Quality Assurance and Performance Improvement (QAPI) in Nursing Homes/QM’s & AntiP.

1. Quality Assurance and Performance Improvement (QAPI) in Nursing Homes/QM’s & AntiP. Cindy Deporter DHSR NH Branch Fall 2013

2. Background Nursing Home QAPI was mandated in the Affordable Care Act enacted in 3/10 Legislation requires CMS to establish QAPI program standards and provide technical assistance to nursing home providers. Identified Training Needs for Surveyors Opportunity to start before the Rule starts.

3. Today’s Topics • Context of QAPI in NHs • The Five Elements and their importance to NH QAPI • CMS QAPI Efforts • Nursing Home Questionnaire • Development of QAPI Tools & Resources • QAPI Demonstration Project • National Rollout and Timeline • Surveyor Training

4. QA&A • F 520 • A facility must maintain a quality assessment and assurance committee consisting of: • The director of nursing services; • A physician designated by the facility; and • At least 3 other members of the facility’s staff. • The quality assessment and assurance committee: • Meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and • Develops and implements appropriate plans of action to correct identified quality deficiencies.

5. QA&A, Cont’d There is no requirement that the facility disclose the records of the QAA 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

6. 2003 OIG Report: Quality Assurance Committees in Nursing Homes • From 1997 – 2001: • 99% of NHs met requirements for committee membership • 99% of NHs met requirements for quarterly meetings (61% meet more frequently) • QA committees relied on an avg. of 8 sources of data (QIs, survey results, and staff/resident input) This is pretty good, but…

7. 2003 OIG Report: Quality Assurance Committees in Nursing Homes Barriers to Effective QA programs: • 33% reported a lack of knowledge about how to conduct QA committee work; • 29% reported unclear guidelines and regulations; • 35% reported lack of knowledge of how to use QIs; • 39% asked for more guidance and examples of how to best use their QA committees; • Knowledge deficits on how to use the data to execute projects

9. What is Nursing Home QAPI? Quality Assurance and Performance Improvement: (QAPI): • data-driven • pro-active approach to quality improvement. • Activities require all members of an organization to continuously identify opportunities for improvement and address gaps in systems. • Comprehensive, systematic interventions improve the overall quality of care and services delivered to nursing home residents.

10. CMS did the following • Conducted environmental scan: • Literature • Quality Models • Tools • Looked at other CMS Providers: • Hospitals, Transplant Hospitals, Hospice, ESRD, & ASC

11. 5 Elements • Element 1 – Design and Scope • Element 2 – Governance and Leadership • Element 3 – Feedback, Data Systems & Monitoring • Element 4 – Performance Improvement Projects • Element 5 – Systematic Analysis & Systemic Action

12. Design and Scope A QAPI program must be: • ongoing and comprehensive, • dealing with the full range of services offered by the facility, including the full range of departments. When fully implemented, the program should address clinical care • quality of life, • resident choice, • care transitions. .

13. Design and Scope It aims for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents (or resident’s agents).  It utilizes the best available evidence to define and measure goals Nursing homes will have in place a written QAPI plan adhering to these principles.

14. Governance and Leadership • The governing body and/or administration of the nursing home: • develops and leads a QAPI program that involves leadership and • working with input from facility staff, • as well as from residents and their families and/or representatives.

15. Governing Body • The governing body assures the QAPI program is adequately resourced to conduct its work. • This includes designating one or more persons to be accountable for QAPI; • developing leadership and facility-wide training on QAPI; • and ensuring staff time, equipment, and technical training as needed for QAPI.  • The facility is responsible for establishing policies to sustain the QAPI program despite changes in personnel and turnover

16. Governance and Leadership – Cont’d. • The governing body and executive leadership are also responsible • for setting priorities for the QAPI program and building on the principles identified in the design and scope. • setting expectations around safety, quality, rights, choice, and respect by 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.

17. Feedback, Data Systems and Monitoring The facility puts in place systems to monitor care and services, drawing data from multiple sources. Feedback systems actively incorporate input from staff, residents, families, and others as appropriate. This element includes using Performance Indicators to monitor a wide range of care processes and outcomes, and reviewing findings against benchmarks and/or targets the facility has established for performance. It also includes tracking, investigating, and monitoring Adverse Events that must be investigated every time they occur, and action plans implemented to prevent recurrences.

18. Performance Improvement Projects The facility conducts Performance Improvement Projects (PIPs) to examine and improve care or services in areas that are identified as needing attention.  A PIP project typically is a concentrated effort on a particular problem in one area of the facility or facility wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements.  PIPs are selected in areas important and meaningful for the specific type and scope of services unique to each facility.

19. Systematic Analysis & Systemic Action • The facility uses a: • systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. • 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 or delivered.

20. Systemic Analysis and Action • Additionally, facilities • will be expected to 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.

21. 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 collaborative • Online Resource Library for demo participants

22. Nursing Home Quality Improvement Questionnaire Administered in 2 waves to a nationally representative sample of 4,200 NHs • 1st Wave (Summer, 2012): • Obtain baseline information; and • Identify potential barriers to implementing quality programs • 2nd Wave (Summer, 2013): • Assess the development of QAPI systems; • Identify what types of TA to make available to nursing homes in the future; • Determine potential impact of TA in advancing QAPI in nursing homes

23. Demonstration Project • Goals • Varied NHs implement QAPI within framework of 5 elements • Design • 17 volunteer nursing homes • 2-year demo, 4 states (MA, MN, FL, CA) • Activities • Individually tailored technical assistance • Access to tools, resources, on-line learning modules, QAPI at a Glance Guide, on-line resource library • Participation in Learning Collaboratives

24. National Rollout Plans • Initial release of QAPI materials on CMS website • Late summer, 2012 • Continued identification of resources and case examples • Engagement of state and national stakeholders • Encouragement of learning Collaboratives with partner organizations • Development of regulation (anticipated in 2013/ 2014) • Development of surveyor training materials and survey worksheet (anticipated in 2013/2014)

25. QAPI Website • Website: Http://go.cms.gov/Nhqapi

26. QAPI CONCEPT: PIPs vs Action Plans Performance Improvement Projects Action Plans PDSA cycles Root Cause Analysis

27. QAPI CONCEPT: Just Culture Balances safety and accountability with fairness and openness Facilitates communication To punish, or not to punish, that is the question…

28. QAPI CONCEPT: Disciplinary Action Important to understand behavioral concepts: • Human Error • Intentional Rule Violation • Recklessness

29. QAPI CONCEPT: Person Centered Care (PCC) Why is this important to QAPI? Why is PCC important to Nursing Homes?

30. QAPI CONCEPT: Team Process Effective Teamwork is Essential to QAPI Provider Teams • Create Teams Surveyor Teams • Assign Teams • Roles and Responsibilities • Communication is critical • Making Meetings Effective

31. QAPI CONCEPTS for Surveyors PIPs vs. Action Plans Just Culture and Disciplinary Action Person Centered Care Team Process Systems Thinking

32. Surveyor Training and Worksheet Surveyor Training Needs: • Understanding Systems Thinking • Evaluating Plans of Correction • How to maneuver around Disclosure issues • Surveyor QA Worksheet imbedded in QIS • Prompts surveyors throughout survey process • Helps identify systems issues to be reviewed during QAPI review

33. Surveyor Training Needs • How and when are surveyors citing F-520 now? • At what point in the survey are QA&A issues identified? • What will help surveyors in the field? • What are the barriers to surveying QA&A currently? • Does this impact POC review by surveyors?

34. QIS Worksheet Review the attached QIS Worksheet. While CMS supports and encourages Just Culture and Person Centered Care they do have zero tolerance in some areas. The expectation is that facilities identify their problems proactively and develop programs and processes to fix them and keep them fixed.

35. Grunt