QAPI What Box Does it Fill?

Person Centered Care QAPI

Objectives Who does QAPI apply to and effect? Why should we use it? Why do I care? What is QAPI? When is QAPI necessary? Where is QAPI used? How do we “do” QAPI?

The Affordable Care Act of 2010 required nursing homes to have an acceptable QAPI plan within a year of the promulgation of a QAPI regulation…… The CMS LTCF Requirements of Participation changes which began implementation in 2016 set the stage…. Phase I: November 28, 2016 Phase II: November 28, 2017 (Facilities now required to have a QAPI plan) Phase III: November 28, 2019 ~ Facilities required to have QAPI feedback, data collection, and monitoring AND a systematic approach for quality improvement

Why??? “QAPI at a Glance: A Step by Step Guide to Implementing Quality Assurance and Performance Improvement (QAPI) in Your Nursing Home” A publication by the University of Minnesota and StratisHealth and endorsed by CMS is one of the best resources for understanding and implementing QAPI first read the left.......

Okay, so… what IS QAPI ??

QA + PI = QAPI QA and PI combine to form QAPI, a comprehensive approach to ensuring high quality care. QAPI is a data-driven, proactive approach to improving the quality of life, care, and services in nursing homes. The activities of QAPI involve members at all levels of the organization to: * identify opportunities for improvement; * address gaps in systems or processes; * develop and implement an improvement or corrective plan; and * continuously monitor effectiveness of interventions.

QAPI features….

5 Elements CMS has identified five strategic elements that are the basic components to an effective QAPI program

Element 1: Design and Scope The QAPI program must be ongoing and comprehensive, dealing with the full range of services offered by the facility - including the full range of departments. It should address all systems of care and management practices, and should always include clinical care, quality of life, and resident choice. It aims for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents. It utilizes the best available evidence to define and measure goals.

Element 2: Governance and Leadership The governing body and/or administration of the nursing home develops a culture that involves leadership seeking input from facility staff, residents, and their families and/or representatives. The governing body assures adequate resources exist to conduct QAPI efforts. This includes designating one or more persons to be accountable for QAPI; developing leadership and facility-wide training on QAPI; and ensuring staff time, equipment, and technical training as needed. The Governing Body should foster a culture where QAPI is a priority by ensuring policies are developed to sustain QAPI despite changes in personnel and turnover. Their responsibilities include setting expectations around safety, quality, rights, choice, and respect by balancing safety with resident-centered rights and choice. The governing body ensures staff accountability, while creating an atmosphere where staff are comfortable identifying and reporting quality problems as well as opportunities for improvement.

Element 3: Feedback, Data Systems and Monitoring The facility puts in place systems to monitor care and services, drawing data from multiple sources. Feedback systems actively incorporate input from staff, residents, families, and others as appropriate. This element includes using performance indicators to monitor a wide range of care processes and outcomes, and reviewing findings against benchmarks and/or targets the facility has established for performance. It also includes tracking, investigating, and monitoring adverse events that must be investigated every time they occur, and action plans implemented to prevent recurrences.

Element 4: Performance Improvement Projects (PIPs) A Performance Improvement Project (PIP) is a concentrated effort on a particular problem in one area of the facility or facility wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvement The facility conducts PIPs to examine and improve care or services in areas that the facility identifies as needing attention. Areas that need attention will vary depending on the type of facility and the unique scope of services they provide.

Element 5: Systematic Analysis and Systemic Action The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. The facility uses 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 or delivered. Additionally, facilities will be expected to 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 focus on continual learning and continuous improvement.

Illustrating QAPI In Action Scenario 1 – QA Vs Scenario 2 - QAPI

How? QAPI at a Glance outlines 12 steps a team needs to take to implement a successful program. The steps do not need to be followed sequentially, but each step builds on the other QAPI principles. Action ... doing something is the most important step.

Step 1: Leadership Responsibility and Accountability Creating a culture to support QAPI efforts begins with leadership. Support from the top is essential, and that support should foster the active participation of everyone on staff as well as the residents and their families. The administrator and senior leaders (which includes YOU) must create an environment that promotes QAPI and involves everyone. “QAPI at a Glance” lays out some great suggestions for administrators - but all of you can help: Create the expectation that everyone is working on improving care and services Establish an environment where everyone feels free to speak up to identify areas that need improvement Expect and build effective teamwork among departments and residents and families

Step 2: Develop a Deliberate Approach to Teamwork Lots of people can and do work together without being a team! An effective team needs to include : A clear purpose ~ defined roles for each team member to play ~ & ~ commitment to active engagement from each member! Task Oriented teams may be formed to look into a particular problem - their work may be limited and focused. PIPs (Performance Improvement Projects) are teams formed for longer-term work on an issue. Leadership needs to convey that being on a PIP is an important function - not merely something to do “if you have the time”. Each PIP team should include interdisciplinary members, even though the issue at hand may appear on the surface to be in the arena of one discipline. PIP teams need to spend time together to get to know each other and plan the work and they need to plan time for each team member to adequately do his/her part. Family members and residents can be great team members, though for confidentiality reasons they may not review data or information that would be HIPPA violations.

Step 3: Take your QAPI “Pulse” with a Self-Assessment In order to establish QAPI in your center, it is helpful to get a “pulse” of where everyone is with their understanding of what it is and how it works in your home. This is generally a function of the administration. “QAPI at a Glance” includes a self-assessment tool that can be used for this purpose.

Step 4: Identify Your Organization's Guiding Principles Most organizations have a mission statement which establishes a purpose and guiding principles that unify the facility by tying the work being done to a fundamental purpose or philosophy. This should be clearly identified by the facility leadership in the QAPI awareness campaign so everyone is aware of the facility's guiding principles. Organizations without clear guiding principles can use the “Guide for Developing Purpose, Guiding Principles, and Scope for QAPI” in “QAPI at a Glance” to establish principles that will give direction.

Step 5: Develop Your QAPI Plan This is generally accomplished by the Administrator or corporation. The written QAPI plan will assist in achieving what has been identified as the purpose, guiding principles and scope for QAPI. It should be a “living” document that is revisited as the facility evolves. “QAPI at a Glance” also has a tool to help develop a QAPI plan if your facility has yet to write one.

Step 6: Conduct a QAPI Awareness Campaign Let EVERYONE know about your QAPI plan - often and in multiple ways!! Plan ongoing education - beyond single exposures for widespread awareness Train through dialogue, examples, and exercises Convey the message that QAPI is about systems - systems need to support quality care &/or acceptable business practices, or they must change Include consultants, contractors and collaborating agencies in the QAPI awareness campaign. Convey the message that any and every caregiver is expected to raise quality concerns, that it is safe to do so, and that everyone is encouraged to think about systems! Communicate with ALL Caregivers (that is all staff members)

Step 6 cont. consider inviting your Administrator and other leaders to the Resident Council to talk about QAPI with the residents.

Step 7: Develop a Strategy for Collecting and Using QAPI Data Decide what data to monitor and collect routinely potential areas to consider : Resident care plans for documented progress towards specified goals Resident and family satisfaction surveys trends in complaints noted in Resident Council Set targets for performance (may choose to have both short and long term goals) Identify benchmarks - standards of comparison - for performance the most important benchmarks are generally based on your own performance Develop a plan for the data collected. Be purposeful about who reviews which data and how often - and about the next steps in interpreting the information. Information is not helpful unless it is actually used.

Collecting and Monitoring

Step 8: Identify Your Gaps and Opportunities Review the sources of information look for patterns or gaps Spend more time with the QAPI Council or Steering Committee - your leadership team - discussing quality themes you've identified. Celebrate the good ones! Look for areas that can be improved. Prioritize areas needing improvement

Step 9: Prioritize Quality Opportunities and Charter PIPs Once the areas for improvement are prioritized, identify those which need focused attention by more than one person (starting with problems that you think can be solved relatively easily is recommended - a quick win is a good start for your QAPI program). The word “Charter” is used on purpose to annotate the importance of the mission of a PIP. This team is being entrusted with a mission and will report back to the Steering Committee at least monthly. The PIP team should have a clear purpose, and leader and should develop a proposed time line and establish appropriate goals. the tool “Goal Setting Worksheet” found in “QAPI at a Glance” can assist

PIP team composition: consideration must be given to the purpose of the PIP - generally each team should be composed of interdisciplinary members. For example a concern with medication administration should include nursing members, however other disciplines or even family members may bring a different perspective to understanding the issue and should be considered. Some examples from QAPI at a Glance: ~ a PIP team with the goal of helping residents go outside more often decided that grounds personnel needed to be on that team so that procedures for snow removal, sun protection, and outdoor seating could be considered. ~ After a PIP team began working on the problem of anxiety among residents, the members realized that many of the affected residents reported reassurance from the pastor and asked the QAPI committee to add him to the team. ~ a PIP team working on reducing falls asked that the housekeeping department be involved as it considered root causes of falls and realized that equipment in the corridors and clutter in bathrooms contributed.

Step 10: Plan, Conduct & Document PIPs

Step 11: Getting to the “Root” of the Problem This “Step” is actually a critical part of Step 10 - studying the problem Getting to the heart or root of the problem is your first major challenge. Root Cause Analysis (RCA) is a term used to describe a systematic process for identifying contributing and causal factors underlying a problem - which then leads to identifying effective interventions that can be implemented in order to make the necessary change(s). RCA focuses primarily on systems and processes - not on individual performance. Collecting the facts surrounding the event or issue help to understand how and why the situation occurred. THEN interventions can be found to make real, sustainable difference. RCA is a process that takes time and practice, but it can be invaluable.

Step 12: Take Systemic Action This “Step” is actually a critical part of Step 10 - conducting a test change Next (not finally because this process is continuous) you want to implement changes that result in the desired improved performance. Implementing actions that are linked to the root cause(s) and lead to a system or process change have the greatest likelihood of being effective & sustainable Changes work best when tested in one area of the facility before launching throughout. Some changes have unintended consequences - and are best experienced in small areas to more easily accommodate adjustments before full launch.

Weak or STRONG change. The Dept Weak or STRONG change?? The Dept. of Veterans Affairs National Center for Patient Safety's Hierarchy of Actions classifies corrective actions as:

“Not all change is improvement, but all improvement is change.” Donald Berwick, MD Former CMS Administrator

Tools can help QAPI is largely about becoming well-functioning and tightly coordinated systems that can identify, solve, and prevent problems effectively. Using QAPI can improve diverse aspects of care and services as well as resident, family, and staff experience and satisfaction. QAPI process tools may include: checklists, templates, flow-charts, reporting forms or outlines, worksheets, and more. QAPI Process tools are important to: organize multiple tasks; enhance communication; help generate ideas and reach decisions, track successes and challenges, keep information organized and accessible +++++ Lots of tools and resources are available! Start with the CMS QAPI site......

In Summary: Quality Assurance and Performance Improvement is at the center of Person Centered Care. It's been with us forever in one form or another, but is now mandated as QAPI for participation in Medicare / Medicaid covered services. If done well it will make the lives of our residents and our staff better. The Centers for Medicare and Medicaid Services (CMS) has defined 5 elements that must be in our QAPI plans and programs: 1. Design and Scope ~ it has to intentionally cover all aspects of our business and services 2. Governance and Leadership ~ it has to come from the top including all of the facility leadership 3. Feedback, Data Systems and Monitoring ~ must seek customer feedback, utilize data gathering systems, & continuous monitoring 4. Performance Improvement Projects ~ there must be evidence of PIPs 5. Systematic Analysis and Systemic Action ~ there must be evidence of systematic analysis and resulting systemic action “QAPI at a Glance” found at http://go.cms.gov/Nhqapi provides lots of tools and 12 basic steps to create your facility's QAPI program. Your QAPI program is not .... cannot be... a “cookie cut-out” program, but will reflect YOU and the culture of your facility as you continuously improve your care and services.

Reference Materials http://go.cms.gov/Nhqapi www.cms.gov Guidanceforrca.pdf U.S. Department of Veterans Affairs. National Center for Patient Safety Root Cause Analysis Tools. http://www.patientsafety.gov/CogAids/RC A/index.htmlpage+page-1