Quality Assessment and Performance Improvement

1. Quality Assessment and Performance Improvement Presented by: Jodi Oglesby, RN, CNN Nurse Manager Dialysis Clinic, Inc. Warrensburg

2. History of QAPI • Quality Improvement • Quality Assurance • Continuous Quality Improvement • Quality Assessment and Performance Improvement • Do we get it yet?????

3. QAPI 2009 • “It’s what you learn after you know it all that counts” • John Wooden, UCLA Basketball coach for 27 seasons, 10 national championships including 7 in a row from 1967-1973.

4. Objectives When solving problems, dig at the roots instead of just hacking at the leaves.  ~ Anthony J. D'Angelo, The College Blue Book Tracking and Trending Identifying Areas for Improvement Creation of a Quality Improvement Plan Defining Goals Measuring and Prioritizing “root” cause Developing Interventions Remeasurement – Testing Changes

5. Vtag 625 Condition: Quality Assessment and Performance Improvement (QAPI) • This Condition looks at: • Facility data • Requires facility-based assessment and improvement of care • This is different from the Plan of Care which is patient-based improvement

6. Quality Indicators • Adequacy of Dialysis • Nutritional Status • Mineral Metabolism and Renal Bone Disease • Anemia Management • Vascular Access • Medical Injuries and Medical Errors Identification • Hemodialyzer Reuse Program (if the facility reuses hemodialyzers) • Patient Satisfaction and Grievances • Infection Control • As well as, Measures of Water and Dialysate Quality and Safety, and Safe Machine Maintenance

7. Program Scope • An “ongoing” program • Continuously looks at all indicators (overall vs. individual) • Trends outcomes (again, overall…) • Develops an improvement plan when indicated. • Generally will require at least monthly review of indicators • Prescribed patient indicators are typically evaluated with laboratory results monthly • Serves as a functional time frame for trending of data within the facility

8. Goals/Benchmarks • Set Facility Specific Goals • Data on current professionally-accepted clinical practice standards must be used • MAT • CPM’s • Goals vs. Outcomes • If facility performance is below average • Expected to take action toward improving those outcomes

9. Monitoring Data/Information • Facility must measure, analyze, and track quality indicators (or other aspects of performance that the facility adopts or develops) that reflect • processes of care • facility operations • Records of QAPI activities including minutes or another method of demonstrating this analysis and action must be available for review • Facility should compare their performance with • community-based standards • other facilities in their State • their Network • the U.S.

10. Measure, Analyze, and Track • Trending Data • Collective patient data • Review HD and PD separately • Priority • Identify potential problems • Prioritize areas for improvement • Identify opportunities for improving care

11. TRACKING TOOL Add your facility determined goals and thresholds You may choose to use a variety of tools and tracking methods for data review: Aggregate trend spreadsheets

12. You may choose to use a variety of tools and tracking methods for data review: Graphs

13. Identifying Problems However…10 accidents a year may cause your insurance company to make some changes in your plan! One vehicle accident may not indicate you are a bad driver….. • Review collective patient data; • Look at trends • Steady improvement or stable outcomes • Abrupt or steady decline in outcomes • Identify any commonalities among patients who do not reach the minimum expected targets;

14. Quality Improvement Plan • Plan that results in improvement in care • Developing • Implementing • Evaluating • Monitor the effectiveness of the plan • Revising • Adjust portions of the plan that are not successful • What are we trying to accomplish? • How will we know if a change is an improvement? • What changes can we make that will result in improvement?

15. Quality Improvement Plan QIP (Quality Improvement Plan) should include the following: • Identify Opportunity for Improvement • Set Specific goal for Improvement • Define and Measure Root Causes – PRIORITIZE! • Identify Interventions • Identify Person(s) responsible • Date Process began • Date/Frequency of Re-measurement • Outcomes-Measurement results

16. Develop Goal Example: GOAL: Reduce number of catheter patients to <10% by December 2009 Or … Reduce number of catheter patients by 2% each month • Work together – entire IDT • Write clear statement identifying problem • Use numerical “measurable” goal • Set specific time range to meet goal • Assure goal is obtainable within specified time range • Use smaller goals in step by step fashion until ultimate goal is reached

17. Identify Root Cause • For Example: If a data report shows that the facility’s ranking for hemodialysis adequacy is below the expected average • Facility must demonstrate QAPI review of global factors that might affect adequacy • Brainstorming with IDT • Data/Spreadsheets to “measure” barriers

18. Identify Root Cause • Show “Root Cause Analysis” • What % • Missed or shortened treatments; • Use Less-efficient dialyzers; or • Fail to achieve the ordered blood flow rates • Prioritize • Which root cause is having the greatest impact on the problem? • Often the “assumed” root cause turns out to be different when the barriers are actually measured! • Avoid Scattergun Approach!

19. Develop Actions/Interventions • Focus on process • What process can you change or create that will have a positive impact? • Make actions barrier-specific • How will changes impact the root cause? • Choose one or two actions which will have the greatest impact (Rapid cycle improvement) • Review available best practices • Will they work in your facility? • Discuss how you will monitor new processes • How will you know if changes are an improvement?

20. You can’t fatten a cow by weighing it. -Middle Eastern Proverb • Doing the same things over and over will not result in change! • If interventions are not having positive effects • Try a different approach • Go back to root cause… has anything changed? • Remember… look at process, not just outcomes

21. Changing A Process Example: Facility determines inadequate BFR’s are highest priority root cause for patients not achieving adequacy Facility reviews current process and determines new process is needed NEW PROCESS > Daily audit checksheet: Nurse rounds after initiation of each shift to assure BFR and other prescription parameters are met Allows action to be taken immediately rather than waiting for monthly lab review to reveal a problem

22. Evaluation:Measuring Changes Graph monthly data Review trends for improvement Discuss and document changes in monthly QAPI meetings What’s working? What’s not working?

23. Electronic Data Collection Some facilities may be able to pull “electronic” reports for trending data REMEMBER… Data reported is only as good as the data entered in the electronic or hard copy collection tools. This takes participation and cooperation of all staff.