Transcript Quality Assessment and Performance Improvement “QAPI”

Quality Assessment and Performance
Improvement
Presented by:
Jodi Oglesby, RN, CNN
Nurse Manager
Dialysis Clinic, Inc. Warrensburg
History of QAPI
 Quality Improvement
 Quality Assurance
 Continuous Quality Improvement
 Quality Assessment and Performance
Improvement
 Do we get it yet?????
QAPI 2009
“It’s what you learn after you
know it all that counts”
 John Wooden, UCLA Basketball coach for 27 seasons, 10
national championships including 7 in a row from 1967-1973.
Objectives
 Tracking and Trending
 Identifying Areas for Improvement
 Creation of a Quality Improvement Plan
 Defining Goals
 Measuring and Prioritizing “root” cause
 Developing Interventions
 Remeasurement – Testing Changes
When solving problems, dig at the roots instead of just hacking at the leaves. ~
Anthony J. D'Angelo,The College Blue Book
Vtag 625 Condition: Quality Assessment and
Performance Improvement (QAPI)
 This Condition looks at:
 Facility data
 Requires facility-based assessment and
improvement of care

This is different from the Plan of Care which is
patient-based improvement
Quality Indicators










Adequacy of Dialysis
Nutritional Status
Mineral Metabolism and Renal Bone Disease
Anemia Management
Vascular Access
Medical Injuries and Medical Errors Identification
Hemodialyzer Reuse Program (if the facility reuses
hemodialyzers)
Patient Satisfaction and Grievances
Infection Control
As well as, Measures of Water and Dialysate Quality
and Safety, and Safe Machine Maintenance
Program Scope
 An “ongoing” program
 Continuously looks at all indicators (overall vs.
individual)
 Trends outcomes (again, overall…)
 Develops an improvement plan when indicated.
 Generally will require at least monthly review of
indicators


Prescribed patient indicators are typically evaluated
with laboratory results monthly
Serves as a functional time frame for trending of data
within the facility
Goals/Benchmarks
 Set Facility Specific Goals

Data on current professionally-accepted clinical
practice standards must be used


MAT
CPM’s
 Goals vs. Outcomes

If facility performance is below average

Expected to take action toward improving those
outcomes
Monitoring Data/Information
 Facility must measure, analyze, and track quality
indicators (or other aspects of performance that the
facility adopts or develops) that reflect


processes of care
facility operations
 Records of QAPI activities including minutes or
another method of demonstrating this analysis and
action must be available for review
 Facility should compare their performance with
 community-based standards
 other facilities in their State
 their Network
 the U.S.
Measure, Analyze, and Track
 Trending Data
 Collective patient data
 Review HD and PD separately
 Priority
 Identify potential problems
 Prioritize areas for improvement
 Identify opportunities for improving care
TRACKING TOOL
(drop down
box)
Frequency
Annual
Quarterly
Monthly
Bi-annual
(drop down
(drop down (drop down
box)
box)
box)
Goal Met
Priority Action Plan
Yes/No
Low
Required
High
Yes/No
Urgent
Ongoing
JAN
FEB
MAR
Anemia (add Threshold/Goal)
Hgb < 10
Hgb > 11
Hgb > 13
Add your facility determined goals
and thresholds
Iron Sat: % pt's >25
Ferritin: % pt's 100 - 800
Discussion:
You may choose to use a variety of tools and tracking methods
for data review:
Aggregate trend spreadsheets
100
90
80
70
54.5
57.1
09/2008
10/2008
60
61.9
60.9
11/2008
12/2008
68.0
68.0
01/2009
02/2009
You may choose to
use a variety of tools
and tracking methods
for data review:
Graphs
50
40
30
20
10
0
100
90
80
70
60
50
40
09/2008
10/2008
11/2008
12/2008
01/2009
02/2009
30
20
10
0
D1
D2
D3
D4
D5
D6
Identifying Problems
 Review collective patient data;

Look at trends



Steady improvement or stable outcomes
Abrupt or steady decline in outcomes
Identify any commonalities among patients who
do not reach the minimum expected targets;
One vehicle accident may
not indicate you are a bad
driver…..
However…10 accidents a year
may cause your insurance
company to make some
changes in your plan!
Quality Improvement Plan
 Plan that results in improvement in care
 Developing
 Implementing
 Evaluating
 Monitor the effectiveness of the plan
 Revising
 Adjust portions of the plan that are not successful
 What are we trying to accomplish?
 How will we know if a change is an
improvement?
 What changes can we make that will result in
improvement?
Quality Improvement Plan
QIP (Quality Improvement Plan) should include the
following:
•
•
•
•
•
•
•
•
Identify Opportunity for Improvement
Set Specific goal for Improvement
Define and Measure Root Causes – PRIORITIZE!
Identify Interventions
Identify Person(s) responsible
Date Process began
Date/Frequency of Re-measurement
Outcomes-Measurement results
Develop Goal





Work together – entire IDT
Write clear statement identifying
problem
Use numerical “measurable” goal
Set specific time range to meet goal
Assure goal is obtainable within
specified time range
 Use smaller goals in step by step
fashion until ultimate goal is
reached
Example: GOAL:
Reduce number of catheter patients to <10% by December 2009
Or … Reduce number of catheter patients by 2% each month
Identify Root Cause
 For Example: If a data report shows that the facility’s
ranking for hemodialysis adequacy is below the
expected average



Facility must demonstrate QAPI review of global factors
that might affect adequacy
Brainstorming with IDT
Data/Spreadsheets to “measure” barriers
Identify Root Cause

Show “Root Cause Analysis”
 What %
 Missed or shortened treatments;
 Use Less-efficient dialyzers; or
 Fail to achieve the ordered blood flow rates

Prioritize
 Which root cause is having the greatest impact on the
problem?
 Often the “assumed” root cause turns out to be different
when the barriers are actually measured!
 Avoid Scattergun Approach!
Develop Actions/Interventions
 Focus on process
 What process can you change or create that will
have a positive impact?
 Make actions barrier-specific
 How will changes impact the root cause?
 Choose one or two actions which will have the
greatest impact (Rapid cycle improvement)
 Review available best practices
 Will they work in your facility?
 Discuss how you will monitor new processes
 How will you know if changes are an
improvement?
You can’t fatten a cow by
weighing it.
-Middle Eastern
Proverb
 Doing the same things over and over will not
result in change!
 If interventions are not having positive effects



Try a different approach
Go back to root cause… has anything changed?
Remember… look at process, not just outcomes
Changing A Process
Example:
 Facility determines inadequate BFR’s are highest
priority root cause for patients not achieving
adequacy
 Facility reviews current process and determines new
process is needed
NEW PROCESS >
 Daily audit checksheet:
 Nurse rounds after initiation of each shift to assure
BFR and other prescription parameters are met
 Allows action to be taken immediately rather than
waiting for monthly lab review to reveal a problem
Evaluation:
Measuring Changes
 Graph monthly data
 Review trends for improvement
 Discuss and document changes in monthly QAPI
7
6
5
4
3
2
1
Jul-06
Jun
May
Apr
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
0
Jul-05
meetings
 What’s working?
 What’s not working?
Electronic Data Collection
 Some facilities may be able to pull
“electronic” reports for trending data
REMEMBER…
 Data reported is only as good as the
data entered in the electronic or hard
copy collection tools. This takes
participation and cooperation of all staff.