How to Direct and Produce a “BLOCKBUSTER”

QAPI Meeting

A learning and action webinar for the South Dakota Nursing Home Quality Care Collaborative October 17, 2013

Presented by: Holly Beving, RN, hbeving@sdqio.sdps.org, 605-228-9594Lori Hintz, RN, lhintz@sdqio.sdps.org, 605 354-3187South Dakota Foundation for Medical Care

This material was prepared by SDFMC, the Medicare Quality Improvement Organization for South Dakota, 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. 10SOW-SD-C7-13-410

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The Plot . . . “aka” the objectives

• Learn key strategies that will assist Quality Assurance Performance Improvement (QAPI) meetings to be more organized, more effective, and produce results.

• Share meeting agenda template designed specifically for QAPI that incorporates an action and follow-up plan for EVERY meeting.

• Learn when to form a PIP Team. Share PIP documentation tool.

• Familiarize participants with the “National Nursing Home Quality Care Collaborative CHANGE Package” and “QAPI At A Glance” document.

• Hear from three South Dakota DONs related to their QAPI best practices.

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The Backdrop: F520 Regulation 483.75(o) Quality Assessment and Assurance

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 (iii) at least 3 other members of the facility’s staff.

2) . . . (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 actions to correct identified quality deficiencies.

The Long Term Care Survey Manual, AHCA, May 2013 Edition

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F520 Regulation continued

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 requirements of this section.

Surveyors will ask for a record of dates of your QAPI meetings and list of attendee names and titles at each meeting. . .You do not have to give them your notes unless you choose to do so.

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

The Long Term Care Survey Manual, AHCA, May 2013 Edition

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F520 Guidance to Surveyors Section helpful

QA? QI? QAA? QAPI?

Technically have different meanings but are used interchangeably. QAA is what is used in F520 now . . . QAPI will probably be the term used in the sequel.

Root Cause Analysis mentioned frequently in the F520 Surveyor Guidance Section. Are you using this term in your building with all staff and departments?

Action Plan and Follow Up mentioned frequently

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Also Helpful: The Investigative Protocol Under Guidance to Surveyors in F520

Prior to the Survey Team visit they review:• CASPER Quality Measure Reports• 4 year history of the facilities’ deficiencies from past surveys,

revisits, and complaint surveys• Look for repeat deficiencies

Survey Team will interview QAPI Committee Leader to determine the PROCESS:• How committee identifies current and ongoing issues• Methods used to develop action plans • How current action plans are being implemented

Survey Team will be looking that QAPI process is demonstrated facility wide.

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Behind the ScenesGet your cast and crew selected

Designate a leader for the QAPI Committee

• Need to BELIEVE in quality improvement• Need to be organized• Need to be given the time, resources, and equipment to do

the “behind the scenes” work– Education, Long Term Care Survey Manual, CASPER QM

reports, computer, email

• Needs to be a good communicator with a hint of outspokenness . . . Can he/she lead the Root Cause Analysis (5 Why’s)?

• Needs to drive accountability

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Behind the ScenesGet your cast and crew selected

• Director of Nursing• Medical Director• Administrator• Board Member(s)• Therapy• Maintenance • Laundry• Housekeeping

• Social Services• Activities• Pharmacist• MDS Coordinator• Infection Control

Coordinator

Recommendation: Every department is represented at your QAPI Committee Meeting

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QAPI Committee Roles

• RESPECT - Each discipline brings a UNIQUE perspective

• Each discipline is responsible for a focus area Review the federal and state regulations that pertain to

member’s focus area. Know what drives the data on the QM report.

• Develops and modifies the QAPI plan• Reviews data measures• Sets benchmarks and goals• Prioritizes focus areas and PIPs

Target high volume, high risk, problem prone areas first Not every focus area requires a PIP

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Meeting Ground Rules

• Meetings start and end on time (may consider having a timekeeper)

• Use a consistent agenda/format• Set a regular time and place for meeting • Recommend MONTHLY QAPI meetings • If need be, post meeting reminders/send members reminders

(email works great, create email data base so easy to send the group notices)

• Avoid distractions and maintain active engagement• Create safe environment to brainstorm and voice concerns• Expectation that everyone is prepared for meeting

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Meeting Ground Rules continued . . . Best Practice Idea!

All members report on their focus areas in the Agenda/Meeting Template PRIOR to QAPI meeting

Why? • Saves time! Increases efficiency! Promotes action!• Meeting time is reserved for real discussion of the facts, NOT to

enter the facts. • Meeting minutes are essentially done with exception of QAPI

leader taking notes of attendance, action plans, and follow-up. How?

• Put Agenda/Minutes Template on shared electronic drive – allows for easy access for members to complete.

• QAPI Leader makes copies available for members at meeting.

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Action Plans and Follow Up are the star attractions

Making action plans and following up on those action plans at EVERY meeting is key to producing results.

“It is not what the latest software or technology does. It’s what the user does.”

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The Script . . . QAPI Agenda Meeting Template

QAPI AGENDA/MEETING TEMPLATE Making a difference in the lives we touch through quality assurance and performance improvement.

ATTENDING (List name and title; save on template) YES NO

MEDICAL DIRECTOR

ADMINISTRATOR

DIRECTOR OF NURSING

QAA COORDINATOR

ENVIRONMENTAL SERVICES

PHARMACY

RD/DM

SOCIAL SERVICES

ACTIVITIES

HUMAN RESOURCES

BOARD MEMBER

(INSERT ACTION PLAN TABLE FROM PREVIOUS MEETING)

MISSION STATEMENT: (Print and save on template)

DATE OF MEETING:

QAPI AGENDA/MEETING TEMPLATE

QUALITY OF LIFE/QUALITY OF CARE

ITEM SYSTEM

CHAMPION REPORT ACTION PIP

Quality Measures: Quality measures >

75% and identify trends/causes

ALL

Facility Focus: Antipsychotic

reduction Advancing

excellence Activities Call lights Enhancing resident

centered care Advanced care

planning Other

DON SS RD/DM ACT ALL ALL

Infection Control: Resident infection

rate Staff infection rate Trends by location

and organism

ICN

Mock Survey: Benchmark set/met

ALL

State Survey/Nursing Home Compare: Finds Barriers Survey readiness Benchmarks set/met Star rating

ALL

EMR: Totally rolled out? Accurate Reports being

utilized Case mix

ALL

Care Transitions Rehospitalization/ Discharges: 30 day discharge

benchmark and results

Follow up on residents discharged home

DON SS

Pilot Projects: Interact 3 Others

ALL

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The Script . . . QAPI Agenda Meeting Template Continued

QAPI AGENDA/MEETING TEMPLATE

ITEM SYSTEM

CHAMPION REPORT ACTION PIP

Daily Rounding: Items/areas

identified

ADM DON

Other:

ACTION PLAN

GOAL ACTION PROCESS CHAMPION

TARGET DATE

COMPLETION DATE

This material was prepared by SDFMC, the Medicare Quality Improvement Organization for South Dakota, 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. 10SOW-SD-C7-13-XXX.

QAPI AGENDA/MEETING TEMPLATE

ITEM SYSTEM

CHAMPION REPORT ACTION PIP

Policies: Current ones

updated New ones

implemented

DON

Secured Unit: New programs Issues that need

attention

DON

Pharmacist Report: Physician response

to recommendations Tracking and

trending of medication

PHARM

Recruitment and Retention: Turnover rate by

department Efforts to recruit and

retain Trends of exit

interviews

HR

Staff Satisfaction: Progression of top

two areas identified in staff survey

ALL

Orientation/Training: # of new people

starting per department

ALL

Incident Reports/Safety: Trends and tracking Falls

benchmark/trends Reportable to the

State Work comp trends

Resident Council: Recommendation

from Council

Concern Forms: Tracking/trending of

staff and family issues

24-48 hour follow-up done?

SS

Family/Resident Survey: Progression of top

two areas identified

ADM

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Stunt Team aka “PIP Team”

erformance mprovement rojectCharter PIP teams with a specific mission to look into a

problem area. • Select those working closest to the challenge to explore the root cause and

problem solve (i.e. direct caregivers, dietary, housekeeping, even family and residents in some cases).

• PIP team always includes one member from the QAPI Committee.

• PIP teams need to be given TIME to work on the issue. Give them a timeline and a budget.

• Need a leader for the PIP team.

• Need to report back to the QAPI Committee.

• PIP teams must be considered VALUABLE and an important assignment.

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Easy to Use Documentation Tool for PIPs

PERFORMANCE IMPROVEMENT PROJECT (PIP) GUIDE

START DATE REVIEW DATE(S) COMPLETE DATE PIP SQUAD MEMBERS

9/1/13 9/15/13, 10/1/13 Projected 11/1/13

PROJECT LEADER:

Lori Hintz, QAPI Coordinator 1. Lori, QAPI Coordinator

2. Holly, ADM

3. Sarah. DON

KEY AREA FOR IMPROVEMENT:

Absence of a written QAPI plan. Incorporate QAPI principles with our current QI program.

4.

5.

6.

7.

GOAL:

Specific PIP Squad will have a draft of written QAPI plan to be presented to entire leadership team for their input and/ or approval by 11/1/13. .

Measureable Action Oriented

Realistic Time Bound

WHAT IS THE ROOT CAUSE(S) FOR THE PROBLEM? Ask “Why is this happening?” 5 times. If you removed this root cause, would the event have been prevented? Don’t know where to start - Have attended several QAPI education webinars and have even downloaded CMS, “QAPI At a Glance” doc but haven’t actually read the doc – time constraints have prevented taking action – it wasn’t a facility priority until now.

BARRIERS:

CMS final regulations for having the written QAPI plan in place not finalized. However, CMS has provided tools for QAPI education and implementation.

BRAINSTORM POSSIBLE SOLUTIONS and START YOUR PDSA CYCLE (PLAN, DO, STUDY, ACT) – See page 2

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PIP Documentation Tool Continued

PERFORMANCE IMPROVEMENT PROJECT (PIP) GUIDE

BRAINSTORM: Read “QAPI At A Glance” . Solicit examples of QAPI plans from peers. Review current QI program. Know the current F520 QAA regs in the survey manual. Educate entire leadership team and then staff utilizing problem solving models (PDSA’s and RCA’s) .

PLAN DO STUDY AND ACT

LIST THE TASKS TO BE DONE RESPONSIBLE

MEMBER START DATE

ACTUAL COMPLETION

DATE

COMMENTS (RESULTS/LESSONS

LEANRED)

ADOPT/ADAPT/ABANDON (CHOOSE ONE)

Read QAPI At A Glance, current facility QI program and F520 reg, then discuss

Lori Holly Sarah

9/1/13 9/15/13 Current QI doesn’t incorp. QAPI principles; but does adhere to F520

Adapt QAPI principles in current QI program/policy

Review examples of QAPI plans (Avera Brady & Golden Living) then discuss

Lori Holly Sarah

9/15/13 9/30/13 Decided on format and key QAPI elements to include in current QI Plan

Adapt

Formulate written draft to be given to leadership team for input / approval

Lori 9/30/13 10/15/13 In leadership daily standup, PIP team informs progress & solicit ideas as plan written

STUDY AND ACT

BENCHMARKS/METRICS How will we measure progress

BASELINE FIRST

MEASUREMENT SECOND

MEASUREMENT FINAL

MEASUREMENT COMMENTS DATE DATE DATE DATE

Facility QI program will be updated to incorporate QAPI principles in a written format

Written QI program only

1st draft done

9/1/13 10/15/13

This material was prepared by SDFMC, the Medicare Quality Improvement Organization for South Dakota, 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. 10SOW-SD-C7-13-405

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National Nursing Home Quality Care Collaborative “CHANGE Package” and “QAPI At A Glance”

“CHANGE Package”

•Gives a menu of strategies, change concepts, and actionable items that will be helpful in finding solutions to challenge areas.

•It is not the intent that nursing homes try to attempt every change concept at the same time.

•Prioritize the areas where you feel change is needed.

•Have document available at QAPI/ PIP meetings. Refer to the document when trying to problem solve and/or looking for ideas.

“QAPI At A Glance”

•It is the “nuts and bolts” of QAPI. •Step by step guide to implementing QAPI, including the steps to write a written QAPI plan. •Excellent problem solving models outlined in this resource.•Have copies available.

Both the “Change Package” and “QAPI At A Glance” can be found

on the CMS, SDFMC websites (addresses on resource slide)

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Metric / Benchmark Formula

Date Chosen Measure for Evaluation

# of Cases Reviewed

(A)

# of Cases w/Positive

Results (B)

(B) out of (A)

(B/A)

9/20/13 New admissions have completed assessment forms within 24 hours

10 7 7/10 =

.70 or 70%

9/20/13 Call lights received response within 10 minutes

20 10 10/20 =

.50 or 50%

FYI: A Way to Calculate Falls Falls will be calculated by taking the total number of falls that have occurred for one month and dividing it by the total number of resident days for that same month. This figure will then be multiplied by 1000 to give you the average number of falls per 1000 resident days.

 

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Best Performances go to . . .

Jenkins Living Center, Watertown, SD - Shawn Gilman, DON

Forming a PIP Squad

Platte Care Center Avera, Platte, SD - Traci Harrington, DON

QAPI and Falls

Firesteel Healthcare Center, Mitchell, SD - Sarah Comp, DON

Using the Connecticut RCA Event Tool

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Credits “aka” resources

South Dakota Foundation for Medical Care: http://www.sdfmc.org/PatientSafety/SDNursingHomeQualityCareCollaborative/SDNHQCCResources/Index.cfm

CMS QAPI Webpage: http://go.cms.gov/Nhqapi

CMS QAPI AT A Glance document: http://cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/QAPIAtaGlance.pdf

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

Agency for Healthcare Research and Quality, STEPPS program: http://www.ahrq/gov/professionals/education/curriculum-tools/teamstepps/ltc/index.html

Department of Veterans Affairs, Root Cause Analysis: http://www/patientsafety.gov/CogAids/RCA/

Getting Better All the Time: Working Together for Continuous Improvement: http://www.susanwehrymd.com/files/gettingbetterall-the-time.pdf

InterAct: www.interact2.net

Oklahoma Foundation for Medical Quality: National Nursing Home Quality Care Collaborative CHANGE Package: http://www.ofmq.com/nhtoolsandresources

Ohio KePro: Quality Improvement Workbook: https://www.ohiokepro.com/shopping/pdfs/QualityImprovementWorkbook.pdf

The Long Term Care Survey, AHCA, May 2013 Edition

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Our Offer

Host Open Office Call

9:00 am MT/ 10:00 am CT

Thursday, January 30, 2014

* Purpose: Share how QI/QAPI meetings are going

What is working? What is not?

Contact Information:Holly Beving: hbeving@sdqio.sdps.org 605-228-9594

Lori Hintz: lhintz@sdqio.sdps.org 605-354-3187