QAPI: What Nursing Home Medical Directors Should Know

1. 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

2. 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

3. Susan M. Levy, MD, CMDDisclosure • CMS Consultant to the Nursing home division • Legal expert review • MMDA advisor to the board • AMDA committees • Governance • Transitions of Care • Public Policy

4. 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

5. QAPI and Other Health Settings • Hospitals • Home Care • Dialysis • Ambulatory Care and now • Nursing Homes

6. 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

7. 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 .

8. 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

9. 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.

10. 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.

11. 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

12. Description: What is QAPI?

13. Comparison of QA and QI

14. 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

15. 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

16. AMDA Medical Director Roles and Responsibilities • Functions • Tasks • Competencies

17. 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

18. AMDA Medical Director Function 3 Tasks • 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 • 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

19. 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.

20. AMDA Medical Director Function 3 Tasks • The medical director ensures that the quality assurance program addresses issues germane to the quality of patient care. • The medical director utilizes the quality assurance program to effect change in policies and procedures. • 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.

21. AMDA Medical Director Function 3 Tasks • The medical director serves as chairman of the institutional committee to review the feasibility and goals of research projects and disseminates research findings • 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)

22. AMDA Medical Director Function 3 Tasks • The medical director reviews periodically admission transfers, and discharges of patients. • The medical director participates in time management studies

23. 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

24. Competency Pyramid

25. 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)  

26. 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

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

28. 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

29. Element #1: Design and Scope • A QAPI program must be: • Ongoing and comprehensive • Dealing with the full range of services offered by the facility • Including ALL departments • It utilizes the best available evidence to define and measure goals. • A written QAPI plan • Address: • Clinical care • Quality of life • Resident choice • Care transitions • Aims for safety and high quality with all clinical interventions • Emphasizes autonomy and choice in daily life for residents  

30. 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

31. Element #2: Governance and Leadership The governing body and/or administration: • Develops and leads a QAPI program • Involves leadership • Uses input from facility staff, residents and their families and/or representatives • Assures the QAPI program is adequately resourced • Designates one or more persons to be accountable for QAPI • Develops leadership and facility-wide training on QAPI • Ensures staff time, equipment and technical training as needed for QAPI • Responsible for establishing policies to sustain the QAPI program despite changes in personnel and turnover

32. Element #2: Governance and Leadership, cont. Also responsible for: • Settingpriorities for the QAPI program • Building on the principles identified in design and scope • Setting expectations around: • Safety, Quality, Resident Rights, Choice, and Respect • Balancing both a culture of safety and a culture of resident-centered rights and choice • The governing body ensures that while staff are held accountable, there exists an atmosphere in which staff are not punished for errors and do not fear retaliation for reporting quality concerns.

33. 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

34. 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.

35. 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

36. 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

37. 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

38. 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

39. 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.

40. 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

41. QAPI at Glance – Step by Step Guide

42. 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

43. 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

44. 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)

45. QAPI Self Assessment

46. 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

47. Guiding Principles and Scope

48. 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)

49. QAPI Plan Outline

50. 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