Quality Assessment & Performance Improvement, Root Cause Analysis and the Model for Improvement

1. Quality Assessment & Performance Improvement, Root Cause Analysis and the Model for Improvement Melody Malone, PT, CPHQ TMF Health Quality Institute

2. Objectives The learner will be able to: • Describe quality assessment & performance improvement (QAPI) • Define the three categories of human factor performance gaps • Explain root causes • Understand rapid cycle quality improvement methodology

3. About TMF TMF Health Quality Institute focuses on improving lives by improving the quality of health care through contracts with federal, state and local governments, as well as private organizations. For more than 40 years, TMF has helped health care providers and practitioners in a variety of settings improve care for their patients.

4. About the QIO Program Leading rapid, large-scale change in health quality: • Goals are bolder. • The patient is at the center. • All improvers are welcome. • Everyone teaches and learns. • Greater value is fostered.

5. About the QIO Program Leading rapid, large-scale change in health quality: • Goals are bolder. • The patient is at the center. • All improvers are welcome. • Everyone teaches and learns. • Greater value is fostered.

6. Have You Ever Said “HUMMMM”

7. How come I CAN’T: • Get my calls returned on time? • Why can’t I document in OmbudsManager? • Stay within budget? • Get my facilities where I want? • Sustain improvements?

8. How do I get here??

9. Through Quality Improvement

10. “Quality is not an act, it’s a habit.”- Aristotle

11. Current State of Affairs “How do YOU do Quality Improvement Now?” {in your office}

12. Current State of Affairs “We have our QAA meeting every month… isn’t that QI?” {Nursing Home}

13. Comparison of QA and QI

14. 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

15. 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 .

16. Quality Assurance and Performance Improvement (QAPI)

17. QAPI Background • Mandated in the Affordable Care Act, enacted March 2010 • Legislation requires the Centers for Medicare & Medicaid Services (CMS) to establish QAPI program standards and provide technical assistance to nursing home providers. • CMS identified training needs for long-term care surveyors. • Demonstration projects are ongoing now and tools are coming.

18. 5 Elements of QAPI • Element 1 – Design and scope • Element 2 – Governance and leadership • Element 3 – Feedback, data systems and monitoring • Element 4 – Performance improvement projects • Element 5 – Systematic analysis and systemic action

19. 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  

20. 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

21. 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 • Rights • Choice • 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.

22. Element #3: Feedback, Data Systems and Monitoring • Use systems 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, and review findings against benchmarks and/or targets the facility has established for performance. • Use tracking, investigating and monitoring adverse events that must be investigated every time they occur,and action plans implemented to prevent recurrences.

23. 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

24. 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.

25. 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

26. 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 • Development of surveyor training materials and survey worksheet

27. Let’s Watch a Movie!

29. Human Errors in Medicine “… and the adverse events that may follow, are problems of psychology and engineering, not of medicine.” - J.W. Senders, PhD, Medical Researcher

30. Human Error – The Old View The bad apple theory: • Complex systems would be fine if it weren’t for some unreliable people. • Human errors cause accidents. • Failures are surprises.

31. What’s wrong with the old view? • Focusing on individuals does not solve underlying problems. • Errors are not intrinsically bad.

32. Human Error • Human error is not the cause of accidents, it is a symptom of deeper trouble. • Human error is not random. • Human error is not the conclusion of an investigation, it is the beginning.

33. What is “Human Factors”? “Human Factors” is about how features of our tools, tasks and work environments continually influence what we do and how we do it.

34. In Other Words Human Factors is about how the designof things impacts how well we do any task. • Design of our workplace • Design of the tools we use • Design of processes (how we do our work)

35. What’s wrong with this picture???

36. Human Factors • How could this happen? • Distracted sign maker • What could happen as a result? • What were conditions and situation like when driving? • What are characteristics of the task?

37. Combating Human Error with Better Designs Where do we start? • Assume that people do reasonable things. • Look at why there is a performance gap.

38. 3 Categories of Performance Gaps • The plan itself was inadequate to achieve desired outcome (planning error). • The plan is not executed properly (execution error). • There was a deliberate departure from “safe” practice (violation).

39. Planning Errors • Driving to favorite gas station—run out of gas • Giving antibiotics to a patient with a viral infection

40. When is it a planning error? • Don’t know what to do • Don’t know how to do it • Don’t know who is supposed to do it • “I couldn't do it” • “I used to do it differently”

41. Planning Errors • Table Talk… • What sort of planning errors have you experienced lately?

42. Planning Errors What may not work: • Punishment • Rewards • Reminders Why? They believe they are acting correctly or following the set process.

43. Planning Errors What may work: • Memory aids • Training or education • Creating/redesigning process

44. Execution Errors • Turning left instead of right! • Giving the wrong medicine when distracted • Forgetting to assess a patient’s pain due to interruptions

45. When is it an execution error? • Forgot • Distracted or interrupted • Steps look alike • “It slipped my mind” • Just “messed up”

46. Execution Errors • Table Talk… • What sort of execution errors have you experienced lately?

47. Execution Errors What may not work: • Punishment • Rewards • Training or education of skilled operators/experts Why? They intended to correctly complete the task.

48. Execution Errors What may work: • Prompts • Reminders • Memory aids

49. Violations • Act itself is deliberate • Negativeconsequences are not intended • Certain conditions more likely to produce violations

50. When is it a violation? • Don’t have to do it • Frustration • Cumbersome rules, policies • Perception of being above the rules • “Saving time if I do it my way”