9/18/2013. Quality Assurance Performance Improvement (QAPI) What s New. Sources. Linking Survey and Quality. New Regulations

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1 Quality Assurance Performance Improvement (QAPI) Linking Survey and Quality New Regulations What s New CMS and contractors working on materials New Publication QAPI at a Glance 2 Sources Centers for Medicare and Medicaid Services. S&C: NH "Preview of Nursing Home Quality Assurance & Performance Improvement (QAPI) Guide - QAPI at a Glance.", 14 December 2012 "QAPI at a Glance: A Step by Step Guide to Implementing Quality Assurance and Performance Improvement (QAPI) in Your Nursing Home (DRAFT)." Centers for Medicare and Medicaid Services, University of Minnesota, Stratis Health, December

2 4 The New Regulation The ACA provision at Section 6102 requires nursing homes to develop a compliance and ethics program including (at part c) a Quality Assurance and Performance Improvement Program [QAPI]. 5 The New Regulation This provision specifies that the Secretary (delegated to CMS) must establish standards relating to quality assurance and performance improvement and must implement a program that will provide technical assistance to facilities on the development of best practices in order to meet such standards. 6 2

3 The New Regulation This new provision significantly expands the level and scope of facility activities in order not only to correct defects but also to constantly monitor all care and services in order to continually improve performance 7 What is Quality Assurance Performance Improvement (QAPI) QAPI is a data-driven and pro-active approach to quality improvement. Activities of this comprehensive approach are designed to involve all members of an organization to continuously identify opportunities for improvement, address gaps in systems through planned interventions in order to improve the overall quality of care and services delivered to nursing home residents. 8 Purpose of QAPI To greatly enhance each nursing home s processes of assessing their quality of care and services Continually correcting defects and improving their performance outcomes 9 3

4 CMS Contract Evaluate current tools that may be useful for providers Develop a web-based resource library for providers and consumers: Examples of QAPI frameworks Core components and best practices Survey procedures and worksheets Initiate rollout November Current QA Regulation Current regulation for Quality Assurance in Nursing Homes requires only a limited group of staff members to be involved in a Quality Committee. DON A physician Three members of the staff 11 Current Regulation Basis for QAPI QAPI uses existing Quality Assessment and Assurance regulation and guidance as a foundation QAPI uses a systems approach to actively pursue quality not just respond to external requirements May be already using parts of the process 12 4

5 Whose Job is Quality? Quality is a team sport. All members of an organization must participate in quality. Everyone has some degree of responsibility to quality from the top of the organization to bottom. Quality is not just the responsibility of a committee or those who attend a meeting. 13 Develop a Steering Committee A team to provide QAPI leadership Overall responsibility to develop and modify the plan, review information, set priorities for PIPs Charters teams to work on particular problems Reviews results and determines next steps Learn and use systems thinking 14 Develop a Steering Committee Must include top leadership Engage medical director in QAPI Adapt QA committee to steering committee May need to meet more often Include more people Establish permanent and time-limited work groups that report to it 15 5

6 QUALITY ASSURANCE & PERFORMANCE IMPROVEMENT QAPI and National Goals Improve Care for Individuals Improve Health for Populations Reduce per capita Costs in healthcare delivery system 17 Quality Assurance QA is a process of meeting quality standards and assuring that care reaches an acceptable level. Nursing homes typically set QA thresholds to comply with regulations. They may also create standards that go beyond regulations. QA is a reactive, retrospective effort to examine why a facility failed to meet certain standards. QA activities do improve quality, but efforts frequently end once the standard is met. 18 6

7 Quality Assurance Quality assurance involves measuring and tracking indicators to find out where the facility is performing well, and where there are opportunities for improvement. 19 Two functions that go hand in hand Performance Improvement PI (also called Quality Improvement - QI) is a proactive and continuous study of processes with 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. 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. 21 7

8 Performance Improvement PI is a proactive and continuous study of processes with 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. 22 Performance Improvement PI in nursing homes aims to improve processes involved in health care delivery and resident quality of life. PI can make good quality better. 23 Performance Improvement Performance improvement is the reaction and correction to an opportunity to improve. 24 8

9 Quality Assurance and Performance Improvement -Comparison Motivation QUALITY ASSURANCE Measuring compliance with standards PERFORMANCE IMPROVEMENT Continuously improving systems and processes Means Valid measurement PDSA Cycles Attitude Required, comprehensive Chosen, specific Focus Outcomes Systems and Processes Scope Resident Care All Services Responsibility QA Staff All Staff 25 Data driven QA+PI=QAPI Proactive approach to performance management and improvement Systematic Comprehensive Improves quality of life, care and services All levels of the organization 26 QA+PI=QAPI Identify opportunities for improvement Address gaps in systems or processes Develop and implement an improvement or correction plan Continuously monitor effectiveness of interventions 27 9

10 Linking Survey and Quality USING THE QIS METHODOLOGY TO IMPLEMENT QAPI QIS Provides the Framework for a Quality Assurance and Performance Improvement System 29 What can be done with QIS Continuous Survey Readiness Continuous Quality Assurance Performance Improvement 30 10

11 Quality Assurance Four Fundamental Steps 1. Develop scientifically valid quality metrics 2. Establish minimum quality standards 3. Systematically evaluate quality using metrics 4. Verify that quality meets minimum standards 31 Scientifically Valid QIS Metrics Quality of Care and Life Indicators (QCLIs) # Residents in Sample With Negative Response # Total Residents in Sample (less relevant exclusions) = RATE (%) 32 Metrics Validated Against Regulation (b) - Self-Determination and Participation The resident has the right to-- (1) Choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care; (2) Interact with members of the community both inside and outside the facility; and (3) Make choices about aspects of his or her life in the facility that are significant to the resident. Source: State Operations Manual, Appendix PP -Guidance to Surveyors for Long Term Care Facilities, (Rev. 70, ) 33 11

12 Establish Minimum Quality Standards - Thresholds The QCLI rate established to govern the decision of whether to conduct an in-depth Stage 2 review or investigation Value is absolute, not relative Rate is facility-level 34 Systematically Evaluate Quality Intervene Intervene Stage 2 Intervene Stage 1 Stage 1 Stage 1 Quality Committee 35 Continuously Assess at a sustainable rate so that continuous use is achieved. This produces the best results

13 Use Two - Stage Approach Stage 1 preliminary investigations Mandatory Facility Level Tasks Stage 2 in-depth investigations Copyright 2011 Providigm, LLC 37 The Five Elements of QAPI 1. Design and Scope 2. Governance and Leadership 3. Feedback, Data Systems and Monitoring 4. Performance Improvement Projects (PIPs) 5. Systematic Analysis and Systemic Action 38 QAPI Strategic Framework 39 13

14 The Five Elements of QAPI 1. Design and Scope 5. Systematic Analysis and Systemic Action 2. Governance and Leadership 4. Performance Improvement Projects (PIPs) 3. Feedback, Data Systems and Monitoring The Five Elements of QAPI 1. Design and Scope 5. Systematic Analysis and Systemic Action 2. Governance and Leadership 4. Performance Improvement Projects (PIPs) 3. Feedback, Data Systems and Monitoring 1. Design and Scope A QAPI program must be ongoing and comprehensive, dealing with the full range of services offered by the facility, including the full range of departments When fully implemented, the program should address clinical care, quality of life, resident choice, and care transitions 42 14

15 1. Design and Scope The Program aims for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents (or resident s agents) The Program utilizes the best available evidence to define and measure goals Nursing homes will have in place a written QAPI plan adhering to these principles. 43 QAPI 1. Design and Scope QAPI is Ongoing and Comprehensive dealing with full range of services offered by the facility,including the full range of departments. When fully implemented the QAPI program,should address all systems of care and management practices, and always include Clinical Care, Quality of Life, and Resident Choice. QIS QIS, covers the whole regulation. Used routinely, it is ongoing. Covers all regulatory care areas and services and departments. QIS looks at systems of care required by Federal Regulation including individual resident care and facility wide care systems which incorporates Quality of Life, Quality of Care and Resident Choice. It aims for safety and high quality with all clinical interventions whileemphasizing autonomy and choice in daily life for residents (or resident s agents). QISwas designed around resident centered care. QIS care areas also look at clinical interventions, choices, resident rights, accidents, choices, and activities. 1. Design and Scope QAPI Utilizes the best available evidence to define and measure goals. Nursing homes will have in place a written QAPI plan. QIS Indepth investigation in QIS is tied to CMS QCLI s and thresholds. If thresholds are exceeded, there is a high likelihood of non compliance and quality issues. QIS can be used in QAPI plan. 15

16 Quality Indicator Survey Full Range of Services Based on the methodology of the Quality Indicator Survey Stage 1 Stage 2 Designed to cover the entire regulation 46 QCLI Dictionary Quality of Life,Care and Resident Choices Copyright 2011 Providigm, LLC 47 QCLI Dictionary 48 16

17 Thresholds Define and Measure Goals 49 The Five Elements of QAPI 1. Design and Scope 5. Systematic Analysis and Systemic Action 2. Governance and Leadership 4. Performance Improvement Projects (PIPs) 3. Feedback, Data Systems and Monitoring 2. Governance and Leadership The governing body and/or administration of the nursing home develops and leads a QAPI program that involves leadership working with input from facility staff, as well as from residents and their families and/or representatives

18 2. Governance and Leadership The governing body assures the QAPI program is adequately resourced to conduct its work. This includes: designating one or more persons to be accountable for QAPI; developing leadership and facility-wide training on QAPI; and ensuring staff time, equipment, and technical training as needed for QAPI Governance and Leadership They are responsible for establishing policies to sustain the QAPI program despite changes in personnel and turnover. The governing body and executive leadership are also responsible for setting expectations around safety, quality, rights, choice, and respect by balancing both a culture of safety and a culture of resident-centered rights and choice Governance and Leadership The governing body ensures that while staff are held accountable, there exists an atmosphere in which staff are not punished for errors and do not fear retaliation for reporting quality concerns

19 2. Governance and Leadership QAPI Administration leads QAPI with input from staff, residents, families. QAPI program must be adequately resourced, designatinga person accountable for QAPI, develops facility wide training and provides training and equipment as needed for QAPI. Establish policies to sustain the QAPI program despite changes in personnel and turnover Set priorities for improvement. Balance a culture of safety and a culture of resident-centered rights and choice. Ensures that while staff are held accountable, there exists an atmosphere in which staff are not punished for errors and do not fear retaliation for reporting quality concerns. QIS QIS integrates interviews obtaininginput from residents, family and staff. Use on an ongoing basis, provides continuous feedback. As QIS isavailable as a QA tool,cms maintains thresholds and measurement, updates, forms, resources and materials. QIS process is sustained despiteturnover in staff. Staff can be educated and with turnover, reeducated as needed. Multiple staff members can be trained in the process. QIS thresholdsassist in identifying care areas where in-depth investigation is needed and based on investigation, priorities set for improvement. QIS assesses resident safety, rights and choice and in-depth investigation determines if the facility is meeting the standard. Resident Interview and Observation Multiple Sources 56 QIS Matrix Care Areas Copyright 2011 Providigm, LLC 57 19

20 Setting Priorities with Threshold Reporting 58 The Five Elements of QAPI 1. Design and Scope 5. Systematic Analysis and Systemic Action 2. Governance and Leadership 4. Performance Improvement Projects (PIPs) 3. Feedback, Data Systems and Monitoring 3. Feedback, Data Systems and Monitoring The facility puts in place systems to monitor care and services, drawing data from multiple sources. Feedback systems actively incorporate input from staff, residents, families, and others as appropriate

21 3. Feedback, Data Systems and Monitoring This element includes using Performance Indicators to monitor a wide range of care processes and outcomes, and reviewing findings against benchmarks and/or targets the facility has established for performance. This element also includes tracking, investigating, and monitoring Adverse Events that must be investigated every time they occur, and action plans implemented to prevent recurrences. 61 QAPI 3. Feedback, Data Systems, and Monitoring Facility puts into place systems to monitor care and services, drawing data from multiple sources. Feedback systems actively incorporate input from staff, residents, families, and others as appropriate. Performance Indicators monitor a wide range of care processes and outcomes. QIS QIS is a systematic process thatmonitors care and services through Quality of Care and Life Indicators (QCLI s), mandatory tasks and indepth investigation. QIS incorporates resident, family and staff interviews, resident observations,record review and MDS. In-depthinvestigation elicits additional input. QCLI s, which are outcome and process indicators, monitor numerous care areas, facility processes and outcomes. Findings are reviewed against benchmarks and/or targets the facility has established for performance. Includes tracking, investigating, and monitoring Adverse Events. Thresholds areused to determine if findings indicate a need for further investigation into performance. QIS identifies resident and family allegations of abuse, which is an adverse event. Feedback, Data Systems and Monitoring How will you know if you are doing well? Without a baseline or point of comparison, it is hard to judge your own performance

22 Feedback, Data Systems and Monitoring A strong approach to quality management, such as QAPI, uses performance indicators to monitor a wide range of care processes and outcomes. Then it reviews findings against benchmarks and targets the facility has established for performance. 64 Develop a Strategy for Collecting and Using QAPI Data - Step 7 Your team will decide what data to monitor routinely. Areas to consider may include: Clinical care areas e.g., pressure ulcers, falls, infections Medications, e.g., those that require close monitoring, antipsychotics, narcotics Complaints from residents and families Hospitalizations and other service use Resident, caregiver, family satisfaction 65 Develop a Strategy for Collecting and Using QAPI Data - Step 7 Resident and caregiver experiences living and working in the setting State survey results and deficiencies Results from MDS assessments 66 22

23 Quality Indicator Survey QIS process incorporates process and outcome measures, thresholds and indepth investigation making an ideal basis for QAPI 67 QP 234 Choices Resident Interview Copyright 2011 Providigm, LLC 68 QCLI Dictionary Copyright 2011 Providigm, LLC 69 23

24 QIS Matrix Copyright 2011 Providigm, LLC 70 Identify Care Areas Facility process concerns (Tasks) Resident outcome concerns (Stage 1): Quality of Care Quality of Life Resident Choice Copyright 2011 Providigm, LLC 71 Stage 1 Preliminary Investigation Census Sample Resident Interviews Resident Observations Family Interviews Staff Interviews Clinical Record Reviews Admission Sample Clinical Record Reviews Copyright 2011 Providigm, LLC 72 24

25 Mandatory Facility Tasks Liability Notice and Beneficiary Appeal Rights Dining Observation Infection Control & Immunization Kitchen/Food Service Observation Medication Administration Medication Storage Quality Assessment and Assurance (QA&A) Resident Council President/Representative Interview Copyright 2011 Providigm, LLC 73 Triggered Facility Tasks Abuse Prohibition Admission, Transfer, and Discharge Environmental Observations Personal Funds Sufficient Nursing Staff QIS Extended Survey Copyright 2011 Providigm, LLC 74 The Five Elements of QAPI 1. Design and Scope 5. Systematic Analysis and Systemic Action 2. Governance and Leadership 4. Performance Improvement Projects (PIPs) 3. Feedback, Data Systems and Monitoring 25

26 4. Performance Improvement Projects (PIPs) The facility conducts Performance Improvement Projects (PIPs) to examine and improve care or services in areas that are identified as needing attention Performance Improvement Projects (PIPs) A PIP project typically is a concentrated effort on a particular problem in one area of the facility or facility 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 facility Performance Improvement Projects (PIPs) QAPI QIS A PIP project is a concentrated effort on a particular problemin one area of the facility or facility wide. A PIP involves gathering information systematically to clarify issues or problems, and intervening for improvements. The facility conducts Performance Improvement Projects (PIPs) to examine and improve care or services in areas that are identified as needing attention. Using QIS to assess thresholds and set targets along with in-depth investigation assist in determining the need for a PIP. QIS QCLI s can be used as measurement and re-measurement for PIPS to determine if goals have been met. QIS assists in the assessment to determine if a PIP shouldbe chartered. 26

27 Performance Improvement Projects (PIPs) Conducting PIPs allows the nursing home to examine performance and make improvements in any area identified as needing attention, or that is found to be high priority or high risk based on the needs of the residents. 79 What are PIPs? A Performance Improvement Project is more than a casual effort - it entails a specific written mission to look into a problem area. During a PIP a facility will try out some changes and then see whether or not they made a difference in the area they were trying to improve. Performance Improvement Charter- PIP A charter is typically a documented plan that identifies the problem, goals and the team members roles and responsibilities. The purpose of the charter is to provide the PIP team with key information that will allow them to have a clear understanding of what they are being asked to do. 27

28 Performance Improvement Charter - PIP The charter helps a team stay focused by setting timelines and displaying milestones. The charter does not tell the team how to complete the work but tells them what they are trying to accomplish. A typical PIP identifies: What the problem is A PIP team that will work on it, meet, and report back to the QAPI team in the building Do root cause analysis to figure out what the cause of the problem actually is (five whys, fishbone diagrams, etc. ) What measure they will use to know if they were successful What interventions they will do to fix the problem Create and Name our PIP 28

29 Define our project Who will be our PIP team? Analyze: why this is happening? 29

30 The Five Elements of QAPI 1. Design and Scope 5. Systematic Analysis and Systemic Action 2. Governance and Leadership 4. Performance Improvement Projects (PIPs) 3. Feedback, Data Systems and Monitoring 5. Systematic Analysis and Systemic Action The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. The facility uses a thorough and highly organized/ structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered Systematic Analysis and Systemic Action Additionally, facilities will be expected to develop policies and procedures and demonstrate proficiency in the use of Root Cause Analysis. Systemic Actions look comprehensively across all involved systems to prevent future events and promote sustained improvement. This element includes a focus on continual learning and continuous improvement

31 QAPI 5. Systematic Analysis and Systemic Action The facility uses a systematic approach to determine when in-depth analysis is needed tofully understand the problem, its causes, and implication of a change. The facility uses thorough and a highly organized/structured approach to determine whether and how identified problems may be cause or exacerbated by the way care and services are organized or delivered. Systemic Actions look comprehensively across all involved systems to prevent future events and promote sustained improvement. Facilities will be expected to develop policies and procedures and demonstrate proficiency in the use of QIS QIS looks at system issues, and has a process that defines when they need indepth analysis. In-depth investigation toolsin QIS Stage 2 assist in the process to identify causative factors. UsingQIS assists to monitor that corrective actions are working on a system level. Systematic Analysis and Systemic Action To be effective, interventions or corrective actions should target elimination of root causes, offer long term solutions to the problem, and be achievable, objective and measurable. 92 Root Cause Analysis Root cause analysis (RCA) provides a structure for evaluating events (e.g., adverse events, incident, near miss, unsafe condition, or complaint) The RCA process looks at events and incidents from a systems perspective

32 Reports help to determine if issue is systemic A Model for Performance Improvement 1. What are we trying to accomplish? 2. How will we know that a change is an improvement? 3. What change can we make that will result in an improvement? Source: "The Foundation of Improvement, Langley, G.J., Nolan, K.M., and Nolan, T.W., Quality Progress, ASQC, June 1994, Milwaukee, pp

33 Plan-Do-Study-Act Try some changes and see whether they made a difference in the area you are trying to improve 97 Plan Team learns more about the problem Plans for how the improvement will be measured Plans for any changes that might be implemented 98 Plan is carried out Do Includes measures selected 99 33

34 Study Team summarizes what it learned 100 Act Team and leadership determine what should be done next The change can be adapted (and restudied) Adopted (perhaps expanded to other areas) Abandoned This decision determines next step in the cycle 101 For information regarding QIS Education Contact: Cindy Mason, VP Provider Services, Providigm 7500 E. Arapahoe Rd, Suite 101 Centennial, CO

35 For information regarding abaqis Contact: Ellen Sandler, VP Sales and Marketing, Providigm 7500 E. Arapahoe Rd, Suite 101 Centennial, CO