Quality Assurance Meeting quality standards Assuring that care
reaches an acceptable level A reactive, retrospective effort WHAT
IS QAPI? 4 Performance Improvement A pro-active and continuous
study of processes The intent to prevent or decrease the likelihood
of problems By identifying areas of opportunity and testing new
approaches to fix underlying causes of persistent/ systemic
problems
Slide 5
QAPI 5 QUALITY ASSURANCE PERFORMANCE IMPROVEMENT Motivation
Measuring compliance with standards Continuously improving
processes to meet standards Means InspectionPrevention Attitude
Required, reactiveChosen, proactive Focus Outliers: bad apples
Individuals Processes, systems Scope ProviderResident care
Responsibility FewAll
Slide 6
THE FEDERAL GOVERNMENT CARES 6
Slide 7
Section 6102(c) of the Affordable Care Act Nursing homes
Requires CMS to establish regulations in Quality Assurance and
Performance Improvement (QAPI) Requires CMS to provide technical
assistance to help them develop best practices to comply with the
forthcoming regulations HEALTH CARE REFORM 7
Slide 8
Not just for nursing homes Our industry is growing up Solve
quality problems Prevent recurrence Achieve new goals Fulfillment
for caregivers Better care and quality of life WHY IS QAPI
IMPORTANT? 8
Slide 9
Major investors, particularly REITs care about quality Health
Care REIT HCP LTC Properties INVESTORS CARE 9
Slide 10
Using data to not only identify your quality problems, but to
also identify other opportunities for improvement, and then setting
priorities for action Building on residents own goals for health,
quality of life, and daily activities Bringing meaningful resident
and family voices into setting goals and evaluating progress
Incorporating caregivers broadly in a shared QAPI mission FEATURES
OF QAPI 10
Slide 11
Developing Performance Improvement Project (PIP) teams with
specific charters Performing a Root Cause Analysis to get to the
heart of the reason for a problem Undertaking systemic change to
eliminate problems at the source Developing a feedback and
monitoring system to sustain continuous improvement FEATURES OF
QAPI 11
Slide 12
Group Project! Whispering Pines has had a problem with staff
turnover. The administrator, Mary, feels like she just cant seem to
keep good staff. But she wanted to see how she measures up to the
rest of the industry as well as other communities in her area. So
Mary started tracking turnover on a monthly basis. CASE STUDY
12
Slide 13
Group Project! 13
Slide 14
Group Project! How could tracking turnover help reduce it? What
factors should be considered when preparing to track turnover? Who
should the data be shared with? CASE STUDY 14
Slide 15
NCAL QUALITY INITIATIVE 15
Slide 16
NCAL QUALITY INITIATIVE 16
Slide 17
Five Elements of QAPI 17
Slide 18
FIVE ELEMENTS OF QAPI 18
Slide 19
Must be ongoing and comprehensive Deal with the full range of
services offered by the community, including the full range of
departments Should address all systems of care and management
practices, and should always include care, quality of life, and
resident choice. Utilize the best available evidence to define and
measure goals 1: DESIGN AND SCOPE 19
Slide 20
Administration develops a culture that involves leadership
seeking input from community staff, residents, and their families
and/or representatives Assure adequate resources exist to conduct
QAPI efforts Develop policies to sustain QAPI despite changes in
personnel and turnover Ensure staff accountability, while creating
an atmosphere where staff are comfortable identifying and reporting
quality problems as well as opportunities for improvement 2:
GOVERNANCE AND LEADERSHIP 20
Slide 21
Put in place systems to monitor care and services, drawing data
from multiple sources Actively incorporate input from staff,
residents, families, and others as appropriate Includes using
Performance Indicators Includes tracking, investigating, and
monitoring Adverse Events 3: FEEDBACK, DATA SYSTEMS, AND MONITORING
21
Slide 22
A concentrated effort on a particular problem in one area of
the community or community wide Gathering information
systematically to clarify issues or problems, and intervening for
improvements Examine and improve care or services in areas that the
community identifies as needing attention 4: PERFORMANCE
IMPROVEMENT PROJECTS 22
Slide 23
Use a systematic approach to determine when in- depth analysis
is needed to fully understand the problem, its causes, and
implications of a change Root Cause Analysis Includes a focus on
continual learning and continuous improvement 5: SYSTEMATIC
ANALYSIS AND ACTION 23
Slide 24
Group Project! Off-label use of antipsychotics Reduce by 15%
Decreases side affects and adverse drug reactions Used as a weapon
by trial attorneys Improved resident and family satisfaction QAPI
IN ACTION 24
Slide 25
Group Project! QAPI IN ACTION 25
Slide 26
Action Steps 26
Slide 27
1. Leadership 2. Teamwork 3. Self-Assessment 4. Guiding
Principles 5. Develop Your Plan 6. Awareness Campaign 7. Data
Collection Strategy ACTION STEPS 27 8. Gaps and Opportunities 9.
Prioritize 10. PIPs 11. Get to the Root of the Problem 12. Take
Systemic Action
Slide 28
1. Leadership 2. Teamwork 3. Self-Assessment 4. Guiding
Principles 5. Develop Your Plan 6. Awareness Campaign 7. Data
Collection Strategy ACTION STEPS 28 8. Gaps and Opportunities 9.
Prioritize 10. PIPs 11. Get to the Root of the Problem 12. Take
Systemic Action
Slide 29
1. Leadership 2. Teamwork 3. Self-Assessment 4. Guiding
Principles 5. Develop Your Plan 6. Awareness Campaign 7. Data
Collection Strategy ACTION STEPS 29 8. Gaps and Opportunities 9.
Prioritize 10. PIPs 11. Get to the Root of the Problem 12. Take
Systemic Action
Slide 30
1. Leadership 2. Teamwork 3. Self-Assessment 4. Guiding
Principles 5. Develop Your Plan 6. Awareness Campaign 7. Data
Collection Strategy ACTION STEPS 30 8. Gaps and Opportunities 9.
Prioritize 10. PIPs 11. Get to the Root of the Problem 12. Take
Systemic Action
Slide 31
1. Leadership 2. Teamwork 3. Self-Assessment 4. Guiding
Principles 5. Develop Your Plan 6. Awareness Campaign 7. Data
Collection Strategy ACTION STEPS 31 8. Gaps and Opportunities 9.
Prioritize 10. PIPs 11. Get to the Root of the Problem 12. Take
Systemic Action
Slide 32
1. Leadership 2. Teamwork 3. Self-Assessment 4. Guiding
Principles 5. Develop Your Plan 6. Awareness Campaign 7. Data
Collection Strategy ACTION STEPS 32 8. Gaps and Opportunities 9.
Prioritize 10. PIPs 11. Get to the Root of the Problem 12. Take
Systemic Action
Slide 33
1. Leadership 2. Teamwork 3. Self-Assessment 4. Guiding
Principles 5. Develop Your Plan 6. Awareness Campaign 7. Data
Collection Strategy ACTION STEPS 33 8. Gaps and Opportunities 9.
Prioritize 10. PIPs 11. Get to the Root of the Problem 12. Take
Systemic Action
Slide 34
1. Leadership 2. Teamwork 3. Self-Assessment 4. Guiding
Principles 5. Develop Your Plan 6. Awareness Campaign 7. Data
Collection Strategy ACTION STEPS 34 8. Gaps and Opportunities 9.
Prioritize 10. PIPs 11. Get to the Root of the Problem 12. Take
Systemic Action
Slide 35
1. Leadership 2. Teamwork 3. Self-Assessment 4. Guiding
Principles 5. Develop Your Plan 6. Awareness Campaign 7. Data
Collection Strategy ACTION STEPS 35 8. Gaps and Opportunities 9.
Prioritize 10. PIPs 11. Get to the Root of the Problem 12. Take
Systemic Action
Slide 36
1. Leadership 2. Teamwork 3. Self-Assessment 4. Guiding
Principles 5. Develop Your Plan 6. Awareness Campaign 7. Data
Collection Strategy ACTION STEPS 36 8. Gaps and Opportunities 9.
Prioritize 10. PIPs 11. Get to the Root of the Problem 12. Take
Systemic Action
Slide 37
1. Leadership 2. Teamwork 3. Self-Assessment 4. Guiding
Principles 5. Develop Your Plan 6. Awareness Campaign 7. Data
Collection Strategy ACTION STEPS 37 8. Gaps and Opportunities 9.
Prioritize 10. PIPs 11. Get to the Root of the Problem 12. Take
Systemic Action
Slide 38
1. Leadership 2. Teamwork 3. Self-Assessment 4. Guiding
Principles 5. Develop Your Plan 6. Awareness Campaign 7. Data
Collection Strategy ACTION STEPS 38 8. Gaps and Opportunities 9.
Prioritize 10. PIPs 11. Get to the Root of the Problem 12. Take
Systemic Action
Slide 39
Leadership Responsibility and Accountability 39
Slide 40
Create a culture to support QAPI Develop a steering committee
Provide resources Set the tone LEADERSHIP RESPONSIBILITY 40
Slide 41
It starts with leadership Support from the top is essential
Foster participation from every member of the team, including all
caregivers CREATING A CULTURE TO SUPPORT QAPI 41
Slide 42
Group Project! Discuss in small groups Identify 5 potential
barriers to a culture that is supportive of QAPI and 2-3 ways to
overcome those barriers Be prepared to share at least one
barrier/solutions with the group CREATING THE CULTURE 42
Slide 43
A team that provides QAPI leadership Overall responsibility to
develop and modify the play, review information, and set priorities
Involve clinical expertise, when possible Who would be on your
steering committee? DEVELOP A STEERING COMMITTEE 43
Slide 44
Caregivers will need time to attend team meetings during work
hours Equipment (computers, poster supplies, resource books, etc.)
Specialized training PROVIDE RESOURCES 44
Slide 45
Open door policy Staff feel they can bring quality concerns
forward without fear of punishment Create expectations Everyone
should feel free to speak up Expect and build effective team work
OPEN COMMUNICATION AND RESPECT 45
Slide 46
A Deliberate Approach to Teamwork 46
Slide 47
Having a clear purpose Having defined roles for each team
member to play Having commitment to active engagement from each
member CHARACTERISTICS OF AN EFFECTIVE TEAM 47
Slide 48
Caregivers Administration/leadership Outside vendors (pharmacy,
home health, etc.) Family members (watch for confidentiality issues
TEAMS SHOULD BE INTERDISCIPLINARY 48
Slide 49
Self-Assessment 49
Slide 50
Group Project! SELF-ASSESSMENT 50
Slide 51
Guiding Principles 51
Slide 52
Step 1: Locate or develop vision statement Step 2: Locate or
develop mission statement Step 3: Develop a purpose statement for
QAPI Step 4: Establish Guiding Principles Step 5: Define the scope
of QAPI Step 6: Assemble document DEVELOP PURPOSE, GUIDING
PRINCIPLES, AND SCOPE 52
Slide 53
Step 1: Locate or develop vision statement Step 2: Locate or
develop mission statement Step 3: Develop a purpose statement for
QAPI Step 4: Establish Guiding Principles Step 5: Define the scope
of QAPI Step 6: Assemble document DEVELOP PURPOSE, GUIDING
PRINCIPLES, AND SCOPE 53
Slide 54
Step 1: Locate or develop vision statement Step 2: Locate or
develop mission statement Step 3: Develop a purpose statement for
QAPI Step 4: Establish Guiding Principles Step 5: Define the scope
of QAPI Step 6: Assemble document DEVELOP PURPOSE, GUIDING
PRINCIPLES, AND SCOPE 54
Slide 55
Step 1: Locate or develop vision statement Step 2: Locate or
develop mission statement Step 3: Develop a purpose statement for
QAPI Step 4: Establish Guiding Principles Step 5: Define the scope
of QAPI Step 6: Assemble document DEVELOP PURPOSE, GUIDING
PRINCIPLES, AND SCOPE 55
Slide 56
QAPI has a prominent role in our management and Board
functions, on par with monitoring reimbursement and maximizing
revenue. Our organization uses quality assurance and performance
improvement to make decisions and guide our day-to-day operations.
The outcome of QAPI in our organization is the quality of care and
the quality of life of our residents. In our organization, QAPI
includes all employees, all departments and all services provided.
EXAMPLES 56
Slide 57
Step 1: Locate or develop vision statement Step 2: Locate or
develop mission statement Step 3: Develop a purpose statement for
QAPI Step 4: Establish Guiding Principles Step 5: Define the scope
of QAPI Step 6: Assemble document DEVELOP PURPOSE, GUIDING
PRINCIPLES, AND SCOPE 57
Slide 58
Step 1: Locate or develop vision statement Step 2: Locate or
develop mission statement Step 3: Develop a purpose statement for
QAPI Step 4: Establish Guiding Principles Step 5: Define the scope
of QAPI Step 6: Assemble document DEVELOP PURPOSE, GUIDING
PRINCIPLES, AND SCOPE 58
Slide 59
Develop Your QAPI Plan 59
Slide 60
Group Project! Break into groups Each group will be assigned to
complete one section of the QAPI plan from the handout provided Be
prepared to share with the group DEVELOP YOUR QAPI PLAN 60
Slide 61
QAPI Awareness Campaign 61
Slide 62
Let them know often and in multiple ways Plan ongoing education
Provide training in small chunks QAPI is about systems Everyone is
expected to raise concerns Discuss the hard questions (e.g., safety
vs. autonomy) COMMUNICATE WITH ALL CAREGIVERS 62
Slide 63
Their views are sought, valued, and considered Ask them to tell
you about quality concerns Open-door policy Suggestion box
Resident/family surveys COMMUNICATE WITH RESIDENTS AND FAMILY
63
Slide 64
Collecting and Using Data 64
Slide 65
Falls Off-label use of antipsychotics Clinical care (pressure
ulcers, narcotics, etc.) Hospitalization rates Re-hospitalization
rates Resident satisfaction Employee satisfaction State survey
results and deficiencies Business processes (financial, turnover,
call outs, etc) AREAS TO CONSIDER 65
Slide 66
Data collection should be systemic, community- wide, big
picture Keep it simple! Monthly, quarterly, annually Incidence vs.
prevalence Per 1000 resident days is a common standard (# of
residents X # of days) HOW TO COLLECT DATA 66
Slide 67
Limited national assisted living data available Internal
benchmarks are often the best BENCHMARKS 67
Slide 68
GOAL SETTING 68
Slide 69
Gaps and Opportunities 69
Slide 70
Potential areas to consider when reviewing your data: Survey
results and plans of correction Resident service plans for
documented progress towards specified goals Trends in complaints
Resident and family satisfaction for trends Patterns of caregiver
turnover or absences Patterns of ER and/or hospital use IDENTIFY
GAPS AND OPPORTUNITIES 70
Slide 71
Problems vs. opportunities Choose issues that you consider
important Consider which ones to make the focus of a PIP PRIORITIZE
OPPORTUNITIES 71
Slide 72
A PIP project typically is a concentrated effort on a
particular problem in one area of the community or community wide
It involves gathering information systematically to clarify issues
or problems, and intervening for improvements PIPs are selected in
areas important and meaningful for the specific type and scope of
services unique to each community PERFORMANCE IMPROVEMENT PROJECT
72
Slide 73
PLAN, CONDUCT, AND DOCUMENT PIPs 73
Slide 74
Root Cause Analysis 74
Slide 75
A term used to describe a systematic process for identifying
contributing causal factors that underlie variations in performance
Structured Designed to get to the underlying cause of a problem
which then leads to identification of effective interventions that
can be implemented in order to make improvements Focuses primarily
on systems and processes, not individual performance ROOT CAUSE
ANALYSIS 75
Slide 76
Take Systemic Action 76
Slide 77
Depend on staff to remember their training or what is written
in the policy Weak actions enhance or enforce existing processes
WEAK ACTIONS 77
Slide 78
Double checks Warnings/labels New policies/procedures/memoranda
Training/education Additional study WEAK ACTIONS - EXAMPLES 78
Slide 79
Actions are somewhat dependent on staff remembering to do the
right thing But they provide tools to help staff to remember or to
promote clear communication Intermediate actions modify existing
processes INTERMEDIATE ACTIONS 79
Slide 80
Decrease workload Software enhancements/modifications
Eliminate/reduce distraction Checklists/cognitive
aids/triggers/prompts Eliminate look alike and sound alike Read
back Enhanced documentation/communication Build in redundancy
INTERMEDIATE ACTIONS - EXAMPLES 80
Slide 81
Actions that do not depend on staff to remember to do the right
thing May not totally eliminate the vulnerability but provides
strong controls Change or re-design the process Help detect and
warn so there is an opportunity to correct before the error reaches
the resident May involve hard stops which wont allow the process to
continue unless something is corrected or gives the chance to
intervene to prevent significant harm STRONG ACTIONS 81
Slide 82
Physical changes: grab bars, non slip strips on tubs/showers
Forcing functions or constraints: design of gas lines so that only
oxygen can be connected to oxygen lines; electronic medical records
cannot continue charting unless all fields are filled in
Simplifying: unit dose STRONG ACTIONS - EXAMPLES 82
Slide 83
Group Project! Hospital readmissions Reduce by 15% Decreases
unnecessary hospitalizations Improve relationship with hospitals
Improve resident retention QAPI IN ACTION 83