Red Alert – QAPI: Tools and Tips to Enhance QAPI Implementation

1. Red Alert – QAPI: Tools and Tips to Enhance QAPI Implementation Jane C. Pederson, MD, MS Stratis Health

2. Stratis Health

3. Objectives Discuss the relationship between QA and PI Describe tools to assist in successful QAPI Gain practical tips to support QAPI efforts Identify three personal steps to enhance your readiness for QAPI

4. What is QAPI? Quality Assurance + Performance Improvement Merger of two reinforcing aspects of quality management

5. Quality Assurance (QA) Has common focus in LTC Aims at “assuring” a certain level of performance Tends to be more retrospective Looks for variation

6. Quality/Performance Improvement (QI or PI) Can come from QA findings Aims at “improving” the level of performance Tends to be more prospective Leads to Performance Improvement Projects (PIPs)

7. Is QAPI Really Different? Nursing homes have pieces in place through QA QAPI builds out the puzzle

8. Shift in Focus • Prospective • Learn from past but plan forward • Systems • Impact on individual behavior • Initiatives based on facility data • Meet unique needs • Modeled by Leadership

9. QAPI is more than a program – it is an integral part of how work is done in an organization.

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

11. Lay a Solid Foundation Ask - What should QAPI look like in your organization? Assess current QAPI readiness Define goals Articulate the scope Create a structure for supporting QAPI

12. Assessing the Foundation “Quality” has moved beyond the QA committee “Quality” is not one person’s job Leadership is actively engaged Addressing not only clinical care but also resident quality of life and choice

13. A QAPI Leader Leads by Example (whether they intend to or not) • Know (really know) your current culture • How do you balance accountability and expectations while creating a fair and non-punitive environment? • Assess your individual skills, practice and attitudes • Do you gather and use data (input) for decision making? • Do you model a proactive approach to improving performance?

14. Signs of Strong Leadership • QAPI is not an “add-on” • Time and resources are provided • Ongoing training for all staff • People ask, “Why did that happen?” instead of “Who did that?”

15. You can have data without information, but you cannot have information without data.Daniel Keys Moran

16. Collect and Analyze Data Choose data to collect that reflects your unique organization Just because data is available does not make it useful Challenge is turning data into useful information

17. Inventory of Potential Measures Tool

18. Data Management Challenge

19. Signs of Data Converting to Information Combining data from variety of sources Creating new measures Asking, “What is this telling us?” instead of just tracking Finding opportunities for improvement Knowing your performance

20. Performance Improvement Projects - PIPs • Creating new systems or processes • Learning from an error or unintended outcome • Root Cause Analysis (RCA) • Proactively improving an existing process • Failure Mode and Effects Analysis (FMEA)

21. The key is not to prioritize what's on your schedule, but to schedule your priorities.Stephen Covey

22. Prioritization Worksheet for PIPs

23. Why Prioritize? Avoids working on “Flavor of the Day” Forces the team to assess opportunities objectively Provides rationale for choosing PIPs Avoids choosing only low-hanging fruit

24. Well Begun is Half Done • Keys to a Successful PIP • Charter • Goal • Resources • People who care

25. PIP Charter Worksheet

26. Tools Can Help • Know the common QI tools and how to use them • Process Mapping/Flowcharting • PDSA: Small tests of change • RCA: Cause and Effect Diagrams • FMEA

27. Look for Best Practice Literature Advancing Excellence INTERACT Institute for Healthcare Improvement National Nursing Home Quality of Care Collaborative - NNHQCC

28. Don’t Assume • Measure the impact of any changes • Process Measures • Outcome Measure • Structural Measures • Ongoing monitoring • Feedback

29. Expect Challenges • Skill Building • Systems thinking/Critical thinking • Basic QI tools • Data analysis and display • Project management • Teamwork • Documentation

30. Expect Challenges Changing the culture Receiving resident and family input Experiencing staff turnover Feeling regulatory pressures Breaking old habits

31. What Can You Do? Define the problem before determining a solution Identify data that is meaningful Know how to use basic QI tools Set goals Don’t get distracted by putting out fires

32. Questions? Jane Pederson 952-853-8575 or 877-787-2847 jpederson@stratishealth.org www.stratishealth.org

33. Stratis Health is a nonprofit organization that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities.  INCLUDE FUNDER CREDIT OR CMS DISCLAIMER: Prepared by Stratis Health, the Medicare Quality Improvement Organization for Minnesota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 9SOW-MN-6.2-10-62 042710