1. Quality Assessment and Performance Improvement: What’s New in QAPI for 2015! June 17, 2015 Michele Kala, MS, RN, Director of Accreditation and Certification 1

2. Objectives The Participant will be able to: 1.Articulate HFAP surveyor expectations regarding demonstration of compliance for performance improvement during the survey process for frequently cited standards. 2.Articulate the changes to the 2015 Acute Care Standards Manual regarding Chapter 12, Quality Assessment and Performance Improvement. 2

3. 2015 Acute Care Manual Changes  Changes reflect the CMS changes to the Surveyor Operations Manual.  Content and standards intent has not changed, but standards have been combined.  HFAP has added interpretive guidelines. 3

4. 2015 Acute Care Manual Changes  Chapter length has gone from 18 to 22 pages.  Total number of standards has been reduced from 34 to 19. (standards deletion and combining of standards)  Ten standards were deleted and one standard was added. 4

5. 2015 Acute Care Manual Changes  12.00.07 Quality Assessment Performance Improvement: New standard—Allows surveyors the option of scoring the Condition of Participation out at a standard level rather than a condition level.  Crosswalk of standards 5

6. New Standards to Old Standards Crosswalk 2015 Acute Care Manual- Chapter 12—NEW 2014 V3 Acute Care Manual-Chapter 12—OLD 12.00.00 CoP citation QAPI12.00.01 CoP citation QAPI 12.00.07 Standard citation QAPINot in requirements 12.00.01 Data Collection and Analysis—Defines requirements of the quality plan. 12.00.03 Program Scope 12.00.09 Program Accountability 12.00.10 Program Data (1) 12.00.12 Data Collection 12.00.02 Quality Improvement Program Activities. 12.00.10 Program Data (2) 12.00.13 Program Activities 12.00.15 Sustained Improvements 12.00.03 Patient Safety, Medical Errors and Adverse Events (Incorporates first two bulleted issues in standard 12.00.01 but is focused on IMPLEMENTATION of the quality plan) 12.00.03 Program Scope 12.00.09 Program Accountability 12.00.14 Medical Errors 12.00.21 Governing Body Responsibilities (3) 12.00.04 Performance Improvement Projects. 12.00.16 Performance Improvement Projects 12.00.17 Information Technology Systems 12.00.18 Required Documentation 12.00.19 QIO Projects 12.00.05 Executive Responsibilities12.00.21 Governing Body Responsibilities (1,2, & 5) 12.00.06 Adequate Resources12.00.21 Governing Body Responsibilities (4) 12.01.01 Quality Management Position12.00.02 Quality Management Position 12.01.02 Quality Committee/Function12.00.05 Quality Committee/Function 12.01.03 Meetings & Documentation of Activities12.00.06 Meetings & Documentation of Activities 12.01.04 Annual Quality Report12.00.07 Annual Quality Report 12.01.05 Education Program12.00.08 Education Program 12.00.06 HFAP Clinical Quality Measurement Program 12.00.20 HFAP Clinical Quality Measurement Program New Standards to Old Standards Crosswalk, continued 12.01.07 Reporting to the Board of Trustees (expanded content) 12.01.08 Reporting to the Board of Trustees 12.02.01 Culture of Safety12.00.22 Culture of Safety 12.02.02 Adverse Event Review Process12.00.23 Adverse Event Review Process 12.02.03 Communication to the Patient of Adverse Events12.01.10 Communication to the Patient of an Adverse Event 12.02.04 Support of Caregivers12.01.11 Support of Caregivers 6

7. Old Standards to New Standards Crosswalk 2014 V3 Acute Care Manual-Chapter 12--OLD2015 Acute Care Manual-Chapter 12--NEW 12.00.01 CoP citation QAPI12.00.00 CoP citation QAPI 12.00.02 Quality Management Position12.01.01 Quality Management Position 12.00.03 Program Scope 12.00.01 Data Collection and Analysis (required content in QA Plan) 12.00.03 Patient Safety, Medical Errors and Adverse Events (program implementation requirements) 12.00.04 Leadership AccountabilityDELETED 12.00.05 Quality Committee Function12.01.02 Quality Committee/Function 12.00.06 Meetings & Documentation of Activities12.01.03 Meetings & Documentation of Activities 12.00.07 Annual Quality Report12.01.04 Annual Quality Report 12.00.08 Education Program12.01.05 Education Program 12.00.09 Program Accountability 12.00.01 Data Collection and Analysis—Defines requirements of the quality plan. 12.00.03 Patient Safety, Medical Errors and Adverse Events (Incorporates first two bulleted issues in standard 12.00.01 but is focused on IMPLEMENTATION of the quality plan) 12.00.10 Program Data 12.00.01 Data Collection and Analysis—Defines requirements of the quality plan.(1) 12.00.02 Quality Improvement Program Activities. (2) 12.00.11 Quality PrinciplesDELETED 12.00.12 Data Collection12.00.01 Data Collection and Analysis—Defines requirements of the quality plan. 12.00.13 Program Activities12.00.02 Quality Improvement Program Activities. 7

8. Old Standards to New Standards Crosswalk, continued 12.00.14 Medical Errors 12.00.03 Patient Safety, Medical Errors and Adverse Events (Incorporates first two bulleted issues in standard 12.00.01 but is focused on IMPLEMENTATION of the quality plan) 12.00.15 Sustained Improvements12.00.02 Quality Improvement Program Activities. 12.00.16 Performance Improvement Projects12.00.04 Performance Improvement Projects 12.00.17 Information Technology Systems12.00.04 Performance Improvement Projects 12.00.18 Required Documentation 12.00.04 Performance Improvement Projects 12.00.19 QIO Projects12.00.04 Performance Improvement Projects 12.00.20 HFAP Clinical Quality Measurement Program12.00.06 HFAP Clinical Quality Measurement Program 12.00.21 Governing Body Responsibilities 12.00.05 Executive Responsibilities (1-3) 12.00.06 Adequate Resources (4) 12.00.22 Culture of Safety12.02.01 Culture of Safety 12.00.23 Adverse Event Review Process12.02.02 Adverse Event Review Process 12.01.01 Tracking Medical ErrorsDELETED 12.01.02 Monitoring System AccountabilityDELETED 12.01.03 Participation in Analysis of Medical ErrorsDELETED 12.01.04 Analysis of Medical ErrorsDELETED 12.01.05 Corrective ActionDELETED 12.01.06 Medical Error ReportingDELETED 12.01.07 Reporting of QAPI DataDELETED 12.01.08 Reporting to the Board of Trustees 12.01.08 Reporting to the Board of Trustees (expanded content) 12.01.09 Statistical AnalysisDELETED 12.01.10 Communication to the Patient of an Adverse Event12.02.03 Communication to the Patient of Adverse Events Old Standards to New Standards Crosswalk, continued 12.01.11 Support of Caregivers12.02.04 Support of Caregivers 8

9. Top Cited Deficiencies for 2014 12.00.07 Annual Quality Report: “There is an annual report based on the annual plan which details all quality activities and their progress or resolution during the year. The report shall be submitted to the governing body for review and approval” 9

10. Top Cited Deficiencies for 2014 Explanation  The report must include the CEO’s review and summary of leadership activities to support the program (deleted requirement in the 2015 publication).  The report must be provided annually.  The report must be presented to the governing body for review and input. 10

11. Top Cited Deficiencies for 2014 Surveyor Process  Review three years of annual reports for required content  Review governance minutes for verification of review and discussion of the reports 11

12. Top Cited Deficiencies for 2014 Frequently Cited Issues  Reports not being provided annually  No CEO summary included in the report  No documentation in governance minutes of review and discussion of the annual report 12

13. Top Cited Deficiencies for 2014 12.00.12 Data Collection: “The frequency and detail of data collection must be specified by the hospital’s governing body.” §482.21(b)(3) Explanation The governing body must approve the performance indicators and the frequency of reporting data each year. 13

14. Top Cited Deficiencies for 2014 Surveyor Process  Review the hospital quality plan for the current year  Review governance minutes to verify the governing body has reviewed and approved the indicators and reporting frequency for the year. 14

15. Top Cited Deficiencies for 2014 Frequently Cited Issues Governance minutes do not reflect review and approval of the current years indicators and frequency of reporting. 15

16. Top Cited Deficiencies for 2014 12.00.21 Governing Body Responsibilities: “The hospital’s governing body, medical staff, and administrative officials are responsible and accountable for ensuring the following:  Quality and patient safety program is defined, implemented and maintained.  QAPI plan addresses priorities …  Clear Safety expectations are established  Adequate resources are allocated  Determination of the number of PI projects conducted annually” §482.21(e)(1-5) 16

17. Top Cited Deficiencies for 2014 Explanation  Governance, medical staff and senior leadership must determine priorities regarding quality improvement efforts.  Governance must provide strong, clear, and visible attention to setting expectations for safety, allocating resources for supporting the PI process and reducing risk.  All leadership is accountable to implement an effective program which improves outcomes and reduces medical errors. 17

18. Top Cited Deficiencies for 2014 Surveyor Process  Review of governance minutes to determine involvement in performance improvement, improvement of patient outcomes and reduction of risk.  Review of processes to verify appropriate involvement and interventions by governance, medical staff and senior leadership. 18

19. Top Cited Deficiencies for 2014 Frequently Cited Issues:  Lack of apparent governance involvement in the QAPI process as reflected in governance minutes.  Apparent lack of involvement and direction from the board, medical staff and/or senior leadership. This would be cited if unresolved quality issues or an ineffective quality plan were identified. 19

20. Top Cited Deficiencies for 2014 12.00.09 Program Accountability: “The hospital must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service and operations.”§482.21(a)(2) 20

21. Top Cited Deficiencies for 2014 Explanation: The hospital must measure, analyze and track quality indicators that assess processes of care, hospital service and operations. This includes contract services. 21

22. Top Cited Deficiencies for 2014 Surveyor Process  Verify that data collection is appropriate to the scope of the hospital (inclusive of all departments/areas). The surveyor will inquire regarding quality initiatives in many/all departments.  Verify contracted services are included in the data collection process through review of quality committee minutes and departmental reports. 22

23. Top Cited Deficiencies for 2014 Frequently Cited Issues:  Hospital departments (often outpatient services, remote locations) not included in data collection and reporting of performance improvement.  Contracted services not included in data collection and reporting of performance improvement. (also cited in Chapter One, Administration of the Organizational Environment) 23

24. Patient Safety Initiatives, 2015 Hospital Quality Assessment Performance Improvement Worksheet—finalized with minor changes to wording but with no changes regarding content. Now applicable for Acute Care Hospitals and Critical Access Hospitals. Final PSI worksheets can be accessed at www.hfap.org under Resources tab, in the Patient Safety folder www.hfap.org 24

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26. Certificate of Attendance __________________________ Awarded 1.0 contact hours Quality Assessment and Performance Improvement A 60 minute audio-conference June 17, 2015 _______________------- Michele Kala Director of Accreditation and Certification 26

27. QUESTIONS? Please submit questions to: info@hfap.org 27