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QAPI: What Nursing Home Medical Directors Should Know Susan M. Levy, MD, CMD VPMA Levindale Hebrew Geriatric Center and Hospital Baltimore, Maryland 21215 VAMDA 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 Disclosure • 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 standards QAPI and Other Health Settings • 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) committee: • 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 6 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 . 7 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 Systems Description: What is QAPI? Quality Assurance Performance Improvement Motivation Measuring compliance Continuously improving with standards processes to meet standards Means Inspection, review Prevention, planning Attitude Required, defensive Chosen, proactive Focus Outliers, “bad apples,” Processes, systems individuals Scope Individual provider Systems for patient care Responsibility Few All Comparison of QA and QI Quality Assurance (QA) Quality Improvement (QI) Focus: Catch “bad apples” or Improve processes—not detect serious problems fault finding Goal: Meet minimal standards Ongoing process improvement Who’s Usually 1-2 individuals Teams Involved: Driven By: Regulation/accreditatio Organizations n Occurs: Monthly or quarterly Continuously 13 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 14 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 care 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 regulations 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 findings 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 Domains • Foundational (Ethics, Professionalism and Communication) • 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 Health 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 29 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 individual Element #2: Governance and Leadership 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. Respect • Balancing both a culture of safety and a culture of resident-centered rights and choice 32 Governance and Leadership : Role of the Medical Director • Educate organizational leaders and staff • Help drive data driven decisions • Support a culture of quality improvement and safety in all that is done • 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. 34 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 recurrences. NEVER EVENTS RCA 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 -wide • 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 37 PIPs: Role of the Medical Director • 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 improvement. 39 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 41 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 Teamwork • Assess the effectiveness of teamwork in the organization • 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- Assessment • Determine when and who will participate in the self-assessment • Complete the baseline self-assessment • Determine when you will reassess (annual) QAPI Self Assessment 45 QAPI: STEP 4 • Identify your organizations guiding principles • 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 Scope 47 QAPI: STEP 5 • Develop your QAPI plan • Determine your timeline for writing the plan • Circulate the Guide for Developing a QAPI plan for all involved in developing the plan • Once completed determine time for review(annual) QAPI Plan Outline 49 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 concerns • 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 improvement 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 improvements 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 discussed Goal Setting Worksheet 55 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 58 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 59 What is a Process Map? vA pictorial representation of the sequence of actions that describe a process 60 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: 61 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 62 Run charts Tracking Process Performance 63 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 65 Goal of the RCA • What happened? • Why did it happen? • What to do to prevent it from happening again 66 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 strategies • There are various tools to use 67 Problem Solving & Root Cause 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) 68 What is the 5 Whys? v A question asking method used to explore the cause/effect relationships underlying a particular problem v The goal is to determine the ROOT CAUSE of a problem 69 5 WHYs Tool 70 71 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) 72 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 change 73 Construction of a Fishbone Diagram v Then for each cause identify deeper root causes Cause 1 Cause 3 Effect/Problem Cause 2 Cause 4 74 Tips for Using Fishbone Diagrams v Find the right problem or effect statement v Find causes that make sense and that you can impact v Make use of your results 75 Summing Up Cause and Effect 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 improve 76 We Have the Root Cause Now what? 77 Quality Improvement Models DMAIC RAPID CYCLE QUALITY IMPROVEMENT FMEA SIX SIGMA PDCA/PDSA SMART LEAN JACHO 10 STEP FOCUS PDSA and Using QI Tools v Using tools as part of the PDSA cycle v Some tools will be useful in the planning stage v Others will help you to implement your QI project v And/or will help you study the impact of your process change 79 Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Act Plan Study Do 80 The PDSA Cycle for Learning and Improvement 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 81 Repeated Use of the Cycle Changes That Result in A P Improvement D AT D S S D Spread A A P A Implementation of Change S P D A P Wide-scale Tests of Change S D Hunches Follow-up Tests Theories Ideas Very Small-scale Test 82 GOAL – Improve Outcomes Concept D Concept C Concept B Concept A Change concepts, theories, ideas 83 84 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 Disease 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 THE STATE OF VIRGINIA 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 OR EXPLAIN WHY YOU ARE DIFFERENT! Levindale and Courtland Gardens 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 LEVINDALE STRATEGIES • 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 Strategy Put your money where your mouth is! Post-acute quality PFP indicator Role of the Medical Director Educational resource Quality oversight Communicate with providers Clinical champion THEY SHOULD NOT BE PART OF THE PROBLEM 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 facilities CMS QAPI Website http://go.cms.gov/Nhqap i Dementia Care Resources • www.amda.com • www.nhqualitycampaign.org • www.cms.gov • www.pioneernetwork.net • www.alz.org
"What is QAPI What nursing home medical directors should know - Susan Levy"