Quality Is Our Everyday Business

1. Quality Is Our Everyday Business QAPI Staff Training Module #1 www.ccmemedicare.org

2. This session is designed for: • Certified nursing assistants (CNAs) • Nurses • Therapy staff • Social work staff • Activities staff • All non-nursing staff This program is a companion to the Process Improvement Handbook developed by The Carolinas Center for Medical Excellence (CCME) nursing home team.

3. Content Quality Care Critical Thinking QAPI Tools for Improving Quality Continuous Quality Improvement

4. Why Quality? • Improved resident outcomes • Increased resident and family satisfaction • Lower costs • Good marketing position • Higher census • Greater employee satisfaction • Reduced staff turnover • Regulatory compliance • Fewer hospital transfers

5. Costs of Poor Quality • Duplication of efforts • Need for rework • Low census and empty beds • Replacing employees • Loss of business and reputation • Survey deficiencies and fines

6. Exercise: What does quality resident care mean to you? • Pair up with one other person. Take three minutes, and answer these two questions. • How do you know when residents on your unit are receiving high quality resident care? • How do you know if your work is high quality? • Come back together, and discuss to find common answers.

7. Quality resident care is… Safe Timely Person-centered Based on clinical guidelines and best practices Coordinated across all departments

8. Finding a way to do it better and be more resident-centered Continuous quality improvement happens during every resident contact.

9. Quality Improvement (QI)

10. Quality Improvement (QI) Data tells us how well we do our business. • Number of facility-acquired pressure ulcers each month Data collected over time shows us trends. • 25% more pressure ulcers on Unit D in last 6 months Feedback provides important details. • Staff – Why do you think there are more pressure ulcers on Unit D? • Residents and families – We would like to discuss Mrs. J’s new pressure ulcer at next Monday’s care plan meeting. Can you come?

11. Quality Improvement (QI) QI is not… • Rocket science • Someone else’s job • Only for management • Too complicated • Just more to do • More red tape • Individual blame QI is... • Part of our day-to-day • For all staff, all departments • Continuous • At individual & facility levels • Based on teamwork • For frontline staff • Focused on process, not individuals

12. Your current systems of care create your outcomes. What you’re doing now produces the results you see. ToGET something different, you have to DO something different.

13. The Affordable Care Act of 2010 Section 6101(c) Centers for Medicare & Medicaid Services (CMS) Quality Assurance Process Improvement (QAPI) is required by law in all certified nursing homes • Expands focus to all aspects of the nursing home • Involves staff in solving everyday problems • Provides guidance on how leadership and staff work together to solve everyday problems

14. The Affordable Care Act of 2010 Section 6101(c) Centers for Medicare & Medicaid Services (CMS) Quality Assurance Process Improvement (QAPI) required by law in all certified nursing homes Website includes tools and resources http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/NHQAPI.html

15. It’s all about quality improvement.

16. QAPI Key Principles • Resident focus • Team-based • Leadership • Data-driven • QI tools • Proactive • Continuous

17. Two types of QAPI Committees 1. QAPI Steering Committee • Develop plan. • Set target goals and objectives. • Train all staff in QI principles. • Measure and assess key processes and outcomes. • Form teams to review data and work together. • Focus on process and not individual performance. • Summarize and review annually.

18. Two types of QAPI Committees 2. Performance Improvement Project (PIP) Teams • Specific topic • Interdisciplinary • Concentrated effort • Report back to Steering Committee.

19. PIP Team Example Our fall rate is 10 percent higher than the corporate average. PIP Falls Team – Interdisciplinary team including frontline staff to collect and monitor falls data, problem solve for root causes, select a process to improve, develop interventions, and evaluate

20. Critical Thinking Is the Foundation of QI Step One: Identify and challenge your assumptions. Step Two: Explore and imagine options. • Clear, logical, attention to facts, and open to alternatives • Used by individuals and teams, frontline and management staff… EVERYONE!

21. Absence of Critical Thinking • Routine list of possible interventions • Put alarm on all residents with unsafe behaviors. • Paper compliance • Check off action when not done. • Lack of deep root cause analysis • Order antipsychotic for yelling or calling out. • Lack of resident and family input • No easy access to resident history to personalize care • Low involvement of frontline staff • No frontline staff in interdisciplinary team meetings

22. Critical Thinking (CT) Steps • Identify and clarify problem. • Gather all related information. • Consider choices of action and evaluate options. • Choose and implement best choices. • Evaluate.

23. QI Tools Root Cause Analysis (RCA) Helps staff • Get to the “cause” or underlying root of the problem • Understand how a change in process can improve outcome Critical thinking depends on deep root cause analysis.

24. CNA Finds Resident Who Fell in Room • Reports resident found on floor (no RCA) Immediately begins to ask: • Direction resident is facing? • Personal agenda? • Placement of wheelchair? Brakes locked? • Footwear? (RCA) • Bed height? Wheels locked? • Last toileted? Wet? Floor surface? • Personal items? Lighting? Clutter? • Pain?

25. Nurse Who Considers New Medication Mrs. T is yelling again. She is very loud and really gets all the other residents upset. (no RCA) Mrs. T yells most often in the afternoon when she is alone in her room after being in her wheelchair most of the day. I see her leaning forward and grimacing. She has a history of osteoarthritis and gets Tylenol PRN. Her cushions are old, and she has not had a seating evaluation in a long time. (RCA)

26. QI Tools 5 Whys • Process of asking “why?” at least five times in a row • Increases understanding of problem • Helps staff use critical thinking skills • Helps staff challenge current situation or problem • Gets to the root of the matter

27. Why? Mr. B has reddened area on right heel. Why? Pressure Pillows don’t stay in position to keep pressure off heels. Why? Restless. Pillows move around and staff can’t keep them in place. Why? Happens too often in between staff rounds. Why? Staff round every 2-3 hours and do not always check heel placement under covers. Increase staff rounding and awareness to check heel position every hour while in bed. Try new position device for heels.

28. QI Tools Brainstorming • Group effort • Produces large number of ideas • No judgment, free of criticism • Thinking “outside the box” • Encourages creativity • Is fun and easy

29. Exercise: Mr. Smith (82 years old) has moderate dementia with unsafe behaviors. He was a construction worker for 40 years. He has severe short-term memory loss, anxiety, and a short attention span. He wanders into unsafe areas. Gather into groups of four at your tables for 3 minutes. Brainstorm ideas about potential new activities. Come back and discuss as a group.

30. Brainstorming in Post-Fall Huddle He says he had to go to the bathroom. He thought he could go on his own and forgot to call for help. • When did you last go in? Scheduled rounding? • When was he toileted last? Pattern? Voiding Diary? • What was he doing when you were there? • When did he get the diuretic? • How far was he from the bed? • What direction was he facing? Wheelchair? Bed locks? • Lighting? Floor? Clutter? Shoes? • Any other symptoms recently? UTI?

31. QAPI Key Principles • Resident focus • Staff partner in decision making • Team-based • Strong leadership • Data-driven decisions • Critical thinking • QI tools • RCA • 5 Whys • Brainstorming

32. All staff know the problems and solutions – be the one to make the difference!

33. Questions? This material was prepared by The Carolinas Center for Medical Excellence (CCME), the Medicare Quality Improvement Organization for North and South Carolina, 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. 10SOW-NC-C7-13-84