AND TRACK PIP PROGRESS

QAPI Performance Improvement Project

This charter team has been specifically selected to address an opportunity for improvement.

Being on this team is an important part of your job and requires that you actively engage and

contribute to the discussion. This team is required to provide written reports to the QAPI

steering committee detailing the following agenda:

Agenda Based on the Scientific Method

PDCA

Culture of Continuous Improvement

PLAN

Define the Problem (what, where, when, magnitude, trend)

SMART Goal (specific, measurable, assigned, realistic, time-bound)

Determine Measures/Data

Root Cause Analysis

Brainstorm Solutions/Experiments

FORMAT & TRACK PIP PROGRESS

Agenda

DO

Construct Hypothesis

Implement Solutions/Experiments

Gather Data

CHECK

Compare Data to Starting Condition/SMART Goal

Successful Yes or No?

Brainstorm Solutions/Experiments

Determine Measures/Data

FORMAT & TRACK PIP PROGRESS

Agenda

ACT

Continue. Spread, or Start Over

Standardize Work

Policies & Procedures

Control/Continuous Improvement

FORMAT & TRACK PIP PROGRESS

FORMAT & TRACK PIP PROGRESS

PIP Status Report Reported at monthly QAPI meetings

PIP Status Report

Subject/Date Problem Goal Report Status

Pre-Selct Menus

1/22

70% compliance on turning

in menus by 11 am Increase compliance to 95%

Everyone feels that fi l l ing

out menus with residents

has become standard

work.

Monthly Avg. 95.5% Next

meeting 2/13

Med Errors 1/30Reduce med errors on routine

passes

lower transcriptional errors to no more than 3 per

month

PCC upgrade coming in

FEB; reducing interuptions

6 transcriptional errors in

JAN; next meeting 2/19

Falls 1/21

Too many falls throughout

the facility on 2nd shift that

have the potential to harm

residents.

root cause analysis;

revising fall report form

still need to establish a goal;

next meeting 2/5

FORMAT & TRACK PIP PROGRESS

Performance Improvement Project

Project: Start Date:

Team Members:

Assess Problem:

SMART Goal:

Measurement: Baseline: Target:

Date Current Date Current Date Current

PIP Tracking Report (page 1) Used for notes in PIP meetings

FORMAT & TRACK PIP PROGRESS

Root Cause Analysis Findings:

Brainstorming Solutions/Experiments:

Experiment Results/Analysis:

Hypothesis:

Performance Improvement Project

Project: Start Date:

PIP Tracking Report (page 2) Used for notes in PIP meetings

PIP MEETING PROTOCOLS

Timing

Hold meetings between shifts

1 hour max

Frequency

Ideally every week

Realistically every two weeks

Atmosphere Closed Door Meeting

Confidential & Safe

Provide Snacks

Follow the Agenda! Facilitator should be a PDCA Purist

Don’t let your Team Rush the Process Let QAPI be the bad guy!

When the Pathway is Unclear When is doubt, use the QAPI forms http://cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/ProcessToolFramework.pdf

Lack of Commitment (I’m too busy!) Look for Champions

Team Dynamics (personalities clash) Must have a Facilitator

Loss of Momentum (we’re stuck!) Learn to be Comfortable with Discomfort

PIP TROUBLE SHOOTING

PIP TROUBLE SHOOTING

PIP TROUBLE SHOOTING

Pre-Select Menus

Problem:

Pre-select menus on all halls are not ready for pick up by 11 am. Lately, approximately 30% of them have not been ready, which results in loss time for dietary having to track them down, food-prep time is delayed, and food shortages occur during the next day’s lunch and supper.

(What, Where, When, Magnitude, Trend)

PIP CASE STUDIES

Pre-Select Menus

SMART Goal:

Achieve 95% compliance on having CNAs turn in pre-select menus by 11 am on all halls for 3 consecutive months.

(Specific, Measurable, Assigned, Realistic, Time -bound)

PIP CASE STUDIES

Pre-Select Menus

Determine Measurement/Data:

Dietary will track % turned in on-time daily, and compile monthly averages, reporting results at PIP meetings.

PIP CASE STUDIES

PIP CASE STUDIES

Pre-Select Menus

Root Cause Analysis:

CNA’s don’t have time to help residents fill them out because they are busy toileting, dressing, feeding

Call lights are top priority so menus get forgotten

Each hall is a little bit different so they require different solutions

Lakeshore has two breakfast times, 7:30 & 9 am, and all of the residents at 9 am require assistance

Not enough volunteers to chart/help out at mealtime

PIP CASE STUDIES

Pre-Select Menus

Brainstorm Solutions:

Put the menus on the breakfast trays when they are delivered

Assign the task to one volunteer

Have volunteers who chart/help out at breakfast do it

Involve family and have them help resident fil l them out a week in advance

Write “Refused” on the menu if the resident is unavailable (sleeping, not responding, doesn’t care)

Fill them out two days in advance (Ex: fi l l out Wed menu on Mon)

Have restorative aids assist residents in fil l ing out menus (Lakeshore)

Pass out menus first, and then pass out breakfast trays

PIP CASE STUDIES

Feb-14 97%

Jan-14 95%

Dec-13 97%

Nov-13 92%

Oct-13 94%

Sep-13 81%

Aug-13 86%

Measurement: track % turned in on-time daily,

and compile monthly averages

Baseline: 70% Target: 95%

Date Current Date Current Date Current

Performance Improvement Project

Project: Pre-Select Menus Start Date: 8/22/13

Team Members: Julie Schmuker, Amanda Krulek, Joel Elsenbroek, Kristen Contreras, Jessica VanBelkum, Amanda Walsh,

Bobbie J. Marzean, Chris TereloAssess Problem: Pre-select menus on all halls are not ready for pick up by 11 am. Lately, approximately 30% of them have not

been ready, which results in loss time for dietary having to track them down, food-prep time is delayed, and food shortages

occur during the next day’s lunch and supper.

SMART Goal: Achieve 95% compliance on having CNAs turn in pre-select menus by 11 am on all halls for 3 consecutive

months.

PIP CASE STUDIES

Experiment Results: Created standard work: 1. Grab the menu when you bring the tray 2. Fill out menu while feeding resident.

3. If the menu is still there when you go to pick up the tray, help them fill it out. 4. put menu back in clearly marked folder on

top of cart.

Analysis: daily compliance fluctuates but overall is up; staff awareness increased; pizza party planned for day when we first hit

95% compliance. Continue monitoring, Change dietary policy regarding pre-select menu choices and add standard work to

competencies.

Performance Improvement Project

Project: Pre-Select Menus Start Date: 8/22/13

Root Cause Analysis Findings: CNA’s don’t have time to help residents fill them out because they are busy toileting, dressing,

feeding

Call lights are top priority so menus get forgotten

Each hall is a little bit different so they require different solutions

Lakeshore has two breakfast times, 7:30 & 9 am, and all of the residents at 9 am require assistance

Not enough volunteers to chart/help out at mealtime

Brainstorming Solutions/Experiments: Put the menus on the breakfast trays when they are delivered

Assign the task to one volunteer

Have volunteers who chart/help out at breakfast do it

Involve family and have them help resident fill them out a week in advance

Write “Refused” on the menu if the resident is unavailable (sleeping, not responding, doesn’t care)

Fill them out two days in advance (Ex: fill out Wed menu on Mon)

Have restorative aids assist residents in filling out menus (Lakeshore)

Pass out menus first, and then pass out breakfast trays

Hypothesis: Compliance will improve if we can get everyone to do it the same way and it becomes a habit.

PIP CASE STUDIES

Pre-Select Menus

70%

75%

80%

85%

90%

95%

100%

Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14

% Compliance

Month

Pre-Select Menus Turned In

Goal: 95% Compliance

Fall Prevention

Problem:

Too many falls throughout the facility on 2nd shift with no or minimum injury, but could have the potential to harm residents.

(What, Where, When, Magnitude, Trend)

PIP CASE STUDIES

Fall Prevention

SMART Goal:

The Falls PIP team will create an effective falls investigation process (including standardized written form, online documentation, and staff training)by the end of May to capture 100% complete & accurate information on all investigations.

(Specific, Measurable, Assigned, Realistic, Time -bound)

PIP CASE STUDIES

Fall Prevention Determine Measurement/Data: Continue to track falls by: Number of Falls Frequent Fallers Shift Unit Classification (witnessed, un-witnessed, lowered to the

floor) Level of injury

PIP CASE STUDIES

PIP CASE STUDIES

Fall Prevention Root Cause Analysis: Toileting demands Resident anxiety/confusion Staff confusion on difference between witnessed and

lowered to the floor (inconsistent language in EMR and written reports)

Medication changes/side effects Infections (UTI & other) Lack of sleep cycle information (gathering & sharing) Changes in assistance level Inconsistent shift reports Incomplete incident report forms

PIP CASE STUDIES

Fall Prevention

Brainstorm Solutions:

Create shift hand-off report for high risk residents

Add hand-off report to daily team meetings

Standardize language in EMR and written report (Fall Witnessed, Fall Un-witnessed, Lowered to Floor)

Revise Falls Incident Reporting Form

Consultants

Physician

Exec’s

Board

Team Pip’s

Communication board

Non-pip sub-committee meetings; roaming

GET EVERYONE ON BOARD

Policy

Edit as you go

Create a culture of change – it’s okay to start and make adjustments as needed.

May need to help individuals with their tracking tool’s depending on their level of comfort with technology

Don’t need to spend any money to start

GIVE IT A WHIRL

QUESTIONS