The Quality Improvement Partnership

1. The Quality Improvement Partnership Name Facility Date

2. Understand the regulatory requirement of quality assurance and assessment (QA&A) and performance improvement (PI). • Understand the resident’s and family’s role in QAPI. • Identify ways and methods for engaging inQAPI. Learning Objectives

3. Nursing Facility • 42 CFR §483.75(o) Quality Assessment and Assurance [F-520] • 12VAC5-371-170. Quality Assessment and Assurance • Affordable Care Act Section 6102(c) • Assisted Living • Not mandated, but it makes good sense. Overview of Regulatory Guidance

4. For more than 20 years, the existing QA&A provision at 42 CFR, Part 483.75(o) specified that each facility should have a QA&A committee with certain members that meets at least quarterly and that “develops and implements appropriate plans of action to correct identified quality deficiencies.” F-520

5. Keeping systems functioning satisfactorily and consistently, including maintaining current practice standards. • Preventing deviation from care processes to the extent possible. • Discerning issues and concerns with facility systems and determining if they are identified. • Correcting inappropriate care processes. Intent of F-520:Maintaining Compliance

6. Surveyors Organization / Staff Consumers Expectations of Stakeholders

7. 100% compliance with certification and state licensure requirements. • QA&A committees provide points of accountability for ensuring quality of care and quality of life in nursing homes. • QA&A committees allow organizations opportunities to deal with quality deficiencies in a confidential manner. Surveyor Expectations

8. Reduced adverse outcomes for residents • Good survey results/good ratings • Staff compliance • Resident/family and staff satisfaction • Financial solvency Organization / Staff Expectations

9. Prevention of avoidable decline • Facility responsiveness • Consistency of care • Compliance with requirements • Person-centered care Consumer Expectations

10. CMS to publish a new QAPI regulation in addition to the existing QA&A regulations. • Requires that all facilities submit to the Secretary of Health and Human Services a plan to meet QAPI standards and implement best practices, including how to coordinate the implementation of a QAPI plan with QAA activities conducted under existing regulations. Affordable Care Act Section 6102(c)

11. Detailed guide outlining QAPI principles and how to incorporate them into systems of care • Illustrates QAPI in action • Details the five elements of QAPI • Action steps for implementing QAPI principles • Tools and resources to further develop systems QAPI at a Glance

12. Merges two complementary approaches to quality management: quality assurance (QA) and performance improvement (PI) What is QAPI?

13. Definitions

14. A process of meeting quarterly standards and ensuring care reaches an acceptable level. • Thresholds set to comply with regulations and/or organizational standards that go beyond the regulations. • A retrospective effort to examine why a facility did not meet certain standards. Quality Assurance

15. A proactive and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems. • Aims to improve processes involved in healthcare delivery and resident quality of life. PI can make good quality even better. Performance Improvement

16. Person-centered care • Relies on the input of residents and families • Measurement of not only process but also outcomes • For defining quality as “how work is done” • Broad scope – entire organization (all staff and all departments) • Leadership expected to be a model • For systems thinking • Proactive analysis • Data and measurement driven • Supported by tools QAPI as a Foundation

17. 5 Elements of QAPI

18. Must be ongoing and comprehensive, dealing with the full range of services offered by the facility, including the full range of departments. • Should address clinical care, quality of life, resident choice, and care transitions. • Aims for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents (or resident’s agents). Element 1: Design and Scope

19. The governing body and/or administration of the nursing facility develops and leads a QAPI program. • Input from facility staff, residents and their families and/or representatives. • Assures the QAPI program is adequately resourced to conduct its work. • Sets the expectation around safety, rights, and choice. Element 2: Governance and Leadership

20. 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. Element 3:Feedback, Data Systems, and Monitoring

21. The facility conducts PIPs to examine and improve care or services in areas that are identified as needing attention. • Typically 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, and intervening for improvements. Element 4: Performance Improvement Projects (PIPs)

22. Used to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. • A thorough approach shows whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered. • Looks comprehensively across all involved systems to prevent future events and promote sustained improvement. Element 5: Systematic Analysis and Systemic Action

23. QAPI emphasizes improvement that will: • Elevate care and experience of all residents • Improve the work environment for caregivers Features of QAPI

24. Use of Data • Identifies your quality problems • Identifies opportunities for improvements • Assists in establishing priority for action Features of QAPI

25. Builds on the resident’s own goals for health, quality of life and daily activities. Features of QAPI

26. Facilitates meaningful resident and family voices into setting goals and evaluating progress. Features of QAPI

27. Incorporates staff in a shared QAPI mission • Develops teams with specific charters, or mission Features of QAPI

28. Performing a root cause analysis to get to the heart of the reason for the concern. • Undertaking systemic change to eliminate problems at the source. Features of QAPI

29. Developing a feedback and monitoring system to sustain continuous improvement. Features of QAPI

30. Communication • Resident preferences, life style, likes/dislikes • Changes in resident condition • Compliments and concerns • General feedback • Collaboration • New admission orientation • Care plan meetings • Resident/family council meetings • Performance improvement opportunities/projects • Engagement • Special events • Customer satisfaction surveys • Recognition programs • Review and discuss quality reports Partnership in Quality Improvement

31. Share information in a complete, consistent, and timely manner. • Strong communication links people and builds relationships between staff and residents. • High-functioning teams respect one another and work interdependently toward common goals. Nourish Teamwork and Communication

32. Process Goals: • Consistent Assignment • Hospitalizations • Person Centered Care • Staff Stability • Clinical Outcome Goals: • Infections • Medications • Mobility • Pain • Pressure Ulcers Advancing Excellence http://www.nhqualitycampaign.org/

33. VHQC www.vhqc.org

34. Get to know the point of contact for the QAPI program and ask how you can become involved • Educate yourself on the facility’s QAPI atmosphere by reviewing the most recent survey report, attending council meetings, participating in care plan meetings, and attending special events • Communicate regularly with the staff about any positives, as well as about any concerns • Do not be afraid to ask questions about the care, the facility, or the QAPI initiatives What Can You Do?

35. Insert Facility Key Contacts For Example: - Administrator - Director of Nurses - Quality Improvement Nurse and/or Point of Contact THANK YOU