Hospital QAPI

1. Hospital QAPI Tanishah Nellom MSPH, MHA, CPHQ SCAHQ September 9, 2016

2. Presentation Objectives • Introduction to hospital QAPI standards and worksheets • Understanding the regulatory requirements of QAPI • Planning a system level QAPI program • Implementation journey at Palmetto Health

3. Introduction to Hospital QAPI

4. What is QAPI? QAPI is the merger of two complementary approaches to quality, Quality Assurance (QA) and Performance Improvement (PI). Overarching Goal: Data-driven, proactive approach to improving the quality of life, care, and services in healthcare settings. Forward-thinking, preventive, proactive.

5. QAPI Process Facilitates a multidisciplinary, systematic performance improvement approach to identify and pursue opportunities to improve patient outcomes and reduce the risks associated with patient safety in a manner that embraces the mission of your hospital.

6. Purpose of QAPI Provide a formal mechanism that utilizes objective measures to monitor and evaluate the quality of services provided to patients. • Closes identified gap in current PI project documentation process • Formal, ongoing source of system level PI process information for leadership • Meets CMS and JCO regulatory requirements

7. Worksheet History • October 14, 2011 CMS issues a 137 page memo in the survey and certification section that was pilot tested in hospitals in 11 states • Memo discusses surveyor worksheets for hospitals by CMS during a hospital survey • Addresses discharge planning, infection control, and QAPI (performance improvement) • May 18, 2012 CMS published a second revised edition and pilot tested each of the 3 in every state over summer 2012 • November 9, 2012 CMS issued the third revised worksheet • Final ones issued November 26, 2014

8. Final Surveyor Worksheets Made Public 11/26/2014: “Via this memorandum we are making the worksheets publicly available. The hospital industry is encouraged, but not required, to use the worksheets as part of their self-assessment tools to promote quality and patient safety.” Worksheet Memo

9. QAPI Worksheet • QAPI worksheet is 15 pages (CMS), JCO 14 pages • Used for validation survey or certification survey in hospitals by CMS • Used by State and federal surveyors on all survey activity in assessing compliance with the CoP • Hospitals are encouraged to use the worksheet as part of their survey self-assessment toolkit

10. QAPI Worksheet Recommendations • Some of the questions asked on the worksheet might not be apparent from reading of CoPs • Use the worksheets as a communication device • helps to clearly communicate to hospitals what is going to be asked in these 3 important areas • Identify and communicate gaps • Pull together a team to complete the form in advance as a self assessment • Attaching the completed assessment documentation and P&P to the worksheet

11. CMS Resources Regulations were first published in 1986 • Tag number 0001 through 1164 and PI starts at tag 263 • QAPI 482.21 • Questions: to CMS at hospitalscg@cms.hhs.gov • CMS regulations are first published in the Federal Register then the Interpretive Guidelines and Survey Procedures • Hospitals should check this website once a month for changes • Survey and Certification Info

12. System Level QAPI Implementation

13. QAPI CoP “The hospital must develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS.” (Rev. 105, Issued: 03-21-14, Effective: 03-21-14, Implementation: 03-21-14)

14. Conditions of Participation The hospital must develop, implement, and maintain an effective, ongoing, hospital‐wide, data‐driven quality assessment and performance improvement program Scoring Procedure: The QAPI program covers each of the following elements: • Development (6.1, 6.3) • Implementation (6.2.a, 6.3) • Maintenance (6.2.a-b) • Effectiveness (3.1.k-m, 5.10.d-f) • Ongoing (5.2.a-d, 5.3, 5.5) • Data‐driven (3.1.a-j, 4.1, 4.2, 4.5, 5.5, 5.8) • Hospital wide (4.2, 4.3, 4.4, 5.5, 5.10.a-c) • Contract services • Improved outcomes (5.1.a-c, 5.5, 5.6, 5.8) • Reduction of medical errors (5.1.a-c, 5.5, 5.6, 5.8)

15. Executive Responsibilities §482.21(e) Standard: The hospital’s governing body, medical staff, and administrative officials are responsible and accountable for ensuring the following: • An ongoing program for quality improvement and patient safety is defined, implemented, evaluated, and maintained; • That the hospital‐wide QAPI efforts address priorities for improved quality of care and patient safety • The annual determination of the number of distinct improvement projects • That clear expectations for safety are established • That adequate resources are allocated for improving and sustaining the hospital's performance and reducing risk to patients.

17. Data‐Driven Processes • Ongoing program that shows measurable improvement in evidence-based indicators for improved health outcomes and reduction of medical errors. §482.21(a)(1) • Measure, analyze, and track quality indicators, adverse patient events, and performance metrics that assess processes of care, hospital service and operations. §482.21(a)(2) • The program must incorporate quality indicator data including patient care data, and other relevant data (QIO, Premier, Navient)

19. Performance Improvement Projects §482.21(d) Standard: As part of its quality assessment and performance improvement program, the hospital must conduct performance improvement projects. • All departments, service lines, and contract services that impact patient care should participate in PIP • System level Information Technology projects that are intended to improve patient care, safety, or outcomes can be used as a QAPI project. • The hospital must document PI projects, the reason for implementation, and associated performance metrics • A QIO cooperative project, or the hospital’s own projects are required to be of comparable effort.

21. Patient Safety Standard §482.21(a)(1) : The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes and identify and reduce medical errors. • The hospital must measure, analyze, and track quality indicators • The hospital must measure, analyze, and track adverse patient events • Other aspects of performance that assess processes of care, hospital service and operations. Standard §482.21(a)(2): Patient Safety activities must • Track medical errors and adverse patient events • Analyze their causes • Implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

23. Contract Services Standard: Is there evidence of PI review for contracted services for clinical care • Services performed under contract are performed in a safe and efficient manner • Contractors furnish services that meet the hospital CoPs and standards for contracted services • Includes shared services and joint ventures • Includes services related to patient care such as environmental cleaning, sterilization, laundry, lab, pharmacy • Identify quality problems and ensure monitoring and correction of any problems ensure corrections sustained

25. The Palmetto Health Journey

29. Questions?