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Achieving a Culture of Excellence

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1 Achieving a Culture of Excellence
QAPI Achieving a Culture of Excellence

2 Objectives To demonstrate an understanding of how to use the elements of QAPI within  the performance excellence framework. To verbalize how a SVH can mobilize an organization to create and sustain a culture of excellence. To identify at least one method to involve team members in creating a culture of learning

3 "Change would be easy if it weren't for all of the people"
Balestracci and Barlow

4 Baldrige Quality Award
All about results and improvement Using a framework A systematic approach Established by congress in 1987 Designed to improve the competitiveness of US businesses Identifies role model organization Internationally recognized and emulated.

5 Baldrige Background Studies done related to industries in the US who were losing market share- such as steel and auto industries. Found a common set of values and process that successful organizations used These process and values are now the framework for performance excellence

6 Why Baldrige Study by Thompson Reuters found that hospitals using the Baldrige criteria were 6X more likely to be in the top 100 hospitals and outperformed non- Baldrige hospitals in: Risk-adjusted mortality index Risk-adjusted complications index Patient safety index CMS core measures score Severity-adjusted average length of stay Adjusted operating profit margin

7 Roadmap Leadership Triad Results Triad

8 Baldrige categories Leadership: How do leaders create a sustainable organization? Strategic Planning: How do you develop strategy? Customer Focus: How do you listen to customers and determine solutions upon feedback from the customer? Measurement, Analysis and Knowledge Management: How do you select and use data to measure and improve performance?

9 Baldrige categories Workforce: How do you assess capacity and capability to meet the needs of the customer and accomplish the plan? Operations: How do you manage key work processes and systems to create long term sustainable value? Results: What results are important to leadership and your customers and how do you share with those that impact performance?

10 Approach Deploy Learn Integrate

11 So what?

12 What’s the Goal? Improvement of some components, processes, or outcomes? OR Complete system transformation to ensure success every time?

13 “Tension for Change” “To leave the comfort of the status quo, most individuals need to believe that change is truly imperative and there is a more attractive alternative.” Silversin, J. & Kornacki M.J, ,(2000) Leading Physicians Through Change

14 QAPI Affordable Care Act
A system to provide technical assistance to nursing homes Transformation of how we deliver quality Shift on delivering excellence proactively, not reactively Approach where problems are caught before serious

15 QAPI “The Centers for Medicare & Medicaid Services (CMS) is leading an initiative that could transform the way nursing homes ensure quality. This initiative goes beyond the current QAA provision, and aims to significantly expand the intensity and scope of current activities in order to not only correct quality deficiencies (quality assurance), but also to put practices in place to monitor all nursing home care and services to continuously improve performance.”

16 QAPI A framework of 5 elements: 1. Design and scope
2. Governance and leadership 3. Feedback and monitoring 4. PI projects 5. Analysis and systematic action

17 Performance Improvement Systematic Analysis and Action
Design/Scope Quality of Care, Quality of Life, Resident Choice Governance/ Leadership Feedback, Data Systems/Monitoring Performance Improvement Projects Systematic Analysis and Action

18 QAPI: Design and Scope Plan should be comprehensive and include all the care and services your facility provide Balancing safety and quality of care with resident choice and autonomy Not just about nursing or the food in the kitchen— involves every aspect of the care and services provided

19 QAPI: Governance and Leadership
Expectation that the executive leadership of your facility must be actively engaged and involved in QAPI It must be real visible involvement at all levels

20 QAPI: Feedback, Data Systems, and Monitoring
This element emphasizes the establishment of systems for proactively identifying and using data to measure performance and identifying opportunities for improvement

21 QAPI: Performance Improvement Projects
Performance Improvement Projects (PIPs) to improve care Builds on the other elements to ensure that the opportunities for improvement are prioritized and incorporated into PIPs

22 Systemic Analysis and Action
Using a systematic formal process for analysis Example: root cause analysis Ensuring that actions taken address changes or improvements to the system Continual improvement and learning

23 Governance & Leadership
Approach Deploy Learn Integrate Design & Scope Governance & Leadership Performance Improvement Projects (PIP) Systematic Analysis/ Systematic Action Feedback, Data Systems Monitoring


25 “Call the Question” Are you proud of “your” performance?
How do your clinical scores compare to your competitors? What did "we" do differently? Does improving quality really matter in your organization? How are quality initiatives prioritized within your organization? Do you “know” how you do what you do to make success repeatable? Developed from AHA Get w/ the Guidelines program (Houston, 2005) In every presentation, I’m always looking for one takeaway that I can apply back home. If there is at least one takeaway from this presentation, it is this slide: I would encourage you to review these questions from both a self reflection perspective as a leader as well as with your leadership team at home. You have an opportunity to be as prepared as possible for the future changes, whatever they may be, that will affect your hospital.

26 QAPI Maine Veterans Homes Journey

27 Converging on Qapi Silver award applications
Affordable Care Act mandate: QAPI Hardwire a culture of excellence Strategic Plan: Direction from the board Needed a framework

28 Leadership and Governance
Developing the QAPI Workgroup: Educate board Obtain senior leadership support Identified initial membership of the Workgroup Board steers the QAPI workgroup

29 MVH QAPI Workgroup Representatives from all 6 homes and central office
Standardized education to introduce QAPI Charter established and approved by Board Purpose – establish a fact based, data-driven system for improving healthcare, safety, operational performance and competitiveness of Maine Veterans’ Homes Goals: Development of an annual QAPI plan Development of a results dashboard Review of outcome results and identification of opportunities for improvement

30 Charter

31 Charter

32 Design and Scope Reviewed organizational profiles Self Assessment:
Baldrige definition: What are your key organizational characteristics? What is your organization's strategic situation? Products, vision, mission, workforce, assets, regulatory requirements, organizational structure, customers/stakeholders, suppliers/partners Self Assessment: CMS QAPI tools: QAPI at a Glance Organizationally and at each home QAPI Plan Development: Purpose Statement Development of guiding principles

33 MVH QAPI Purpose Statement
Design and Scope MVH QAPI Purpose Statement The purpose of our Quality Assurance and Performance Improvement (QAPI) Program is to achieve and sustain a culture of excellence by using a fact based, data driven decision making model with a proactive approach to continually improving the way we “Care for Those Who Served”.

34 QAPI Plan Goals QAPI Plan Goals:
Utilize a  dashboard to monitor key measures and improve organizational performance Establish a framework for performance improvement practices at MVH Promote a culture of safety for residents, families, and staff Enhance quality of life for our resident through culture change activities

35 Design and Scope MVH QAPI Guiding Principles 1. In our organization, QAPI includes all employees, all departments, and all services. 2. QAPI has a prominent role in our management and board functions. 3. Our organization uses QAPI to make informed decisions and guide our day to day operations. 4. The outcome of QAPI in our organization is the quality of care and quality of life of our residents within a framework of resident directed care and recognition that “Veterans are Unique”. 5. QAPI focuses on systems and process. The emphasis is on identifying system gaps rather than blaming individuals.

36 Design and Scope MVH QAPI Guiding Principles 6. Our organization has a culture that supports “Honesty and Integrity” by encouraging employees to identify errors and system breakdown. 7. Our decisions to improve will be guided by data, in conjunction with individual care and choice, which includes to input and experience of residents, families, caregivers, health care practitioners, and other stakeholders. 8. Our organization sets goals for performance and measures progress towards those goals with a focus on “Leading the Way” within our industry and sustaining a culture of “Excellence”. 9. Our organization supports performance improvement by encouraging our employees to “Respect” and support each other as well as be accountable for their own professional performance and practice. 10. MVH encourages “Team” collaboration, sharing of best practices, and celebrating successes across the organization.

37 Development of Measures
Measures were reviewed for alignment with: Industry goals and initiatives MVH Strategic Plan Customer Expectations Core Values Performance Excellence Framework for Improving Organizational Quality QAPI elements

38 Tool to determine measures


40 Dashboard Measures Non-clinical Measures: Clinical Measures:
Workforce – Total facility turnover; Nursing turnover; Days Away Restricted Transferred Duties (DART) Operations – Days in Accounts Receivable; Occupancy Customer – Overall satisfaction; Recommends to others; Culture change Clinical Measures: Healthcare – Hospital Readmissions; Serious Reportable Events; Long-Stay, Short-Stay, & Res Care Antipsychotic Drug Use

41 Results Dashboard Visual representation of organizational performance
Displays clinical and non- clinical results called measures Displays MVH target Reflects trends in organizational performance


43 Review of Measures Measures approved by board and senior leaders
QAPI Element: Actively involved governing body Standardized training across organization

44 Accountability Measure Freqency Person Responsible Notes
Freqency Person Responsible Notes Post to M-Drive by Total Facility Turnover Quarterly Ken/Lori 4/20, 7/20, 10/20, 1/20 Nursing Turnover Hospital Readmissions Monthly Alain with Rhona backup Data entered by DNS by 15th 20th Culture Change Every 6 months Admistrators to Deb Data due to Deb by 12/30, 6/30 1/20, 7/20 Days in AR Jeremy with Karen backup Overall Satisfaction Jeff DART Recommend to Others Occupancy Serious Reportable Events Administrators enter data by 15th Long Stay Antipsychotics Jim with Rob backup Short Stay Antipsychotics Res Care Antipsychotics RCD to send QIQM report to Jim 5/20, 11/20

45 Systematic Analysis and action: Root Cause Analysis
Developed a root cause analysis tool Reviewed with VAMC liaison Educated clinical leaders Implemented

46 Root Cause analysis Tool
What happened? Why did it happen? Policy/procedures/practice Human Factors Communication Factors Equipment Factors Information Factors Environmental Factors Other

47 Root cause analysis tool

48 Root cause analysis tool

49 Cause and effect diagram tool

50 Performance Improvement projects
One of our organization-wide PIPs was regarding hospital readmissions We began this PIP by looking at best practices and researching tools to assist us Reviewed data using Trend Tracker Chose to use Interact tools Interfaced with local hospitals

51 Hospital Readmission PIP

52 Next Steps Finalization of MVH QAPI Plan to include:
Descriptions of: Scope Guidelines for Governance and Leadership Feedback, Data Systems, and Monitoring Guidelines for Performance Improvement Project Teams Systematic Analysis and Systemic Action Communications Evaluation Board review and Approval of Annual QAPI Plan Standardized training across the organization

53 Achieving a Culture of Excellence
QAPI: Achieving a Culture of Excellence

54 One Home’s Journey Maine Veterans’ Home, Scarborough

55 The past Reviewing QIQM reports Counting beans

56 Department Measures Each department measuring their own area
Narrow focus

57 Functional Measures Transition to functional measures
Interdisciplinary Measures across departments for functional groups

58 Engaging and Building Relationship with Stakeholders
In the true sense of resident directed and person-centered approach to all that we do, we have developed and/or revised seven teams.

59 Engaging and Building Relationship stakeholders
These committees are: Communications Safety Employee Recognition Wellness Public Relations & Marketing Activities and Dining Recycling

60 Engage Staff, residents, and family members agreed to populate them.

61 Where we are now Prior to QAPI we were adding pieces but not building from the foundation Using the Baldrige criteria and the elements of QAPI to hardwire a culture of excellence Not only understand HOW but WHY we have quality assurance and performance improvement activities

62 Engaging and Building Relationship with Staff: Cultivating Excellence & Improve Staff Satisfaction
Not easy Persevere

63 Make it THE most important
Engaging and Building Relationship with Staff: Cultivating Excellence & Improve Staff Satisfaction Hear the negatives Stay focused Don’t overwhelm Make it THE most important Let them do their work, if they do it wrong at least they are doing it.

64 Celebrate the successes Acknowledge the failures
Engaging and Building Relationship with Staff: Cultivating Excellence & Improve Staff Satisfaction Celebrate the successes Acknowledge the failures Thomas Edison said, “I did not fail, I discovered thousands of things that did not work”

65 Contact Information Debra Fournier, Chief Operations Officer Maine Veterans’ Homes Kevin Warren, Deputy Commissioner Texas State Veterans Homes & Cemeteries

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