How To Embed QAPI In Your Transition Process

Transcription

1 How To Embed QAPI In Your Transition Process Objective 3 Getting Started With Your Care Transitions PIP Sarah Dereniuk, MHA, NHA Program Administrator This material was prepared by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode Island, 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.

2 Objectives Learn how to conduct a PDSA Cycle Understand Root Cause Analysis Develop a Performance Improvement Plan (PIP) to improve care transitions Next steps 5/7/2015 2

3 PDSA Model for Improvement Act Plan Study Do 5/7/2015 3

4 Plan Agrees that a focused attention on hospital readmissions is needed Do Appoints a PIP and work with the PIP in identifying root cause Work with the PIP to set-up improvement target Approves the PIP plan Study Identifies the need to improve incidents of readmission to the hospital Starts determining root cause Act Ensures improvement plan is carried out and approved resources are obtained Communicates as needed with Board of Directors, referring hospitals and physicians, ACOs, and others as needed

5 Considerations for Determining Determine if Root Cause The issues are facility-wide, limited to a unit, or associated with a few residents Family involvement in decisions to hospitalize The reasoning behind physician decision to hospitalize RN, LPN and weekend staffing contribute to decision to hospitalize

6 Considerations for Determining Determine if Root Cause Staff perceive issues with threat of liability If readmissions are associated with a particular diagnosis Readmission are associated with covering physicians Residents readmitted are at end-of-life

7 PIP Outline Facility Name: ABC Nursing & Rehabilitation Date: 4/1/ Name your PIP: Improving diagnostic services to avoid hospital transfers 2. List the names of staff participating in the PIP: K. Smith, Administrator S. Johnson, Unit Secretary N. Acosta, DNS R. Lee, Mobile Lab Rep R. Harrison, ADON V. Bailey, Mobile x-ray Rep K. Blanche, RN Supervisor

8 PIP Outline 3. Identify any supplies/equipment needs: Staff time for in-service training 4. Identify PIP meeting schedule & information review: Meet the first Tuesday of every month at 11am to review recent transfers

9 PIP Outline 5. Identify data sources to monitor project impact: Facility developed a tool to track the turn-around time for diagnostic testing 6. Name project data reviewer and how often is done: Unit Secretary to track hospital transfers daily. ADON to review transfers and monitor turnaround time for diagnostic services weekly.

10 PIP Outline 7. Name person who will prepare/present project results: K. Smith Administrator 8. Establish a protocol/procedure (P&P) that addresses your problem: Name your policy and/or procedure(s) that address your quality project

11 PIP Outline 9. Identify the problem solving model that will be used: PDSA 10. Identify root cause analysis processed used: INTERACT QI Tool to address readmissions identified on transfer tracking log and evaluate plan and plan changes for effectiveness; learning circle discussions.

12 Next Steps Start Implementing QAPI!

13 For More Information: QI Tools Download the PDSA Worksheet and other QI Tools: Included in the QI Tools folder: Fishbone Diagram PDSA Worksheet Root Cause Analysis and Action Plan Framework Template

14 For More Information Download the QAPI Program Packet: Included in the Packet: Charter and Sample PIP and Sample Notebook Sections