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New England Nursing Home Quality Care Collaborative

(NE NHQCC)

Learning Series: QAPI: Process, Plan, Outcomes, Part II

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Call-In Number: (888) 895-6448 Access Code: 5196001

This material was prepared by the New England Quality Innovation Network-Quality Improvement Organization (QIN-QIO), the Medicare Quality Improvement Organization for

New England, 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. CMSQINC22017040976.

QAPI: Process, Plan, Outcomes, Part II

Sandy Fitzler, RN

Senior Program Coordinator, NE QIN-QIO

Florence Johnson RN, MSN, MHA

Consulting Manager, NE QIN-QIO

Katie Lasewicz, MBA, LNHA

Executive Director, Beechwood Post Acute & Transitional Care

Agenda

Impact of Final Rule on Training

Sharing: Milford Health & Rehabilitation Center QAPI Program

Sharing: Beechwood Post Acute & Transitional Care QAPI Program

Q&A

POLLING QUESTION

Since the first webinar have you made and revisions to your QAPI/PIP teams?…

a) 0

b) 1-2

c) 3-4

d) ≥5

Please elaborate in chat

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Impact of Final Rule on Training

Sandy Fitzler

3 Phase Requirement Implementation

• Effective date: 11/28/16 Phase 1:

Existing requirements with minor changes to survey

process.

• Effective date: 11/28/17 Phase 2:

All Phase 1 and those needing more development

time.

• Effective date: 11/28/19 Phase 3:

All Phase 1 and 2 and those requirements needing more

development time.

https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2016-10-27-LTC-Presentation.pdf

Phase 1 - Current Training Requirements on 11/28/16

• Resident Rights & Facility Responsibility

• Abuse/Neglect/Exploitation

Phase 2 – Training Requirements on 11/28/17

• QAPI & Infection Control

• Resident Rights

• Compliance & Ethics Programs

• Abuse & Neglect

• CNA In-Service Training

• Behavioral Health

Phase 3 – Training Requirements on 11/28/19

• Behavioral Health

• QAPI & Infection Control

• Compliance & Ethics Programs

• Communication

Some Available Resources for Dementia & Behavioral Health Training

• Habilitation Therapy Toolkit: New England

QIN-QIO: http://www.healthcarefornewengland.org/wp-

content/uploads/HabTherapyToolkit_090816.pdf

• National Partnership to Improve Dementia

Care: https://www.cms.gov/Medicare/Provider-Enrollment-

and-Certification/SurveyCertificationGenInfo/National-

Partnership-to-Improve-Dementia-Care-in-Nursing-

Homes.html

• OASIS: http://www.maseniorcarefoundation.org/OASIS.aspx

POLLING QUESTION

Did your team identify a project to focus on after the first webinar? Yes No If yes, please share in chat

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QUALITY ASSURANCE AND PERFORMANCE

IMPROVEMENT

BY: JENNIFER STARZMAN, RN, BSN, DON

MILFORD HEALTH & REHABILITATION CENTER

• 120 bed facility

• 32 bed short term rehab unit focus on joints and

CHF/pulmonary programs

• 5 star facility

• 5 star Quality Measures

• Yale preferred provider and partnership with Dr. Lahav

(joint bundles)

DEVELOPMENT OF QAPI PROGRAM DESIGN & SCOPE

“We touch people’s lives

• It is our mission to provide our residents and their families with superior care

delivered by staff dedicated to the principles of: Kindness, Compassion, Service,

and Excellence in an environment where the individuality, dignity and value of those

who are served, as well as those who serve, is nurtured and appreciated.

• We believe that life, at all stages, and with all of its challenges is a precious gift to

be shared and celebrated.

• It is our privilege to participate in the lives of our residents, their friends, and

families by offering them not only physical but emotional care, comfort, and

support.”

GOVERNANCE & LEADERSHIP

• Administrator and DON

accountable for overseeing

committee

• Provide annual education on

committee purpose and how

to participate in program as

well as focused education

with identified areas

• Awareness

• Story boards

• Posters

• Pamphlets

• Newsletters

• Staff meetings

FEEDBACK, DATA & MONITORING

• Casper reports

• Quality Indicators

• LTC trend tracker

• Pinnacle interviews

• Strive for 5 interviews

• Food questionnaires

• Interact trending

• Ambassador Program

PERFORMANCE IMPROVEMENT PROJECTS

• Monthly Quality Risk Council (QRC) Meetings where we look at

Key Performance Improvement areas set by company as well

as data gathered from multiple sources

• Performance Improvement Projects are selected based on

quality standards set by team and CMS guidelines

* less than 10% of residents experience mod-severe

pain

* FA PU <2%

Quality – Risk Council (QRC) Monthly Meeting

KPI Process

Owner

Status of

KPI

SMART Goals and Plan

(Leading Indicators)

Results

Fin

an

ce

Facility daily Medicare rate is at or above the

targeted facility adjusted daily rate

EBITDAR is at or above budget

Days in AR are ≤ 38 days or the facility is

achieving improvement at the rate of 25%

reduction in total days

Long stay residents are participating in a

formal rehabilitation program at a rate of

15% of average monthly census

Clin

ica

l

Quality measures trigger at a rate of ≤ 2 per

month

The facility fall rate is ≤ 6.5 falls per 1000

days

Facility acquired pressure ulcers occur at a

rate of < 2% of average monthly census

Less than 10% of residents experience

moderate to severe daily pain

Re-hospitalizations within first 30 days of

SNF stay occurs for ≤ 14% of residents

Star Rating is ≥ 4 (QM star rating is = 5)

SYSTEMATIC ANALYSIS AND APPROACH

• Use reasoning mapping to find root cause of issues

• Focus on “why”

• Drill down to priority reason why issue had occurred

• Formulate and implement a PIP

• Evaluate effectiveness of PIP

• Update PIP as indicated

• Review monthly at QRC

Possible Reasons Likely Reason Priority Reason:

KPI

30 Day Goal:

Likely Reason

Get there:

Ways to get there:

1.

2.

Likely Reason 3.

4.

____________________

____________________

____________________

____________________

PIP – PRESSURE ULCERS

• Goal <2% facility acquired pressure ulcers

• Where we started 3.0% average over a 3 month period

before implementation of plan

• 0.9% after implementation of plan and continued

monitoring of the plan

Possible Reasons Likely Reason Priority Reason:

KPI

30 Day Goal:

Likely Reason

Get there:

Ways to get there:

Likely Reason

Facility

acquired

pressure ulcers

occur at a rate

of <2% of

average

monthly census

Care guides may not

reflect the accuracy of

the resident’s current

condition

Identification of those

residents at risk

Preventive measures on

in place on all areas

Care guides may not reflect the

accuracy of the resident’s current

condition

Upon reading care guides, aides will

identify those resident at risk for

skin breakdown and their

preventive measures.

1. Lack of at risk

identification for those

residents at risk – ie:

assignments, TAR, unit

list, etc.

2. Care guides may not

reflect accuracy of the

resident’s current

condition

3. Preventive measure

not in place on all areas

ie: care guide, care plan,

orders, etc. (boots,

mattresses, cushion,

etc.)

4. Discrepancies in

orders – heel boots vs.

lifts vs. pillow etc.

5. Staff not able to

identify those at higher

risk for pressure

breakdown

6. Braden scales may

not accurately reflect

overall status/condition

of the patient

1. ICN will audit each resident and

compile a list of those resident at risk

for skin breakdown

2. Each resident at risk for skin

breakdown will have preventive

measures identified on care guide,

care plan, and TAR as indicated

3. Each unit will be supplied with a

list of residents who have a

alternating mattress, heel

lifts/boots/cushions etc. and list will

be updated monthly by ICN

4. ICN will audit for accurate orders

and preventive needs based on risk of

the resident

5. Monthly review at QRC and

finding/trends

Facility acquired pressure ulcers occur at a rate

of < 2% of average monthly census Wound RN

FA PU <2%

December rate :

3:0 %

Goal: Upon reading care guides, aides will

identify those resident at risk for skin

breakdown and their preventive measures.

ICN will audit each resident and compile a list of those resident at risk for skin breakdown

Each resident at risk for skin breakdown will have preventive measures identified on care guide, care plan, and TAR as indicated

Each unit will be supplied with a list of residents who have a alternating mattress, heel lifts/boots/cushions etc. and list will be updated monthly by ICN

ICN will audit for accurate orders and preventive needs based on risk of the resident

Monthly review at QRC and finding/trends

1/31-2017 – Wound nurse

completed audits. HR/Bill/Sally

complete audit on alt. air

surfaces. Working to get short

term residents off surfaces that

we own and move them to

rental. Brief attendant in and

did audit on each resident for

correct sizing of briefs. Wound

nurse continue to update list of

residents at risk for skin

breakdown with any new

interventions.

BARRIERS

• Team wanted to focus on how to fix issue not on the “why”

it was happening

• Picking just one reason to “why” the issue was occurring

(the hope is to implement a plan to improve one reason

will trickle down and fix the others)

• It takes FOCUS and TIME to improve!!

SUCCESS!!

• Rate dropped to 0.9%

• Staff able to better identify those at risk and preventive

measures to put into place

Beechwood Post Acute & Transitional Care & Long Term Care

Katie Lasewicz, MBA, LNHA

Executive Director

Beechwood Post Acute & Transitional Care & Long Term Care

• 60 Beds

• 30 Short term (2 dedicated hospice beds)

• 30 Long term

• Independently Owned

• Live & Breathe QAPI

QAPI Committee

• Our committee does double duty as our Medical Staff Meeting- meets on a quarterly basis – Physician

– APRN

– IDT Team

– Vendors

• In between quarters if a need arises it is initiated by the IDT team in morning report.

Last year‘s/Current PIPs

• Revisited Steamtable Dining “Steam Team” • Re-hospitalization Rate • Discharge Process • Employee Injury/ Body Mechanics- Team Name “Body Safety champs” • Elopement • Quality Measures • Satisfaction Survey • Pressure Ulcer • Alarm Reduction • Grievance Process • Mega Rule Changes

– Hearing Aide/Dentures – Care Plans – Etc…

Pressure Ulcer Reduction

• Identified on our Quality Measures that our Short Term & Long Term rates were increasing.

• Long Stay Residents with High Risk Pressure Ulcers: – Q1 2016 6.9% – Q2 2016 11.1% – Q3 2016 12.9%

• Short Stay – Q1 1.3% – Q2 1.3% – Q3 1.3%

• Goal set by SMART formula to reduce percentages below State Average & Improve Quality Measures

• Root Cause Analysis Initiated with IDT team

Root Cause Analysis

• Identified Multiple Areas to Improve: – Wound Care Products & Application – Equipment – Skin Care

• Implementation – Multi Step Process

• Evaluated Current Wound Care Protocol & Skin Protocol – Vendor Switch, new protocol

• Evaluated Current Equipment – Heel equipment – Mattresses

– Goal for Q4 to show reduction once all pieces were in place

Pressure Ulcer Reduction

• Q4 2016 Long Stay- 0% Short Stay 1%

• Q1 2017 Long Stay- 3.2%** Short Stay 0%

Alarm Reduction PIP

• Quality of Life Improvement

– Hope to improve quality of life and potentially reduce falls

• IDT Team initial team to discuss

• Goal set by SMART formula to reduce Alarms

Root Cause Analysis

– Nursing learning circles/meetings identified 3-5 residents at a time to remove alarms

• Alternative intervention education given

– Letter sent to Families

– Other Staff (dietary, housekeeping, maintenance, recreation, office) educated on alarm reduction

– Each month a review was done, and then next residents identified per the Nursing team

Alarm Reduction

• Initiated End of March

• End of August- 2 residents with Alarms left (2 per family were never to be removed)

• October- facility was completely Alarm Free

• Falls have decreased, including repeat customers!

POLLING QUESTION

Have you developed your PIP team?

Yes

No

If yes, please share in chat

37

Q&A

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Upcoming Events

• Webinar - QAPI: Process, Plan, Outcomes - Part II:

Thursday, April 20th at 11am

• Webinar - Antimicrobial Stewardship in LTC 6-part Series – Approach to the

Patient with Suspected UTI (Part 3)

Tuesday, April 25th at 11am

• Face to Face Event- Pain Conference with Carol Curtiss

June 21st in West Lebanon, NH

• Face to Face Event - Pain Conference with Carol Curtiss

June 20th in Portsmouth, NH·

• Affinity Group: Focus on Improving Incontinence

4 monthly 1-hour calls with guest speakers, sharing and action plans

Starting in May

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Contact your Nursing Home

Quality Improvement State Lead

• Connecticut

Florence Johnson:

fjohnson@qualidigm.org

• Maine

Danielle Watford

dwatford@healthcentricadvisors.org

• Massachusetts

Sarah Dereniuk:

sdereniuk@healthcentricadvisors.org

• New Hampshire

Pamela Heckman:

pamela.heckman@area-N.hcqis.org

• Rhode Island

Nelia Silva Odom:

nodom@healthcentricadvisors.org

• Vermont

Gail Harbour:

gharbour@qualidigm.org

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Connect with the New England

QIN-QIO on Social Media!

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Win Complementary Entries to Our

Pain Conferences

To enter, like us on Facebook between April 6th and June 7th:

https://www.facebook.com/pages/The-New-England-QIN-QIO/1792031427682514

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The New England QIN-QIO Nursing Home Quality

Care Collaborative will choose one winner for per

location.

Each winner will receive 2 entries to the event of their

choice.