HEALTH CARE COMMUNITIES POLICY STATEMENT 2016 Quality Assurance & Performance Improvement Plan DEPARTMENT(S): Quality Management/Compliance Org.: 01/01/16 Rev: 05/18/16 Vision: Where the Spirit creates Abundant Life in Community. Mission: Our Mission is to transform Aging by building a culture of community, wholeness and peace. Purpose: The purpose of QAPI Plan is to provide a written plan for how we monitor the healthcare and hospitality services provided for our residents by caregivers and other staff members and contractors in an effort to realize our Vision and Mission in a manner consistent with applicable regulatory requirements, industry best practices and United Church Homes (UCH) core values. It also describes the essential components of UCHs QAPI Program. Each senior living community will participate in continuous quality assurance/performance improvement (QAPI) activities, including the publication of annual community level QAPI Plans for incorporation into the UCH system-wide annual QAPI Plan adopted by the Board of Directors. Guiding Principles: 1. Compassion: We believe demonstrating God s love through active listening, gentle touch and gracious presence honors the humanity of the people we serve. 2. Hospitality: We believe working to help all feel safe and at home builds a diverse community which we imagine to be radically open and inclusive of everyone. 3. Respect: We believe honoring the experience and perspective of others releases the richness of the gifts within our community. 4. Integrity: We believe acting with the courage of our convictions builds trust and aligns our actions with our values. 5. Stewardship: We believing using all God s gifts wisely advances the well-being of others and equips us to serve the common good. 6. Transparency: We believe living by a high ethical calling empowers us to be agents of transformation and to grow in excellence. QAPI Plan 2016 Policy & Procedure UCH Page 1
Scope: UCH recognizes that individual performance is integral to achieving our mission and further acknowledges that the most significant advances in performance improvement will result from collaboratively focusing on important processes of service within our communities. This continuous performance improvement culture has been integrated into all UCH community operations. When appropriate, there is also coordination or integration of quality activities within UCH services and/or with external contracted service entities and ancillary services providers (such as collaborative quality improvement activities). The QAPI Plan addresses the monitoring and reporting requirements set forth in federal and state regulations and proactively pursues opportunities for improvement in these areas. Additionally, the QAPI Plan documents, facilitates and monitors UCHs organizational quality assurance/performance improvement priorities. The QAPI Plan includes all segments of care and services provided by UCH senior living communities that impacts clinical care, quality of life, resident choice and care transitions with participation of all departments: Services Clinical Care Services Dining Services Pharmacy Services Services Summary We provide clinical care to residents with acute and chronic disease, rehabilitative needs as well as palliative and end of life care. All care is resident directed and focused on resident choice and individualized treatment plans. We strive to meet each resident s goals of care, including developing and executing transitional plans for return to home. We provide nutritious meals under the supervision of a licensed dietician. We consider resident choices and preferences by providing several options for meals and embrace open dining hours. We provide supervision and collaborate with the medical and nursing team by reviewing, dispensing, and monitoring medication effectiveness to ensure therapeutic goals are maintained for each resident. Maintenance/Engineering We provide comprehensive building safety, repairs and inspections to ensure all aspects of safety are enforced, assuring the safety and well-being for each resident, visitor and staff member entering a community. Housekeeping Administration We provide and ensure that all health, sanitation and OSHA requirements are met through regular cleaning, disinfection and sanitation of all aspects of the community. We align all business practices to ensure every resident has individualized care and we work to support the providers with the resources and equipment required to meet or exceed residents care goals. QAPI Plan 2016 Policy & Procedure UCH Page 2
The UCH QAPI Program will target safety and quality with clinical interventions, while allowing resident (or resident s agent(s)) autonomy and choice in daily life. This will be done through proactive analysis using data collection tools and on-going performance monitoring systems. The best available evidence and industry benchmarks will be used to define, measure and monitor performance. QAPI Goals: QAPI Program goals are developed each calendar year for at both the UCH system-wide and community levels (see Appendix A). Governance and Leadership: The Board of Directors, corporate officers and the community administrators will oversee the annual QAPI Program activities. The President/CEO (or designee) has direct oversight responsibility for all functions of the Healthcare Services Committee of the Board of Directors (the designated QAPI Program Steering Committee) and reports directly to the governing body. The QAPI Program Committee for each community (which includes the Medical Director, Administrator, Director of Nursing and no fewer than three additional members) is responsible for assuring compliance with federal and state requirements and continuous improvement in the quality of care and resident/family satisfaction. Each community will assure that staff member, residents, and contractors are aware of the QAPI Program, including the annual QAPI Plan, and their views are sought, valued and considered in community decision-making and process improvements. Every caregiver will be educated to assure they understand that they are expected to raise quality concerns, that it is safe to do so, and that everyone is encouraged to think about improving processes, systems and service performance. Consultants, collaborating agencies, and contractors will be educated to assure they understand their role in the QAPI Program and annual plan. The QAPI Program and annual plan will be discussed at resident council meetings. Feedback, Data Systems and Monitoring: UCH will implement systems and processes to monitor care and services, drawing data from multiple sources. Feedback systems will actively incorporate input from staff members, residents, families and others as appropriate. The systems and processes will include using performance indicators to monitor a wide range of care processes and outcomes, and reviewing findings against benchmarks and/or goals established by each community to continuously improve performance. It will also include tracking, investigating and monitoring adverse events and action plans implemented through the incorporation of the Plan, Do, Study, Act (PDSA) model of improvement to prevent recurrences. QAPI Plan 2016 Policy & Procedure UCH Page 3
UCH will determine what data metrics to monitor/benchmark for the organization. Each community will determine those performance indicators specific to their community, which may include, but not be limited to, the following examples: Resident satisfaction Family satisfaction Staff member satisfaction Care plans, including implementation and evaluation of measurable interventions Annual licensure survey results and plans of correction (POC) Complaint survey results and plans of correction (POC) Hospitalizations and other service usage Clinical care performance metrics Formulary performance MDS assessments and metrics Business and administrative processes Targets for performance in the performance areas being monitored will be set by the UCH QAPI Program team. Benchmarks for performance such as the CMS Nursing Home Compare website (www.medicare.gov/nhcompare), CASPER reports, senior living industry benchmarks, UCH performance reports and community performance metrics will be used to monitor performance improvement. Performance Improvement Projects: The QAPI Program team will review information sources to determine if gaps or patterns exist in systems and processes of care that may result in quality of care performance deficits; or if there are opportunities to make improvements. The information sources may include, but are not limited to, the following: MDS metrics, CMS Nursing Home Compare key indicators, resident/family complaints, patterns of caregiver absences or turnover, caregiver satisfaction and resident/family satisfaction. Based on the results of the information and data reviews, the QAPI Program team will prioritize opportunities for improvement, taking into consideration the importance of the issues (high risk, high frequency and/or problem prone). The QAPI Program team will determine which problems will become the focus for performance improvement projects (PIPs). Depending on the PIP to be started, the QAPI Program team will charter a PIP Team who is entrusted with an assignment to analyze a problem area and develop plans for correction and/or improvement for implementation. QAPI Plan 2016 Policy & Procedure UCH Page 4
Systematic Analysis and System Action: UCH uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes and implications for change. Each community applies 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. UCH s approach comprehensively assesses all involved systems to prevent future events and promote sustained improvement. Policies and procedures are developed regarding expectations for the use of root cause analysis when problems are identified. This element includes a focus on continual learning and continuous improvement. Tools that may be used include, but are not limited to, fish bone diagrams, flow charting processes, five whys, brainstorming, and utilization of root cause analysis forms. Communication: The UCH Director of Quality Assurance/Risk Management and executive leadership will report no less than annually to the Board of Directors on the status of the current year QAPI Plan and proposed QAPI Plan and goals for the upcoming calendar year. The report will be made available to the Corporation Board of Directors, executive leadership, management team, staff members, residents, family members and other stakeholders as key stakeholders as determined by UCH. Each community s QAPI Program Committee will meet no less than quarterly and report the program of established annual QAPI Program goals, PIP teams and current data trends to the President/CEO, Chief Operating Officer (COO), community staff members, residents and family members. Evaluation: The Chief Operating Officer, Director of Operations and community management teams, along with the UCH Director of Quality Assurance/Risk Management, will conduct community-wide systems evaluations and may use the QAPI self-assessment (http://www.cms.gov/ Medicare/Provider-Enrollment-and- Certification/QAPI/downloads/QAPISelf Assessment.pdf) or other tools each calendar year to report findings and plans for improvement to the Healthcare Service Committee of the Board of Directors. The progress made during the previous year toward achieving designated QAPI Program goals and current status of measurement in meeting and sustaining performance indicators will be reviewed. Other factors to consider will be current trends in the long-term care industry as well as strategic organizational and community goals. Gaps in the systems and processes will be identified and addressed in the coming year s annual QAPI Plan. QAPI Plan 2016 Policy & Procedure UCH Page 5
References 1. The Centers for Medicare & Medicaid Services. QAPI at a Glance: A Step by Step Guide to Implementing Quality Assurance and Performance Improvement (QAPI) in Your Nursing Home. https://www.cms.gov/medicare/provider- Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and- Cert-Letter-13-05.pdf. Accessed August 18, 2014. 2. The Centers for Medicare & Medicaid Services. QAPI Process Tool Framework. http://www.cms.gov/medicare/provider-enrollment-and- Certification/QAPI/Downloads/ProcessToolFramework.pdf. Accessed August 18, 2014. 3. Carolinas Center for Medical Excellence. Atlantic Quality Innovation Network: Action Collaborative for Excellence in Long-Term Care 2014 QAPI Plan. QAPI Plan 2016 Policy & Procedure UCH Page 6
APPENDIX A. 2016 United Church Homes Corporate QAPI Plan Goals: 1. Annual Medicare 30-day all cause hospital readmission rate less than 12.0%. 2. Annual percentage of residents with one or more falls with major injury <5.0%. 3. CMS 5-Star Program Overall Rating >3-Stars by 12/31/16 4. CMS 5-Star Program Quality Domain Rating >4-Stars by 12/31/16. 2016 Community QAPI Plan Goals: 1. Each community will identify two goals from the AHCA Advancing Excellence Program. One goal must be process related and the second clinically focused. 2. Each community will comply with the State of Ohio requirements by identifying one project approved by the Ohio Department of Aging. 3. Each community will complete ODH annual licensure survey(s) with the number of ODH recorded deficiency citations less than the statewide mean value and with no Level G or higher nursing care citations. 4. Each community will participate in the Ohio Department of Aging 2016 nursing facility family member satisfaction survey and achieve an overall score exceeding the statewide median value. 5. Each community will participate in the Ohio Department of Medicaid Quality Improvement Program (QIP) and earn the maximum score of 5.0 points (100% compliance). 6. Each community will achieve a CMS 5-Star Program Quality Domain rating > 4- Stars by 12/31/16 by managing, monitoring and improving performance on the CMS reported quality measures. QAPI Plan 2016 Policy & Procedure UCH Page 7