Presentation on theme: "Achieving a Culture of Excellence"— Presentation transcript:
1Achieving a Culture of Excellence QAPIAchieving a Culture of Excellence
2ObjectivesTo 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
4Baldrige Quality Award All about results and improvementUsing a frameworkA systematic approachEstablished by congress in 1987Designed to improve the competitiveness of US businessesIdentifies role model organizationInternationally recognized and emulated.
5Baldrige BackgroundStudies 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 usedThese process and values are now the framework for performance excellence
6Why BaldrigeStudy 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 indexRisk-adjusted complications indexPatient safety indexCMS core measures scoreSeverity-adjusted average length of stayAdjusted operating profit margin
8Baldrige categoriesLeadership: 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?
9Baldrige categoriesWorkforce: 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?
12What’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
14QAPI Affordable Care Act A system to provide technical assistance to nursing homesTransformation of how we deliver qualityShift on delivering excellence proactively, not reactivelyApproach where problems are caught before serious
15QAPI“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.”
16QAPI A framework of 5 elements: 1. Design and scope 2. Governance and leadership3. Feedback and monitoring4. PI projects5. Analysis and systematic action
17Performance Improvement Systematic Analysis and Action Design/ScopeQuality of Care, Quality of Life, Resident ChoiceGovernance/LeadershipFeedback, DataSystems/MonitoringPerformance ImprovementProjectsSystematic Analysis and Action
18QAPI: Design and ScopePlan should be comprehensive and include all the care and services your facility provideBalancing safety and quality of care with resident choice and autonomyNot just about nursing or the food in the kitchen— involves every aspect of the care and services provided
19QAPI: Governance and Leadership Expectation that the executive leadership of your facility must be actively engaged and involved in QAPIIt must be real visible involvement at all levels
20QAPI: 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
21QAPI: Performance Improvement Projects Performance Improvement Projects (PIPs) to improve careBuilds on the other elements to ensure that the opportunities for improvement are prioritized and incorporated into PIPs
22Systemic Analysis and Action Using a systematic formal process for analysisExample: root cause analysisEnsuring that actions taken address changes or improvements to the systemContinual improvement and learning
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.
27Converging on Qapi Silver award applications Affordable Care Act mandate: QAPIHardwire a culture of excellenceStrategic Plan: Direction from the boardNeeded a framework
28Leadership and Governance Developing the QAPI Workgroup:Educate boardObtain senior leadership supportIdentified initial membership of the WorkgroupBoard steers the QAPI workgroup
29MVH QAPI Workgroup Representatives from all 6 homes and central office Standardized education to introduce QAPICharter established and approved by BoardPurpose – establish a fact based, data-driven system for improving healthcare, safety, operational performance and competitiveness of Maine Veterans’ HomesGoals:Development of an annual QAPI planDevelopment of a results dashboardReview of outcome results and identification of opportunities for improvement
32Design 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/partnersSelf Assessment:CMS QAPI tools: QAPI at a GlanceOrganizationally and at each homeQAPI Plan Development:Purpose StatementDevelopment of guiding principles
33MVH QAPI Purpose Statement Design and ScopeMVH QAPI Purpose StatementThe 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”.
34QAPI Plan Goals QAPI Plan Goals: Utilize a dashboard to monitor key measures and improve organizational performanceEstablish a framework for performance improvement practices at MVHPromote a culture of safety for residents, families, and staffEnhance quality of life for our resident through culture change activities
35Design and ScopeMVH 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.
36Design and ScopeMVH 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.
37Development of Measures Measures were reviewed for alignment with:Industry goals and initiativesMVH Strategic PlanCustomer ExpectationsCore ValuesPerformance Excellence Framework for Improving Organizational QualityQAPI elements
43Review of Measures Measures approved by board and senior leaders QAPI Element: Actively involved governing bodyStandardized training across organization
44Accountability Measure Freqency Person Responsible Notes FreqencyPerson ResponsibleNotesPost to M-Drive byTotal Facility TurnoverQuarterlyKen/Lori4/20, 7/20, 10/20, 1/20Nursing TurnoverHospital ReadmissionsMonthlyAlain with Rhona backupData entered by DNS by 15th20thCulture ChangeEvery 6 monthsAdmistrators to DebData due to Deb by 12/30, 6/301/20, 7/20Days in ARJeremy with Karen backupOverall SatisfactionJeffDARTRecommend to OthersOccupancySerious Reportable EventsAdministratorsenter data by 15thLong Stay AntipsychoticsJim with Rob backupShort Stay AntipsychoticsRes Care AntipsychoticsRCD to send QIQM report to Jim5/20, 11/20
45Systematic Analysis and action: Root Cause Analysis Developed a root cause analysis toolReviewed with VAMC liaisonEducated clinical leadersImplemented
46Root Cause analysis Tool What happened?Why did it happen?Policy/procedures/practiceHuman FactorsCommunication FactorsEquipment FactorsInformation FactorsEnvironmental FactorsOther
50Performance Improvement projects One of our organization-wide PIPs was regarding hospital readmissionsWe began this PIP by looking at best practices and researching tools to assist usReviewed data using Trend TrackerChose to use Interact toolsInterfaced with local hospitals
52Next Steps Finalization of MVH QAPI Plan to include: Descriptions of:ScopeGuidelines for Governance and LeadershipFeedback, Data Systems, and MonitoringGuidelines for Performance Improvement Project TeamsSystematic Analysis and Systemic ActionCommunicationsEvaluationBoard review and Approval of Annual QAPI PlanStandardized training across the organization
53Achieving a Culture of Excellence QAPI:Achieving a Culture of Excellence
56Department Measures Each department measuring their own area Narrow focus
57Functional Measures Transition to functional measures InterdisciplinaryMeasures across departments for functional groups
58Engaging 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.
59Engaging and Building Relationship stakeholders These committees are:CommunicationsSafetyEmployee RecognitionWellnessPublic Relations & MarketingActivities and DiningRecycling
60EngageStaff, residents, and family members agreed to populate them.
61Where we are nowPrior to QAPI we were adding pieces but not building from the foundationUsing the Baldrige criteria and the elements of QAPI to hardwire a culture of excellenceNot only understand HOW but WHY we have quality assurance and performance improvement activities
62Engaging and Building Relationship with Staff: Cultivating Excellence & Improve Staff Satisfaction Not easyPersevere
63Make it THE most important Engaging and Building Relationship with Staff: Cultivating Excellence & Improve Staff SatisfactionHear the negativesStay focusedDon’t overwhelmMake it THE most importantLet them do their work, if they do it wrong at least they are doing it.
64Celebrate the successes Acknowledge the failures Engaging and Building Relationship with Staff: Cultivating Excellence & Improve Staff SatisfactionCelebrate the successesAcknowledge the failuresThomas Edison said, “I did not fail, I discovered thousands of things that did not work”
65Contact InformationDebra Fournier, Chief Operations OfficerMaine Veterans’ HomesKevin Warren, Deputy CommissionerTexas State Veterans Homes & Cemeteries