1. June 2017 All-Stakeholder Call
NNHQI Campaign
June 2017 All-Stakeholder Call

2. Welcome to the June 2017 All-Stakeholder Call!
National Nursing Home Quality Improvement Campaign
Contact Us via HelpDesk at .

3. Improving Nursing Home Quality Measures: QAPI push
Linda Savage, RN, BSN, CDONA/LTC
Program Specialist
June 13, 2017

5. Who is Telligen? What is the QIN-QIO Program?
Telligen: The Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Colorado, Iowa and Illinois
QIN-QIO Program Purpose: To improve the efficiency, effectiveness, economy, and quality of services delivered to Medicare beneficiaries

6. Who is Telligen? What is the QIN-QIO Program?
QIN-QIOs
-have performance-based contracts with the Centers for Medicare & Medicaid Services (CMS)
-help achieve national quality goals through focused efforts at the community level
-provide technical assistance and convene learning and action networks at no cost to support healthcare quality improvement at the community level

7. National Nursing Home Quality Care Collaborative
Evaluation goals (CMS performance expectations)
Recruit 75% of Colorado nursing homes (at least 161) to participate in Collaborative I
At least 50% of recruited NHs (79) will obtain a quality measure composite score of 6.00 or less by January 2019

8. QAPI push
Six-week course designed to improve 2 long-stay quality measures through Quality Assurance Performance Improvement (QAPI) methodology utilizing rapid-cycle improvement and the learning and action network structure
Limited to 20 nursing homes per cohort
With advance notice of participation, state health department (committed supporter) will not conduct annual survey in the home during the course
Currently, 200+ nursing homes have completed the course across Colorado, Iowa and Illinois

9. QAPI push Results

10. Colorado Department of Public Health and Environment (CDPHE)
Jo Tansey
Health Facilities and Emergency Services Division, Section Manager for Nursing Facilities

11. Southeast Colorado Hospital District
Burning Britches
QAPI push
Southeast Colorado Hospital District
Springfield, Colorado

12. QAPI push participant: Southeast Colorado Hospital District KayCee McCallum, Activity Director

13. Team Charter Goal for Burning Britches QAPI
Reduce UTI’s by 25% by
Method of Measurement – Casper report
Baseline %-10%
Our Target goal- 7.5%

14. Baseline Graph information

15. PDSA 1(Plan Do Study Act) CMS’s RAI Coding instructions for UTIs
Cycle 1
Make sure the facility is coding correctly
Double check those resident’s triggering with UTI to ensure they meet the requirements of the CMS RAI Manual instructions for UTI
Results of Cycle 1
3 of the 5 resident’s triggering on the Casper report were due to a coding error on the MDS
QI Casper report down to 8.0% for UTIs

16. PDSA 2 Peri-care /peri-wash education
Cycle 2 ( )
Huddle with CNA’s, Nurses, Resident Care Coordinator, DON, ADON-discussion on the use of peri wash and proper peri care procedures
Peri care policy posted for all staff to review
UTI staff education added to health stream for staff to complete.

17. PDSA 3 Handwashing and pericare audit
Audit Information
Audit Results
25 staff audited for hand washing including nursing, CNA’s, activities, respiratory therapy, and laundry
9 resident’s with peri care audited
Out of 25 staff, 12 passed and 13 failed, resulting in 52% improper handwashing-Staff educated at time of audit.
Out of the 9 resident’s 6 passed and 3 failed, resulting in 33% of peri care done improperly – staff educated at time of audit

18. Graph information from February 2016 to August 2016

19. August Spike
In August of 2016 there was a spike up to 8.7% again in the facility UTIs
Repeated Cycle 1 and reviewed all resident’s triggering and found a coding error resulting in a decrease of % on the Casper report the following month after corrections to MDSs were submitted.

20. UTI Graph information From September 2016 to February 2017

21. Significant spike in UTI’s on Casper report from 4.7% to 9.1%
The team immediately went to work going over the cycles that were already in place
After further investigation by the DON it was found that the disinfecting mechanism of the tub wasn’t functioning properly.

22. PDSA 4 Order and Install New Tub for Facility
The first month after the installation of the tub, the UTIs remained the same
The second month after the installation of the tub the UTIs decreased to 8.0%
The 3rd month after the installation of the tub the UTIs decreased significantly to 3.9%.
And as of the percent is down to 3.8%.

23. Final Casper report graph on facility UTIs

24. Story board Burning Britches QAPI Project

25. Welcome!
Kate
LaFollette

26. Iowa and Illinois

27. QAPI Push and Communities

28. Next Steps

29. Contact
Linda Savage, RN, BSN, CDONA/LTC (cell)
This material was prepared by Telligen, the Medicare Quality Improvement Organization for Colorado, 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. 11SOW-QIN-C2-06/12/

30. National Nursing Home
Quality Improvement Campaign
Thank You For making our nursing homes better places to live, work, and visit!