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Copyright © 2016 All Rights Reserved 1

QAPI:Play or Pay

Colleen Gouldrick, Vice President of QAPI/QM

Harmony Healthcare International, Inc. (HHI)

Disclosure

• Disclosures: The planners and presenters of this educational activity have no relationship with commercial entities or conflicts of interest to disclose

• Planners:

– Coleen Gouldrick, Vice President of QAPI

– Elisa Bovee, MS, OTR/L

– Diane Buckley, BSN, RN, RAC‐CT

– Keri Hart, MS CCC, SLP, RAC‐CT

– Presenter: Coleen Gouldrick, Vice President of QAPI/QM


Objectives

• Understand the basic framework and history of QAPI

• Learn the quality expectations for the future

• Implement the two strategies that will impact financial, operational and quality outcomes




Agenda

• Let’s talk QAPI!

• SNF Industry highlights that drive your QAPI Program direction

• What is QAPI?

• HHI QAPI Five Elements

• HHI Ten Step QAPI Work Plan

• HHI QAPI Work Plan Initiative Suggestions (Domain based)

• Summary



Let’s Talk QAPI

Are You Already Doing QAPI?

• Does your facility…

– Investigate problems and try to prevent their recurrence systemically?

– Track and report adverse events? To whom?

– Compare the quality of your home to that of other homes in your state or company?

– Create systems that focus on improving care and achieving nursing home regulation compliance?




What is QAPI?

• QAPI is a data‐driven, proactive approach to improving the quality of life, care, and services provided to residents in nursing homes

• The activities of QAPI involve members at all levels of the organization to: – Identify opportunities for improvement

– Address gaps in systems or processes

– Develop and implement an improvement or corrective plan; and

– Continuously monitor effectiveness of interventions


• Reactive• Single episode• Organizational mistake• Prevents something from

happening again• Sometimes anecdotal• Retrospective• Monitoring based on audit• Sometimes punitive

• Proactive

• Aggregate Data

• Organizational process

• Improves overall performance

• Always measureable

• Concurrent

• Monitoring is continuous

• Positive change

Quality Assurance

Performance

Improvement


“We Already Do That…”

• Rather than simply addressing a symptom, QAPI focuses the efforts of the team to determine and address root cause of problems or potential problems and, in doing so, ensure lasting success




SNF Industry Changes

Industry Highlights

• Health care delivery is changing – FAST

• Nursing facilities are transforming from sites of custodial care into sites of high intensity care for sick, complex patients

• Expectations from hospitals, payers, regulators, etc. are rising – greater scrutiny of quality and cost

• Pay for performance ‐ OUTCOMES

• Much more is and will be expected of facilities, physicians and medical directors

• More care will be provided by fewer practitioners

• Customer Expectations – Service Delivery


The Challenge…

“Not all change is improvement, but all improvement is change”

Donald Berwick, MD

Former CMS Administrator




IMPACT Act

• Improving Medicare Post Acute Care Transformation Act of 2014 (IMPACT Act) puts in place new and streamlined quality measures for nursing homes, home health agencies, and other post‐acute care providers participating in Medicare

• Expand and strengthen Medicare’s widely‐used 5 Star Quality Rating System for Nursing Homes, also known as Nursing Home Compare


IMPACT Act

• Many of the measures outlined in the IMPACT Act can be classified as measures related to unintended health care outcomes:

– Pressure Ulcers

– Falls

– Rehospitalization


Six New Measures

• 6 New Measures were added to NHC in April 2016

• 5 were added to Five‐Star Rating in July 2016 (*)

• Short – Stay: – Discharge to Community*

– Emergency Room Use*

– Re‐hospitalizations*

– Improvement in Function Since Admission*

• Long – Stay:– Decline in Mobility*

– Use of Hypnotics/Anxiolytics




Current & Future Initiatives

• Expand focused surveys verifying MDS data:

– MDS/Staffing Focused Surveys

– Adverse Events – New Focused Survey

• July 2015 Proposed Rule addresses facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, as well as how the facility will use the data to develop activities to prevent adverse events


SNF Quality Reporting Program Expansion

• On August 4, 2015, CMS published a Final Rule (CMS 1622‐F) outlining three measures they are adopting for FY 2018 that SNFs are required to report under the SNF Quality Reporting Program:

– Skin Integrity

– Incidence of major falls

– Functional status, cognitive function and changes in function


March ODF Notes

• Payroll Based Journal (PBJ) will not be used for Five‐Star

– PBJ is mandatory July 1st

– 1% of facilities are reporting

• CMS plans to add additional Quality Measures to the Five‐Star Quality Rating System in 2017 or 2018 including:– Staffing turnover and retention

– Staffing levels based on the data from the mandatory staffing data collection from the Payroll Based Journal (PBJ)




Quality Assurance and Performance Improvement

(QAPI)

What is QAPI?

• Quality Assurance and Performance Improvement (QAPI)

• “QAPI is about critical thinking. It involves figuring out what is causing certain problems, and implementing interventions and solutions that address the root causes of the problems, rather than just the symptoms.”

– Karen Schoeneman, Past Technical Director, CMS Division of Nursing Homes


QAPI Regulatory Update

• New Section “Quality Assurance and Performance Improvement (QAPI)” (§ 483.75) per the Medicare and Medicaid Programs; Reform of Requirements for Long‐Term Care Facilities; Proposed Rule (7‐16‐15)

• In accordance with the statute, we propose to require all LTC facilities to develop, implement, and maintain an effective comprehensive, data‐driven QAPI program that focuses on systems of care, outcomes of care and quality of life




Current Regulations

• Require a facility to maintain a Quality Assessment and Assurance (QA&A) committee consisting of the Director of Nursing, Physician, and three other members of the facility staff. The QA&A Committee must:

– Meet at least quarterly

– Identify quality deficiencies and develop and implement plans of action to correct deficiencies


Proposed Regulations

• Requires each facility develop, implement and maintain a data driven QAPI plan that focuses on systems of care, outcomes and services for residents and staff

• The facility must maintain documentation and demonstrate evidence of its QAPI program

• Submit QAPI plan to surveyors during survey process



• Required to address all systems of care and management of clinical care, management practices and quality of life

• As part of QAPI, each facility will have to use feedback from direct care and access workers, residents, and families to identify areas of opportunity for improvement

• Must involve all departments and be added to any facility‐based policy and procedures accordingly





• The SNF QAPI must include initiatives that address any adverse events ‐ preventable and non‐preventable – such as:– Failure to diagnose or treat

– Medication errors (less than 5%)

– Injury due to falls

– Abuse or reject by caregivers or residents

– Failure to identify change of condition

– Spread of disease due to infection control errors

– Pressure Ulcers due to inappropriate care


CMS’ QAPI: The Five Elements


HHI QAPI Program Five Elements

Element 1: Quality Assessment and Assurance Committee:

Required per provision‐ 42 CFR, Part 483.75(o) Specifies composition of Committee (DON, MD and 3 facility staff members)

Committee must meet quarterly Committee MAIN objectives: Remove barriers that prevent subcommittee’s from reaching QAPI Work Plan initiative targets and lead the development of annual QAPI based on areas that present the most risk to the residents and facility!




QAA Committee Development

Committee Charter Scope must be clear and describe breadth of

responsibilities to QAPI Program overall initiatives Committee members MUST approve QAPI (Quorum) Facility specific Policy required that describes how the QAPI

program works Meeting minutes, Sign‐In sheet and binder creation and

maintenance for Survey readiness Regulators will be allowed to look at all QAPI Program

materials including committee approved, written work plan, working papers and data tracking tools

Privilege???


HHI QAPI Five Elements

Element 2: Data Driven Initiatives True QAPI efforts are based on a clean audit trail which

translates into a valid and reproducible data stream Externally – Identify benchmarks and reports for baseline data

and target projections (NHC Five Star QM Ratings) Internally ‐This requires understanding (systems reviews): What are the current mechanisms for data collection? (Sources – specifically)

Is the data collected supportive of QAPI measure and target attainment?

Who will create a valid, reproducible data stream? Data integrity is a MUST!



Element 3: QAPI Work PlanThe written, QAA Committee (Governing Body) approved, QAPI Work Plan is the core of the QAPI process

A concrete QAPI Work Plan describes the areas of focus/risk that the QAA committee agrees require a long‐term solution to improve overall quality of care

Remains in place for at least one year – nothing added, nothing removed

HHI Ten Elements for a thorough QAPI




QAPI Work Plan Domains

• Domain: A specified sphere of activity or knowledge

• Work Plan initiatives are selected to reflect a global approach to quality improvement

• HHI (CMS) Suggested Domains: Clinical Care (Safety)

Resident Choice (Rights)

Quality of Life and Care Transitions (Quality)

Utilization of Services (Choice)

Non‐Clinical Areas (Respect/Satisfaction)


QAPI Scorecard (see Attachment #1)

Domain Measure Baseline Target Comments

Clinical Care

Residents’ Choice

Quality of Life and Care Transitions

Utilization of Services

Non‐Clinical Areas



Element 4: Initiative Development and Performance Improvement Plans

**See later slides and handout




HHI Ten Step QAPI Work Plan

Write a clear OBJECTIVE

DEFINE the problem

Set your data based TARGET (annual)



RESPONSIBLE for data

ACCOUNTABLE for Measure

Committee CONSULTED


RACI Matrix – Who is Who?





Process and Source for Data Collection

Standard Benchmark and Source

Questions to Address as part of the QAPI


HHI Ten Steps for QAPI Planning

• And last but not least…….


GOAL

Initiative #3

Initiative #2

Initiative #1

Pressure Injury Prevention Initiative

• See Attachments #2 and #3





Element 5: Subcommittees • Valuable, NECESSARY, asset to the QAPI Program overall

• Subcommittee charters revolve around QAPI initiative targets

• Role: Implement PIP’s developed to meet Work Plan initiative targets; track data; report to QA committee quarterly

• Subcommittee members perform “Gap Analysis” each month based on data ‐ identifying issues, underlying causes, corrective actions and subcommittee plans to address issues

• Based on these findings from the Gap Analysis – PIP’s can be adjusted to more acutely focus on the issues at hand


SNF Internal QAPI Reporting Structure Example

Quality Assessment and Assurance Committee

Infection Prevention

Fall Prevention

“Pressure Injury Prevention

Risk Management


HHI Initiative SuggestionsDomain Initiative

Clinical Care • Pressure Injury Prevention• Fall Prevention: Reduce Falls with Major Injury• Appropriate Use of Antipsychotic Medication ‐

gradual dose reduction documentation by physicians• Appropriate Monitoring of Anticoagulation Status• Medical Record/EMR will provide an accurate and up

to date comprehensive diagnosis list• Adverse Event Identification and Reporting• Medication Variance Reporting Compliance

Residents’ Choice (Dignity) • Incontinence Reduction• Meaningful Choices ‐ dining, activities, scheduling of

care• Pain Management






• Unintended Weight Loss• Safely Reduce Hospital Readmissions within 30 days• Hand Hygiene ‐ infection prevention• Resident Satisfaction• Family Satisfaction• Employee Satisfaction• Employee perceptions of whether necessary

information is communicated during hand‐offs• Medical Record Documentation Compliance• Gradual Dose Reductions ‐ Antipsychotic medications

Utilization of Services • Polypharmacy: Reduce Resident Medication Utilization including antipsychotics, antibiotics, hypnotics and opioids in general



Utilization of Services(cont.)

• Antibiotic Utilization• Reduce Worker's Compensation Utilization• Reduce the utilization of overtime in CNA staffing

patterns (Improve CNA regular staffing)• UB‐04 coding compliance • Significant Change Identification and Completion

Non‐Clinical Areas • Policy and Procedure Maintenance • Employee Retention and Staffing: Open Clinical

Positions• Property Loss Reduction


QAPI Principles Summarized

• QAPI may not be new for you—build on what you have

• QAPI leadership starts at the top with executive management, Board of Directors, Owners or Trustees and includes top management in each home

• Systems, Systems, Systems!!!!!




QAPI Principles Summarized

• Residents’ perspective is key in setting QAPI priorities for PIPs

• Two key activities are setting priorities and chartering PIPs, and everyone should have the opportunity to participate in both

• Maintain each subcommittee charter to include tasks, deliverable and completion timeline

• Celebrate and reward success!

• Survey Readiness always: Binder upkeep


Final Thoughts….

• The future of healthcare is all about partnerships – solidify relationships

• Be aware of and transparent about your quality outcomes, baselines (data) and continuously “move the needle”

• Be willing to provide all levels of care and market your strengths


Five Steps to Organizational Success

1) Use data to track performance and track goals that are facility‐specific

2) Conduct Root Cause Analysis, Systems Reviews and implement Project Management strategies for task and deliverable tracking

3) Identify Champions to pilot new ideas and approaches

4) Leadership: Staff empowerment is key!!

5) Learn from others




Resources

• http://www.cms.gov/Medicare/Provider‐Enrollment‐and‐Certification/QAPI/downloads/ProcessToolFramework.pdf ‐ QAPI

• http://www.cms.gov/Medicare/Provider‐Enrollment‐and‐Certification/SurveyCertificationGenInfo/QIS‐Survey‐Forms.html ‐ QIS Survey Forms and Audit Tools

• https://www.cms.gov/Regulations‐and‐Guidance/Guidance/Transmittals/Downloads/R127SOMA.PDF ‐revisions to Appendix PP – State Operations Manual

• http://www.cms.gov/Medicare/Provider‐Enrollment‐and‐Certification/SurveyCertificationGenInfo/QIS‐Survey‐Forms.html ‐ QIS Tools

• http://www.medicare.gov/nursinghomecompare/search.html ‐ CMS Nursing Home Compare


Resources

• http://www.cms.gov/Medicare/Provider‐Enrollment‐and‐Certification/SurveyCertificationGenInfo/Downloads/Survey‐and‐Cert‐Letter‐15‐25.pdf MDS Focused/Staffing Surveys ‐ CMS Memorandum

• http://www.cms.gov/Medicare/Provider‐Enrollment‐and‐Certification/SurveyCertificationGenInfo/Downloads/Survey‐and‐Cert‐Letter‐15‐31.pdf Dementia Focused Surveys ‐ CMS Memorandum

• http://www.ahcancal.org/quality_improvement/qualityinitiative/Pages/default.aspx ‐ AHCA Quality Initiatives

• https://www.nhqualitycampaign.org/ ‐ Advancing Excellence

• http://www.ahcancal.org/advocacy/solutions/Documents/Value%20Based%20Purchasing%20‐%20IB.PDF – SNF Value Based Purchasing


Key References

• Top 5 Policies That Will Impact Your Post‐Acute Customers, HIDA. Andrew E Van Ostrand, VP, Government Affairs, First Quality. October 2014.

• Trends in Hospital‐Post Acute Acute Provider Relationships. Erik Johnson, SVP, Avalere Health. September 2014.

• QAPI Boot Camp, Carol Benner, Sc.M., 2014

• http://www.stratishealth.org/pubs/qualityupdate/f13/reform.html

• The Post‐Acute Care Environment, Compliance and the Affordable Care Act. Alissa Vertes & John Armstrong, HealthPRO. January 2015.




Key References

• www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/Post‐Acute‐Care‐Quality‐Initiatives/IMPACT‐Act‐of‐2014‐and‐Cross‐Setting‐Measures.html – IMPACT Act of 2014 & Cross Setting Measures

• SKILLED NURSING FACILITY READMISSION MEASURE (SNFRM) NQF #2510: ALL‐CAUSE RISK‐STANDARDIZED READMISSION MEASURE DRAFT TECHNICAL REPORT https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/NursingHomeQualityInits/Downloads/SNFRM‐Technical‐Report‐3252015.pdf

• Adverse event in Nursing Homes OIG report https://www.cms.gov/Medicare/Provider‐Enrollment‐and‐Certification/QAPI/Adverse‐Events‐NHs.html

• Oregon Patient Safety Commission Root Cause Analysis Toolkit: http://oregonpatientsafety.org/RCA‐Training/RCA‐Training/root‐cause‐analysis‐toolkit/1769


• Harmony Healthcare International• 800.530.4413• www.Harmony‐Healthcare.com• CGouldrick@harmony‐healthcare.com

@Harmonyhlthcare

facebook.com/HarmonyHealthcareInternational

linkedin.com/company/harmony‐healthcare

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56Copyright © 2016 All Rights Reserved

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Copyright © 2016 All Rights Reserved - 1 - Seminars:Association:2016/FHCA

I. Fall Prevention

1. Objective: Fall prevention in nursing homes continues to be a major focus for quality improvement in patient safety. Although only approximately 5% of adults aged 65 years and older live in nursing homes, this population accounts for approximately 20% of fall-related deaths in this age group. Between 50% and 75% of nursing home residents fall annually, which is twice the rate of falls in community-dwelling older adults. In addition, elderly individuals fall at an average rate of 2.6 falls per person per year. Falls result in disability, functional decline, reduced quality of life, and even death. In fact, approximately 1800 nursing home residents die from falls each year. In addition, fear of falling can cause further loss of function, depression, feelings of helplessness, and social isolation. As the above data demonstrates, fall prevention is essential; however, this endeavor is challenging as there is a lack of compelling evidence that any one intervention will reliably decrease the incidence of falls. This is because many falls have multiple etiologies, requiring consideration of multiple physical, cognitive, and environmental factors. Therefore, reducing the risk of falls and fall-related injuries in long-term care (LTC) facilities requires a comprehensive approach that focuses on identifying the myriad conditions that predispose to falls and addressing each resident’s identified risk factors; this needs to start on each resident’s first day of admission. (See http://www.annalsoflongtermcare.com/article/strategies-for-reducing-falls-long-term-care#sthash.1JHJrFhI.dpuf )

2. Definition: XXXXXXXXX has established Falls Prevention Plan throughout the facility due to the population XXXXXXXXX cares for. Falls are defined as a sudden, often unexpected change in position, in which the person comes to rest unintentionally on the floor. Minor injury includes skin tears, abrasions, lacerations, superficial bruises, hematomas, or sprains or any fall related injury that causes the resident to complain of pain. Major injury is defined as bone fractures, joint dislocations, closed head injuries with altered level of consciousness and subdural hematoma per the CMS RAI Version 3.0 Manual.

3. Problem Statement: Falls within our patient population pose a significant risk to our ongoing belief in maintaining our patients functional independence and quality of life. Frail seniors are at an increased risk of falls as a population, therefore fall prevention, and the prevention of major injury, is a key aspect of XXXXXXXXX quality assurance program.

4. 2016 Target: 5.79 falls per 1000 Patient days.

5. Responsible for Data: Director of Rehabilitation and Director of Nursing.

6. Accountable for Measure: VP of Support Services and Radiation Therapy at XXXXXXXXX.



7. Committee Consulted: Quality Improvement Committee (biweekly); Pharmacy

Committee (falls among Residents with infections/Polypharmacy) and Quality Assurance Committee (monthly).

8. Source for Data Collection: Accident and Incident (SAFE) Reports, Morning Meetings,

Nursing, MDS Section J data, Monthly Infection Reports and Home Compare Five Star Quality Rating System.

9. Standard Benchmark: 2015 XXXXXXXXX overall fall rate from July - December = 8.25 per 1000 Residents days; Nursing Home Compare Quality Measure results for 2015:

1/1 - 3/31/15 = 58.9% 4/1 - 6/30/15 = 62.6% 7/1 - 9/30/15 = 60.8% 10/1 - 12/31/15 = 66.7% 2015 State Average = 52.6% 2015 National Average = 44.8% Using the 1000 resident days model, 5% = 0.41 for our calculations.

Facility would require a 16% reduction from baseline average of 62.0% to reach State Average. (1% reduction = 0.62; 16% reduction = (0.62 x 16) = 9.92; 62.0% - 9.92 = 52.08%.) To meet National Average, the facility would need to reduce the total number of falls in 2016 by 29% for an average of 43.4%.

10. Questions to be addressed as part of the initiative

a. How many residents are falling when trying to get to the bathroom? b. How many residents actually fall in the bathroom? c. How many residents are incontinent at the time of the fall? d. Was the resident being treated for an infection, such as a UTI, at the time of the

fall? e. Is there a correlation related to staffing and falls on the patient care units?

11. 2016 Initiatives to Reach Target:

a. Implement impromptu team “huddles” after a Residents fall. b. Complete post-evaluation fall assessment that aligns with IPRO Spreadsheet

reporting for all falls. c. Develop firm link between interdisciplinary team care planning, communication of

care changes to nursing team and the timely communication of the care plan adjustments to the caregivers (LNA's).

d. Solid, immediate post-fall assessment performed and documented in record. e. Improve investigation details after a fall to discern individual care planning needs

and/or program improvement opportunities. f. Redefine the column names on the IPRO spreadsheet to meet facility needs. g. Care Plan individualization.



h. Identify patients who fall related to needing to go to the bathroom, perform 7 day pattern analysis and then implement individualized toileting program for those patients.

i. Provide education to all employees to report subtle noted functional declines or witnessed non-safe behaviors that put a patient at risk for falls.

j. Develop guidelines/policy for reporting functional declines to therapy and what their responsibilities to the referral are.

QAPI Scorecard 2016



Domain Measure Baseline Target Notes

Clinical Care

Fall Prevention Medication Variance Reporting Compliance Pressure Injury Prevention

8.25*

TBD

3.5%

5.79*

Increase

≤ 4.9% (State Average)

Target = 30% reduction to meet National Average in QM's Baseline and targets to be established based on 1st and 2nd Q 2016 data Baseline established based on 2015 overall average based on Five Star Rating percentages.

Resident Choice (Dignity)

Incontinence Reduction Pain Management

54.8%

ST: 33.9%

LT: 21.3%

46.1%

(National average)

ST: 16.6%

LT: 8.0%

Baseline = 2015 facility average 3rd Q implementation Baselines derived from 2015 and 1st Q 2016 QM averages as reported on Nursing Home Compare website.


Unintended Weight Loss Safely Reduce Hospital Readmissions within 30 days (during SNF stay)

12.2%

11.0%

7.1%

13% or less

Baseline reflects 4th Q 2015 CMS Five Star Quality Rating Measure result; Target is 2016 National average for unintended weight loss. Target established based on AHCA recommended targets for best practicing SNF's as of 4/22/16. Baseline = 2015 NHC. Rate of 10% by 2018.

Utilization of Services

Polypharmacy: Reduce Resident Medication Utilization including antipsychotics, antibiotics, hypnotics and opioids in general.

22.8%

16.4%

Baseline = 2015 3rd Q average per MDS 3.0 Quality Measure for Provider report (CASPER) Target = 2016 Vermont State Average per CMS Five Star

Non-Clinical Areas

Policy and Procedure Maintenance (2 year initiative) Employee Retention and Staffing: Open Clinical Positions

N/A

43

100% by the end

of 4th Q 2017

TBD

43 open clinical positions in Feb.2016; 19 at end of May.

(* )= per 1000 resident days

Pressure Injury Prevention Committee Charter 2016



Co-Chairs: XXXXXXXX, RN

XXXXXXX, PT

Committee Data Analyst: XXXXXXX, PT

Meeting Frequency: Every week on Thursday @ 10:00 am through June 9th, 2016 then monthly

Committee Members:

XXXXXXX XXXXXXX, RN, MDS Coordinator XXXXXX, RN, Unit Manager XXXXXX, RD XXXXXX, Interim DON LNA XXXXXX LNA XXXXXX LNA XXXXXX Rotating NP (?) As needed: Hospital Wound Nurse

Committee Scope and Overall Objective

To improve skin integrity alteration identification and treatment in an effort to improve resident clinical

conditions and outcomes.

Identified Outcome Associated Metric/Target

Maintain a Facility Percent for both Five Star Ratings having to do with Pressure Ulcers below State and/or National Averages posted on NHC.

1) Short Stay = % of residents with pressure ulcers that are new or worsened

a. 2015Q2 = 0.7% b. 2015 Q3 = 0.7% c. 2015Q4 = 0.7% d. 20161Q = 1.2%

2) Long Stay = % of high-risk long stay residents with pressure ulcers

1) Short Stay New or Worsening pressure injuries (2016 NHC Benchmarks)

a. State = 0.7% b. National = 1.3%




Committee Scope and Overall Objective

To improve skin integrity alteration identification and treatment in an effort to improve resident clinical

conditions and outcomes.

a. 2015Q2 = 4.5% b. 2015Q3 = 4.7% c. 2015Q4 = 3.5% d. 2016Q1 = 1.2%

3) Reduce/insulate the number of recurrent pressure related wounds in resident population.

4) Identify new pressure ulcer development trends within the resident population through the promotion of early detection and treatment.

2) Long Stay Hi-risk Pressure Ulcer (2016 NHC Benchmarks)

a. State = 5.0% b. National = 6.4%

3) Develop baseline data using

2016 data for 2017 target.

4) Stage II healed in 30 days or less.




Current Initiatives Due Date

QAPI: Simplify reporting to ensure reporting compliance.

QAPI: Expand reporting to include all skin integrity alterations.

QAPI: Develop resident specific, anatomical location specific data for accurate diagnoses of recurrent pressure wounds.

QAPI: Develop/revise annual practical competency for all clinical team members. (Education)

Develop focused medical record audit tool to align with standards of practice and internal policies.

Develop PowerPoint directed at licensed clinical team members that combines standard wound information along with facility specific documentation and communication processes/guidelines with post-test to ensure competency.

Develop recurrent pressure injury development benchmark for 2017.

In process. Expected outcome Jan. 2016

Clarify expectations surrounding when to complete full skin assessment: new admission, after hospitalization, after illness that contributed to reduced functional status of resident – even if short lived, during showers.

Revise internal policy & procedure to reflect SAFE reporting requirements as well as new NPUAP Pressure Injury definitions.

In process (May)

Expand committee membership to include members from all facility disciplines with expectation of information sharing.

Focused education for Safety Champions: If Apples were Pressure Ulcers - pressure ulcer risk identification and clinical identifiers to accurately assess, document and report.

Share committee tracked data in a GAP Analysis format each month during the Quality Improvement meeting and during the Quality Assurance meeting.

All Nurses will report any and all skin integrity alteration identified on the day of discovery by email to ___________

Compare EMR skin documentation templates and develop new nursing templates to mirror expected clinical data, if needed.

Research the utilization of photographic wound evidence in medical record. (Privacy, consent, process)

mailto:[email protected]




Accomplishments to Date

Skills Workshop - mandatory for all nursing staff. Included: Medline products, education about Braden Scale - how to use tool, what risk factors lead to interventions; clean vs sterile wound care techniques.

May 2016




Roles and Responsibilities

Role Responsibilities

Chair/Co-Chairs Responsible for ensuring committee members have the support and resources necessary to meet demands of committee membership.

Manage the committee’s performance of tasks.

Schedule and facilitate committee meetings.

Responsible for ensuring deliverables of committee are met including: work plans/reports, future/desired state processes, establishing measurable goals and timelines, tracking issues, establish education and communication plans.

Coordinate timely sharing of information.

Completes meeting agenda and minutes and submits these, with attendance record, to the Director of Nursing for review, approval and maintenance.

Maintains list of accomplishments/goals met throughout the year.

Participates in completing GAP analysis on a monthly basis and adjusts committee initiatives and plans to remain on task to meet established goals.

Presents committee findings each month during Quality Improvement Committee meeting as well as monthly/quarterly results during monthly Quality Assurance Committee meeting.

Establishes committee objectives and goals for 1st and 2nd Q by Jan. 30th annually (February).

3rd Quarter tactics, including goals and outcomes, due by June 30th for review during 2nd Q QM meeting (July).

4th Q tactics, including goals and outcomes, are due by September 30th for review at the 3rd Q QM meeting (October).

Data Analyst Maintains integrity of internal data tracking process.

Prepares presentation slides for monthly Quality Improvement Committee meeting by due date and shares insight with Committee.

Performs GAP Analysis on data gathered each month and shares with committee chair and stakeholders.




Clinical Team Members Provide clinical insight/ oversight for committee initiatives and assists with the escalation/resolution of issues as needed.

Assists to build and broaden Committee membership to include caregivers and front-line team members.

All Committee Members Role and Responsibilities

Attend monthly meetings either in person or receive approval from supervisor for stand-in/replacement.

Carry out work plans and provide monthly updates.

Compliance with meeting ground rules.

Completes medical record audits as assigned.

Establishes committee objectives and goals for 1st and 2nd Q by Jan. 30th annually (February).

3rd Quarter tactics, including goals and outcomes, due by June 30th for review during 2nd Q QM meeting (July).

4th Q tactics, including goals and outcomes, are due by September 30th for review at the 3rd Q QM meeting (October).

We C.A.R.E. About Care › uploads › 70_QAPI_Play_or_Pay.pdf · • Payroll Based Journal (PBJ)...

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