Quality Assurance and Process Improvement

1. Quality Assurance and Process Improvement Karyn P. Leible, RN, MD, CMD Chief Medical Officer Jewish Senior Life of Rochester, NY Immediate Past President, AMDA

2. Speaker Disclosures: Dr. Leible has disclosed that she has no relevant financial relationships.

3. Learning Objectives: By the end of the session, participants will be able to: • 1) discuss the changes in nursing facility Quality Assurance and Assessment (QA&A) as outlined in health care reform legislation • 2) discuss tools and processes that are associated with best practices for quality assurance and process improvement • 3) discuss the role of the facility medical director in the facility Quality Assurance Process Improvement program

4. Definitions • QualityAssessment-is an evaluation of a process to determine if a defined standard of quality is being achieved. • QualityAssurance-is the organizational structure, processes, and procedures designed to ensure that care practices are consistently applied • QualityImprovement- (Process or Performance Improvement)is an ongoing interdisciplinary process that is designed to improve the delivery of services and resident outcomes.

5. Quality Assurance and Process Improvement • The Patient Protection and Affordable Care Act (ACA) • Signed into law March 23, 2010 • Many provisions for which CMS is responsible for implementing • Survey and Certification Group • Section 6102 • Establishment of standards relating to quality assurance and process improvement • Purpose of program is to strengthen current requirements and promote accountability for resident care and safety by nursing facilities

6. Transforming nursing homes through continuous attention to quality of care and quality of life Nursing Home QAPI: A Proactive Approach to Improving Quality and Safety

7. Quality Assurance and Performance Improvement (QAPI) Overview • Expands current regulations for QAA • Sets expectation for a sound, basic plan for QAPI that will support the systems of care and quality of life in every nursing home • A demonstration project is testing QAPI in 17nursing homes, and preparing for national implementation

8. QAPI Nursing Home Demonstration • CMS contracted with University of Minnesota, with Stratis Health serving as a subcontractor, to develop the demo and early implementation strategies • CMS will support stakeholders, providers, consumer advocates, consumers, and surveyors through outreach and communication • Technical Expert Panel (TEP) is reviewing QAPI program materials

9. QAPI Nursing Home Demonstration • Two year demo began September 2011 • Four states - Florida - Massachusetts - California - Minnesota • Diversity of participating nursing homes • Learning Collaborative based on IHI model • Tools and resources being developed • Extensive evaluation planned

10. Five Elements of QAPI • Design & Scope • Governance & Leadership • Feedback, Data Systems and Monitoring • Performance Improvement Projects (PIPs) • Systematic Analysis & Systemic Action

11. 5 Elements of QAPI • Design and Scope • Comprehensive and ongoing plan • Includes all departments and functions • Addresses safety, quality of care, QOL, resident choice, transitions • Based on best available evidence • QAPI plan

12. 5 Elements of QAPI • Governance and Leadership • Boards/owners and executive leadership • Buy in and support • Training and organizational climate • Administration sees value • Sufficient resources • Sustainability

13. 5 Elements of QAPI • Feedback, Data monitoring Systems, and Monitoring • Multiple sources, including resident and staff • Benchmarking and targeting • Adverse events

14. 5 Elements of QAPI • Performance Improvement Projects • Prioritized topics • Number of PIPs depend on the facility program • Team Chartered • PDSA Cycle

15. 5 Elements of QAPI • Systematic Analysis and Systemic action • Root cause analysis • Systems thinking • Systematic changes as needed

16. AMDA Position Paper • The Role of the medical director on the QA committee begins with an awareness of the current program in the facility. (March 2011) • Structure and process of the facility program • Role of the IDT participants • How issues are identified, addressed and monitored

17. Case presentation • You are the medical director/ administrator/ director of nursing of a 100 bed facility just outside of Denver. During the facility QAA meeting it is brought to your attention that the facility use of antipsychotics is above the state average based on data just released from the CMS.

18. QAPI • The facility provided data through monitoring • a potential problem is identified. • Next steps will be to evaluate if a true problem exists • look at root causes, analyze and interpret data and develop interventions. • Monitor and re-evaluate • All part of an over all program to proactively monitor facility processes of care in order to ensure the highest quality of care and quality of life

19. QAA Tools • Proprietary programs/ Corporate programs • ABAQIS • My InnerView • Facility reports • Pressure ulcers • Falls • Accidents • Infection Control • QI/QM data • MDS derived • MDS 3.0 data

20. MDS 3.0 • Opportunities to assess quality through the facility own data collection opportunities with 3.0 • Assessments are done for OBRA • Day 14 then quarterly • Annual review • Discharge • Assessments are done for PPS • Days 5, 14, 30, 60, 90

21. Quality Measures • Short stay • % of residents on a scheduled pain medication regimen on admission who report a decrease in pain intensity or frequency • % of residents who self report moderate to severe pain • % of residents with pressure ulcers that are new or worsened

22. Quality Measures • Short stay • % of residents assessed and given, appropriately, the Seasonal Influenza vaccine • % of residents assessed and given, appropriately, the Pneumococcal Vaccine • Long stay • % of residents assessed and given, appropriately, the Seasonal Influenza Vaccine • % of residents assessed and given, appropriately, the Pneumococcal Vaccine

23. Quality Measures • Long Stay • % of residents experiencing one or more falls with major injury • % of residents who self report moderate to severe pain • % of high risk residents with pressure ulcers • % of long stay residents with a urinary tract infection • % of long stay residents who lose control of bowels and bladder

24. Quality Measures • Long Stay • Residents who have/had a catheter inserted and left in their bladder • % of residents who were physically restrained • % of residents who needed help with physical activities has increased • % of long stay residents who lose to much weight • % of residents who have depressive symptoms

25. Quality Measures- Antipsychotics • June 2012 Public Reporting • Short Stay Measure • Incidence of short stay residents that are given an antipsychotic medication after admission to the nursing home

26. Quality Measures- Antipsychotics • Long Stay Measure • Percentage of long stay residents receiving an antipsychotic who do not have a diagnosis of Tourette’s, Huntington's or Schizophrenia • Diagnosis of hallucinations, delusions or bipolar are no longer excluded • Reporting currently last quarters of 2011 and first 2 of 2012

27. Quality Measures-Antipsychotics • National average 23.9% (long stay) goal for 15% reduction would bring the national prevalence rate to 20.3%

28. MDS 3.0- Section N Medications N0400. Medications Received.Check all medications the resident received at any time during the last 7 days or since admission/reentry if less than 7 days. Antipsychotic. Antianxiety. Antidepressant. Hypnotic. Anticoagulant (warfarin, heparin, or low-molecular weight heparin). Antibiotic. Diuretic. Z. None of the above were received.

29. MDS 3.0- Section I • In the past 7 days: Check all that apply • Anxiety Disorder • Depression (other than bipolar) • Manic Depression (bipolar) • Psychotic Disorder (other than Schizophrenia) • Schizophrenia (schizoaffective, schizophreniform disorders) • Post traumatic stress disorder

30. MDS 3.0 • Potential areas for quality monitoring • BIMS scores • PHQ-9 scores • Pain management • Late loss ADL (toileting, eating, transfers, bed mobility) • Urinary incontinence • Weight loss • Prognosis (less than 6 months) • Pressure ulcers

31. Quality Assurance and Assessment • Facility Reports • Pressure ulcers • Infection control • Falls • Antipsychotic use

32. Incidence • Number of new whatevers Average census x time Average census x time = bed days of care Assume stable census of 100 elder in month of September then BDOC= 3000 Multiply incidence by 1000 to get # per 1000 resident days

33. Incidence • In September Shady Pines had 5 facility acquired urinary tract infections. They had a stable census of 100 residents. • What is the incidence of facility acquired urinary tract infections?

34. Incidence 5_UTI X 1000 = 1.7 3000 (BDOC) BDOC = 100 resident x 30 days

35. Prevalence • Prevalence is defined as the total number of cases of the disease in the population at a given time, or total number of cases in the population • Number of whatevers that exist number at risk

36. Prevalence Shady Pines has 4 residents with pressure ulcers. Non of the ulcers are new. What is the prevalence of pressure ulcers in the facility?

37. Prevalence 4 elders with pressure ulcers X 100 100 elders at risk .04 X 100 = 4 % Consider unit of measure number of ulcers versus number of elders with ulcers

38. Prevalence • Sunny Acres has 100 long stay residents. 25 of those residents are receiving an antipsychotic. 2 residents are schizophrenic and one resident is bipolar. What is the prevalence of antipsychotic use in the facility? • What is the incidence?

39. Prevalence 23 residents are on antipsychotics without dx 100 long stay residents .23 X 100 = 23 % Incidence cannot be determined with the information given.

40. Run Charts

41. Control Chart • View a process over time • Give a visual description of what the process has done and is doing • If the process is in control, (random normal variation or random walk), you can predict how the process will perform over time

42. Control Chart

43. Process Improvement Projects • Performance Improvement Project (PIP) team to address a question • Involve staff working closest to the residents whenever possible • PIP team meets identifies potential root case • Develops action plan/intervention • Monitors and reports back to QAA

44. Root Cause: 5 Whys • Why is the resident screaming in her room? • When she is in the dining room she was trying to strike out at other residents • Why is she trying to strike out at other residents? • She is fearful that someone is trying to take her food • Why is she fearful that someone is trying to take her food? • The doctor cut back on her risperdone dose 2 days ago

45. Root Cause: 5 Whys • Why is cutting back on the risperdone dose important? • She is more alert at meals and is afraid that someone is taking her food • Why is she afraid someone is taking her food? • She grew up in Germany at the end of world war 2 and Russian soldiers used to come through the village she lived in and steal food

47. residents facility “Our patients are different” Multiple units all function independently Secured unit for dementia Employed physician model 6 social workers for 362 residents No GDR process Geriatric nurse practitioner and psychiatrist round weekly No monitoring of which residents are on meds Independent consultant pharmacist Staff Policies and procedures

48. Interventions • Meet with attending physicians • Identify barriers to GDR • Monthly review of residents on antipsychotics and GDR • Meet with facility psychiatrist and geriatric psych ANP • Require nursing have MD consult request • Meet with pharmacy consultant • Request monthly reports regarding psychoactive medication usage

49. Interventions • Meet with Director of Nursing • Identify potential barriers • Address staff education opportunities • Meet with facility administrator • Identify barriers • Identify potential opportunities • Review of current policies and revise as indicated

50. Prevalence of Antipsychotic Use: Jan-Oct 2012