What is QAPI What nursing home medical directors should know - Susan Levy by wuzhenguang


									 QAPI: What Nursing
    Home Medical
Directors Should Know
            Susan M. Levy, MD, CMD
 VPMA Levindale Hebrew Geriatric Center and Hospital
            Baltimore, Maryland 21215
                September 14, 2013
QAPI: Learning Objectives

• Understand how CMS QAPI initiative developed

• Learn the five components of QAPI

• Know the medical directors role in QAPI

• Update on the CMS Partnership to Improve
  Dementia Care
  Susan M. Levy, MD, CMD
• CMS Consultant to the Nursing home division

• Legal expert review

• MMDA advisor to the board

• AMDA committees
  • Governance
  • Transitions of Care
  • Public Policy
           QAPI and ACA

• Provisions in section 6102
   • Secretary shall establish and implement a QAPI program
     in facilities that includes the development of standards
     related to QAPI through regulations
   • The Secretary shall provide technical assistance to facilities
     on the development of best practices in order to meet the
     QAPI and Other Health
• Hospitals

• Home Care

• Dialysis

• Ambulatory Care

and now

• Nursing Homes
                 QA & A F520
• A facility must maintain a quality assessment and 
  assurance committee consisting of:
  • The director of nursing services 
  • A physician designated by the facility
  • At least three other members of the facility’s staff 

• The quality assessment and assurance (QA & A) 
  • Meets at least quarterly to identify issues with respect to 
    which QA & A activities are necessary
  • Develops and implements appropriate plans of action to 
    correct identified quality deficiencies

         QA & A F520, cont. 

• The state or the Secretary may not require 
  disclosure of the records of such committee 
  except insofar as such disclosure is related to 
  the compliance of such committee with the 
  requirements of this section. 
• Good faith attempts by the committee to 
  identify and correct quality deficiencies will not
  be used as a basis for sanctions .

  Description: What is QAPI?

• Quality Assurance (QA) and Performance Improvement
  (PI) are complementary approaches to quality
  management. Both involve seeking and using information,
  but they differ in key ways
  Description: What is QAPI?

• 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.

• PI is a pro-active and continuous study of processes with
  the intent to prevent or decrease the likelihood of problems.
  PI identifies areas of opportunity and tests new approaches
  to fix underlying causes of persistent/systemic problems.
              QA + PI = QAPI

• QA and PI combine to form QAPI, a data-driven,
  proactive approach to improving the quality of life, care,
  and services 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.
      QAPI builds on QA&A

• Committee structure

• Review complaints and concerns

• Conduct audits

• QAPI will go beyond QA&A with
  • Prospective approach through comprehensive plan and
    leadership engagement
  • Greater involvement of all staff, residents, families
  • Focus on performance improvement projects (PIPs) and
   Description: What is QAPI?
                 Quality Assurance         Performance
Motivation       Measuring compliance      Continuously improving
                 with standards            processes to meet
Means            Inspection, review        Prevention, planning
Attitude         Required, defensive       Chosen, proactive
Focus            Outliers, “bad apples,”   Processes, systems
Scope            Individual provider       Systems for patient care
Responsibility   Few                       All
 Comparison of QA and QI
           Quality Assurance (QA)    Quality Improvement
   Focus: Catch “bad apples” or      Improve processes—not 
          detect serious problems    fault finding
    Goal: Meet minimal standards     Ongoing process 
    Who’s Usually 1-2 individuals    Teams
Driven By: Regulation/accreditatio   Organizations
   Occurs: Monthly or quarterly      Continuously

           CMS QAPI Efforts

§ Nursing home quality improvement questionnaire

§ Development of QAPI tools and resources

§ Development of QAPI website

§ QAPI demonstration project:
  • Test tools/resources
  • Conduct learning collaboratives
  • Online resource center for demo participants

               QAPI FAQs

• Aren’t we already meeting the requirements?
    • Formal improvement model
    • Ongoing accountability

• When will the QAPI regulations be issued?
    • TBA but will have one year to submit written plan

• Will surveyors have access to QAPI documentation?
    • Until regulations promulgated remains unclear
AMDA Medical Director
Roles and Responsibilities

• Functions
• Tasks
• Competencies
 AMDA Medical Director

Function 3 – Quality Assurance
The medical director participates in
the process to ensure the
appropriateness and quality of
medical care and medically related
    AMDA Medical Director
      Function 3 Tasks
1. The medical director participates in the monitoring
   of care within the facility through a quality
   assurance program that encourages self-evaluation,
   anticipates and plans for change and meets

2. The medical director maintains knowledge of state
   and national standards for nursing home care and
   ensures that the facility meets the minimal
   acceptable standards of care
     AMDA Medical Director
       Function 3 Tasks
3. The medical director understands basic research
methods when conducting medical care evaluations
studies, evaluates and reviews the feasibility and goals
of research projects, and fosters a facility wide attitude
that is supportive of research and open to change.

4. The medical director monitors physician
performance and involves the attending physician in
the setting of quality assurance standards.
     AMDA Medical Director
       Function 3 Tasks
5. The medical director ensures that the quality assurance
   program addresses issues germane to the quality of
   patient care.
6. The medical director utilizes the quality assurance
   program to effect change in policies and procedures.
7. The medical director establishes with the administration
   a means for disseminating information gained from the
   quality assurance program to residents, family members,
   staff members, attending physicians and other
   appropriate personnel.
    AMDA Medical Director
      Function 3 Tasks
8. The medical director serves as chairman of the
   institutional committee to review the feasibility and
   goals of research projects and disseminates research

9. The medical director participates in the quality
   review of care within the facility n those specific
   areas mandated by law (e.g. drug level monitoring,
   laboratory indicator monitoring)
    AMDA Medical Director
      Function 3 Tasks
10. The medical director reviews periodically
    admission transfers, and discharges of patients.

11. The medical director participates in time
    management studies
Framework for Competencies

• Based on ACGME Outcome Project’s General 
  • Foundational (Ethics, Professionalism and 
  • Medical Care Delivery Process
  • Systems
  • Nursing Home Medical Knowledge
  • Personal QAPI
Competency Pyramid
          AMDA Competencies
            Personal QAPI
•   5.1 Develops a continuous professional development plan 
    focused on post-acute and long-term care medicine, utilizing 
    relevant opportunities from professional organizations (AMDA, 
    AGS, AAFP, ACP, SHM, AAHPM), licensing requirements (state, 
    national, province) and maintenance of certification programs

•   5.2 Utilizes data (e.g. PQRS indicators, MDS data, patient 
    satisfaction) to improve care of their patients/residents  

•   5.3 Strives to improve personal practice and patient/resident 
    results by evaluating patient/resident adverse events and 
    outcomes (e.g., falls, medication errors, healthcare acquired 
    infections, dehydration, return to hospital)  
      AMDA Position

• HOD resolution A 06 - 2006
• White Paper C 11“Role of the
  Medical Director Quality
  Assurance and Process
  Improvement in Long-Term Care -
  2011 in
   Five Elements of QAPI

• Design and Scope

• Governance and Leadership

• Feedback, Data Systems, and Monitoring

• Performance Improvement Projects (PIPs)

• Systemic Analysis and Systemic Action
 Role of the Medical Director
       in Each Element
“Beyond the Quick Fix: The Medical Director’s Role
in QAPI” Geriatric Medicine and Medical Direction
Vol. 34(4) April 2013-Jane Pederson, MD Stratis

Personal Comments
   Element #1: Design and Scope

                                           • Address:
§ A QAPI program must be:                   •   Clinical care
 • Ongoing and comprehensive                •   Quality of life
 • Dealing with the full range of           •   Resident choice
   services offered by the facility         •   Care transitions
 • Including ALL departments                § Aims for safety and high 
§ It utilizes the best available              quality with all clinical 
  evidence to define and                      interventions
                                            § Emphasizes autonomy and 
  measure goals.                              choice in daily life for residents 
§ A written QAPI plan                          

Design and Scope: Role of the
      Medical Director
Should be integrally involved as they can weigh the
balance between quality and safety, and resident
quality of life and individual autonomy

Vision of what is good care for all as well as each
   Element #2: Governance and 
The governing body
and/or administration:
§ Develops and leads a         § Develops leadership and
  QAPI program                   facility-wide training on
§ Involves leadership            QAPI
§ Uses input from facility     § Ensures staff time,
  staff, residents and their     equipment and technical
  families and/or                training as needed for
  representatives                QAPI
§ Assures the QAPI             § Responsible for
  program is adequately          establishing policies to
  resourced                      sustain the QAPI
                                 program despite changes
§ Designates one or more         in personnel and turnover
  persons to be accountable
  for QAPI
      Element #2: Governance and 
           Leadership, cont.
Also responsible for:
§Setting priorities for the QAPI            § The governing body ensures
program                                       that while staff are held
                                              accountable, there exists an
§Building on the principles
identified in design and scope                atmosphere in which staff
                                              are not punished for errors
§Setting expectations around:                 and do not fear retaliation
      • Safety, Quality, Resident             for reporting quality
        Rights, Choice, and                   concerns.
      • Balancing both a culture of
        safety and a culture of
        resident-centered rights and

Governance and Leadership : Role
    of the Medical Director

• Educate organizational leaders and
• Help drive data driven decisions
• Support a culture of quality
  improvement and safety in all that is
• Encourage team problem solving
   Element #3: Feedback, Data 
     Systems and Monitoring
§ Put systems in place to monitor care and services,
  drawing data from multiple sources.

§ Feedback systems actively incorporate input from staff,
  residents, families and others as appropriate.

§ Use performance indicators to monitor a wide range of
  care processes and outcomes

§ Review findings against benchmarks and/or targets the
  facility has established for performance.

  Element #3 Feedback, Data
 Systems and Monitoring (cont.)

• Tracking, investigating, and monitoring ADVERSE
  EVENTS that must be investigated every time they
  occur and action plans implemented to prevent


Feedback, Data Systems and Monitoring:
         Role of the Medical Director

• Help the facility gather data that will evaluate their
  current performance

• Use their skills in data management

• Solicit feedback from the medical staff

• Develop process to obtain feedback and monitor
  provider performance
    Element #4: Performance 
   Improvement Projects (PIPs)
• Conduct PIPs to examine and improve care or 
  services in areas identified as needing attention. 
• A PIP is: 
  • A concentrated effort
  • On a particular problem in one area of the facility or facility
  • Involves gathering information systematically to clarify 
    issues or problems
  • Intervening for improvements
  • Selected in areas important and meaningful for the specific 
    type and scope of services unique to each facility

    PIPs: Role of the Medical
• Participate and in some cases lead teams with
  facility support

• Review and assist with developing team charters

• Be kept in the loop through updated reports at
  facility meetings and/or minutes

• Be available as a consultant to other team leaders
Element #5: Systematic Analysis 
     and Systemic Action
•   Use a systematic approach to determine when in-depth analysis is 
    needed to fully understand the problem, its causes and implications 
    of a change (a.k.a. root cause analysis).

•   Use 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/delivered.

•   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 

  Systemic Analysis and Systemic
Action: Role of the Medical Director

• Support culture of avoiding individual
  blame and focusing on system fixes
• Understand and support RCA
  approach to problems that gets to the
  long term fix
     QAPI at Glance – Step by 
           Step Guide

      Implementing QAPI: A 12
       Step Program -STEP 1
• Leadership responsibility and accountability
  •   Availability to staff
  •   Visibility on units
  •   Commit, follow through, lead by example
  •   Recognize staff and give the credit
  •   Involve staff and build leadership skills
  •   Ensure staff have equipment to do their job
  •   Openly admit errors-culture of transparency
  •   Set high expectations
           QAPI: STEP 2

• Develop a Deliberate Approach to
   • Assess the effectiveness of teamwork in the
   • Discuss how PIP teams will work to address
     QAPI goals
   • Determine how direct care staff, residents, and
     families can be involved in PIPs
   • Identify communication structures that need to
     be developed or enhanced
         QAPI: STEP 3

• Take your QAPI “pulse” with a Self-
   • Determine when and who will participate
     in the self-assessment
   • Complete the baseline self-assessment
   • Determine when you will reassess
     QAPI Self Assessment

          QAPI: STEP 4

• Identify your organizations guiding
   • Review, update and/or develop your
     organizations mission and vision statement
   • Develop a purpose statement for QAPI
   • Establish guiding principles
   • Define the scope of your QAPI program
   • Assemble the document
     Guiding Principles and 

         QAPI: STEP 5

• Develop your QAPI plan
  • Determine your timeline for writing the
  • Circulate the Guide for Developing a
    QAPI plan for all involved in developing
    the plan
  • Once completed determine time for
     QAPI Plan Outline

             QAPI: STEP 6

• Conduct a QAPI Awareness Campaign
   • Share mission, vision, and guiding principles with all staff
   • Include the mission, vision, and guiding principles in new
     orientation for staff
   • Develop communication plans that use multiple
     approaches to reach all staff across all shifts
   • Hold meetings
   • Share performance date openly and transparently with
     staff, board, residents, families
   • Set up scorecard for staff to monitor progress towards
     important goals and post in visible areas
         QAPI: STEP 7

• Develop a Strategy for Collecting &
  Using QAPI Data
            QAPI: STEP 8

• Identify Your Gaps and Opportunities
   • Measure important indicators of care that are relevant and
     meaningful to the residents you serve
   • Guide and empower staff to solve problems
   • Hold short stand up meetings across all shifts to identify
   • Establish the nursing home as a learning organization
   • Discuss processes and systems to identify areas for
     improvement in all meetings
   • Empower residents to get involved in identifying areas for
           QAPI: STEP 9

• Prioritize Quality Opportunities and Charter
  Performance Improvement Projects (PIPS)
   • Get everyone involved in setting goals
   • If practices are not making sense or seem
     frustrating to staff, residents, and families
     challenge and sort out what you have
     control over and look for ways to address
           QAPI: STEP 10

• Plan, Conduct, and Document PIPs
   • Identify and support a change agent for each
     improvement project
   • Use an action plan template that defines the who and
     when to establish timelines and accountability
   • Seek creative ideas from multiple sources within and
     outside the organization to foster innovation
   • Create a safe environment to test changes
   • Include all “voices” that have a stake in what is being
     Goal Setting Worksheet

        QAPI: STEP 11

• Get to the “Root” of the Problem
 • Use the RCA process to look at systems
   rather than individuals when something
   breaks down.
        QAPI: STEP 12

• Taken Systemic Action
 • Before initiating a change in the
   organization, meet with any staff and
   residents that will be impacted by the
   change in order to gain their support, buy-
   in, and feedback.
        Using QI Tools

There are many tools that can help you meet the goal
   of improving your work processes and services

         Useful QI Tools

v Process Mapping
v Check Sheets
v Pareto Charts
v Cause and Effect Diagrams
  § Fishbone Diagrams
  § The 5 Whys

v Run Charts

What is a Process Map?

vA pictorial representation of
 the sequence of actions that
 describe a process

What are the Symbols Used
  in Process Mapping?
v Start and End of the Process:

v A process Activity:

v A process Decision:

v A Break in the process:

   What is the Purpose of a
       Check Sheet?
v To turn observational data into numerical data
  § From records
  § Newly collected

v To find patterns using a systematic approach
  that reduces bias

v Use check sheets when data can be observed or
  collected from your records

  Run charts
Tracking Process Performance

Individual Facility Quality Improvement
Data: Suburban Pavilion Nursing Home
        Root Cause Analysis

• Inter-disciplinary
• Involving experts from
  the frontline services
• Continually digging 
  deeper by asking why, 
  why, why at each level of 
  cause and effect

           Goal of the RCA
• What happened?

• Why did it happen?

• What to do to prevent it 
  from happening again

          Root Cause Analysis
• Identifies needs for systems changes 

• Is a process that is as impartial as possible

• As well as a tool for
  identifying prevention

• There are various tools 
  to use

     Problem Solving & Root
v When confronted with a problem most people like to tackle 
  the obvious symptom and fix it

v This often results in more problems 

v Using a systematic approach to analyze the problem and 
  find the root cause  is more efficient and effective

v Tools can help to identify problems that aren’t apparent on 
  the surface (root cause)

     What is the 5 Whys?

v A question asking method used to explore the 
  cause/effect relationships underlying a particular 

v The goal is to determine the ROOT CAUSE of a 

5 WHYs Tool

  An Example of the 5 Whys

v My car will not start. (the problem) 
v Why? - The battery is dead. (first why) 
v Why? - The alternator is not functioning. (second why) 
v Why? - The alternator belt has broken. (third why) 
v Why? - The alternator belt was well beyond its useful service 
  life and has never been replaced. (fourth why) 
v Why? - I have not been maintaining my car according to the 
  recommended service schedule. (fifth why, root cause)

   What is the Purpose of
    Fishbone Diagrams?

vTo  identify underlying or root causes of
a problem

vTo identify a target for your
improvement that is likely to lead to

   Construction of a Fishbone

v Then for each cause identify deeper root causes

           Cause 1    Cause 3


           Cause 2   Cause 4

    Tips for Using Fishbone

v Find the right problem or effect statement

v Find causes that make sense and that you can 

v Make use of your results
   Summing Up Cause and
v Use Fishbone and 5 Whys to explore and
  graphically display in increasing detail all of
  the possible causes related to the problem

v Use Fishbone and 5 Whys to find dominant
  causes rather than symptoms

v Use Fishbone and 5 Whys to identify the
  root cause of the problem we seek to

We Have the Root Cause

    Now what?

  Quality Improvement Models
              RAPID CYCLE QUALITY 
              SIX SIGMA
              JACHO 10 STEP
     PDSA and Using QI

v Using tools as part of the PDSA cycle
v Some tools will be useful in the planning
v Others will help you to implement your QI
v And/or will help you study the impact of
  your process change

  Model for Improvement
    What are we trying to
   How will we know that a
 change is an improvement?
What change can we make that
 will result in improvement?

       Act         Plan

     Study         Do

The PDSA Cycle for Learning and
                  Act           Plan
       • What changes       • Objective
         are to be made?    • Questions and
       • AdApt? AdOpt?        predictions (why)
                            • Plan to carry out
         or Abandon?
                              the cycle (who,
       • Next cycle?          what, where, when)
                  Study          Do
     • Complete the         • Carry out the plan
       analysis of the data • Document problems
       • Compare data to      and unexpected
           predictions        observations
          • Summarize what • Begin analysis
             was learned      of the data

     Repeated Use of the Cycle

                                                     Changes That
                                                       Result in
                                            A P      Improvement

                        D AT     D S
                                            S D

                          A     P A
                                               Implementation of Change
                    S       P
           A P                      Wide-scale Tests of Change
           S D
Hunches                 Follow-up Tests
 Ideas      Very Small-scale Test
             GOAL – Improve 

                 Concept D
                                                    Concept C

                                Concept B
Concept A

            Change concepts, theories, ideas
 CMS National Partnership to
  Improve Dementia Care
Launched in 2012 with one goal reduction in use of
antipsychotic medications for short and long stay
nursing home residents

Excludes Schizophrenia, Tourette’s and Huntington’s

Short Stay and Long Stay Measures
CMS Partnership Strategies

• Education and Training at all levels but Hand in
  Hand for GNA/CNA level

• PIPs/QA team focus

• Review Individual Cases

• Behavioral Rounds

• Clinical Champion

• Family education
        Region III-Results

STATE     %       Rank   %change
MD        17.31    8      12.5
DC        17.42    9      12.84
DE        17.99    12     15.51
WV        19.77    19     3.53
PA        20.49    28     8.14
VA        22.08    31     4.19

Work with your state coalition

Reach out to your area medical directors

Reach out to area mental health providers

Work with industry

Start PIPs in your nursing homes around AP reduction

   Levindale and Courtland 
               Q2-4 2011          Q3 2012-Q1 2013

Courtland       14.2%            11.8%(9.7)
Levindale       18.8%          8.5%(7.9)
Courtland           16.9% reduction
Levindale           54.8% reduction
• Oversight team met monthly-Medical director, DON, QA 
  nurse, psychiatrist, unit managers, consultant pharmacist 
  (now quarterly)

• Monthly behavioral rounds

• Letter to families about dementia care and antipsychotics

• Consent form

• Neighborhood model/Culture change
        Courtland Strategies
• Work with Psychogeriatric services

• NP and CP working on GDR collaboratively

• Track results through QA process
  Levindale and Courtland 

Put your money where 
your mouth is!  
Post-acute quality PFP 
 Role of the Medical Director

— Educational resource
— Quality oversight
— Communicate with providers
— Clinical champion

AMDA (4)
Don’t prescribe antipsychotic medications for 
behavioral and psychological symptoms of 
dementia (BPSD) individuals with dementia 
without an assessment for an underlying cause 
of the behavior.
           CMS Efforts

• National Calls
• Regional Calls
• Individual Facility/Chain calls
                CMS Lessons
• Provider buy in (primary and mental health)

• Provider availability

• Returns from “acute” psych stays

• Reluctant families- “buddy” system

• “creep” of other psychoactive medications-anecdotal

• Letters from state survey agencies to high utilizing 
       CMS QAPI Website

 Dementia Care Resources

• www.amda.com
• www.nhqualitycampaign.org
• www.cms.gov
• www.pioneernetwork.net
• www.alz.org

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