Transcript QAPI in Action

QAPI in Action
Lessons Learned, Results Achieved
Reginald M. Hislop, III Ph.D.
Diane R. Hislop, RN
A Brief History
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Before QAPI Came to Be: In 1990, the process started to
create accreditation compliance with JCAHO.
The basic principles: Measure Quality Indicators, Measure
Customer Satisfaction, Audit for Opportunities, Revise
Processes
Initial Indicators: Falls, Pressure Sores, Medication Errors,
Infections, Hospitalizations, Staff Turnover/Retention,
Resident/Family Satisfaction.
Added: Physician Performance, Polypharmacy,
Psychoactive Drugs, Food Temps/Dining Satisfaction,
Service Wait Times (call lights)
What Was Achieved?
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First organization in the nation to achieve all three (back
then) JCAHO long-term care accreditations with
commendation (skilled nursing, sub-acute, dementia).
Throughout the Years….
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Falls = 5% or less of average census in all facilities (over 300
SNF beds)
Medication Errors = less than .05% of all meds passed and
dispensed (over 200,000 administrations per month!)
Staff turnover = less than 10% (1,000 FTEs total) annually,
average length of service = 10+ years
Resident/Family Satisfaction = 98% rated the organization as 5
(excellent)
How Did this Happen?
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Less About Data, More About Analyzing the Data
Set Expectations High and Measured Progress
Audit, Improve, Re-Teach
Integrated Disciplines
Staff, Residents, Administration all Directly Tied to Quality
Outcomes
Compensation and Gain Sharing Tied to Quality
Outcomes
We Marketed Results
Business Model Driven by Quality Innovations –
Improvements Identified Equaled Business Opportunities.
Now In Kansas: Larksfield
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Fast Forward to 2011: Larksfield
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No Formal QA/QI Program
72 bed SNF Averaging 50 plus Falls per Month
Call Light Response Times – 40% longer than 7 minutes with
an average of 10% longer than 10 minutes
Psychoactive/Anti-Psychotic Meds = 50% plus
Weight Loss/Supplement Use = 50% of residents
No resident satisfaction measures
No monitoring of hospitalizations
No audits
Annual Survey 2011 – 3 Gs, 2 Fs, 2 Es, multiple Ds
Shifting the Paradigm – Putting QA/QI in
Action
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Build the Foundation – Audit the “GAP”
Set Expectations/Targets
Build the Team – all disciplines
Build the Tools and Processes
Gradually, add and monitor, Indicators
Focus on the Data – Weekly Clinical Review, Monthly
QA/QI meeting
Build core competency – staff education, training,
accountability
Audit more, identify more, re-direct processes
What Happened
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Actual Results – 2011 to 2012 – about 15 months postsurvey
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Falls – from an average of 50 or more to an average of 10 or
less
Anti-Psychotics/Psychoactive Medications – 5 residents total,
each with a history of mental illness – none used for dementia
Supplements – gone, except for one or two hospice residents.
Weight Loss – gone!
Dehydration – gone!
Total Meds – reduced by over 1/3 and falling
Survey in 2012 – deficiency free! 2013 – 2 minor citations, no
POC required for either. 5 Star!
Today and Going Forward
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Today, we monitor falls, med errors, infections, care transitions,
drugs, weight loss/dehydration, CASPER, skin/wound, ADL
decline, call light response times, aspiration/dysphasia risk,
unusual occurrences (bruises, theft, unusual behaviors, skin
tears, etc.), use of PRNs for pain, resident satisfaction.
View and analyze trends, discuss monthly, target improvement,
focus on education and information.
Target audits for gaps, compliance and process improvement.
QA Committee – chaired by CEO, board participation, all
disciplines, CNA representation, senior management.
Reports to Board Quality and Compliance committee
Key Results: Examples
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Call Lights: Average of 10,000 plus per month; 97.5%
answered in under 7 minutes! Only .5% (one half of one
percent go over 10 minutes).
Falls: Average of 10 per month across 2,135 resident days
of care = fall risk of .4%.
Infections: Average of 9 per month = Risk of .4%
Re-Hospitalizations: Two year rate of 8.7%; state average
of 18%.
Anti-Psychotic Meds: 6% (4 residents) vs. State average of
23% and national average of 20%.
Monthly Indicator Dashboard
ADMISSIONS
DISCHARGES
DEATHS
HOSPICE
SUMMARY OF QUALITY INDICATORS
HEALTH CARE
FALLS
Un i t
#
Sunflower
MED ERRORS
Level
Level
Level
Level
Level
S hi f t
1st:
2nd:
3rd:
Me a d o wWo o d s
# Occur
Nu rs e
Un i t
#
D ay
OOF:
LTF:
# M o /# Y r
#
Wed.
Sun.
Mon.
Tues.
Al ar m
Thurs.
Fri.
Sat.
T y pe
R e du c t i o n
P r ev M o.
M o.
MW:
SF:
D ay
Un i t
#
Rat e
S hi f t
0
1
2
3
4
INFECTIONS
Sunflower
CARE TRANSITIONS
Total Visits
Avoidable
Unavoidable
PHARMACY
H o s p . A dm .
E R Vi s i t
#
Rat e
PCP
T y pe
EYE
ENTERIC
OTHER
E m pl oy ee I n f ec t i on
TOTAL RATE
D en t i s t
S pec
O t he r
O t he r / S p e c i a l i s t
T y pe
Cancer Center, Ortho, Neuro,
Wound Clinic, Anemia Clinic,
Optometrist, Dialysis, Cardiologist
M e a do w W o o ds
RTN
Anti-Depressants
Anti-Psychotics
Anxiolytics
Hypnotics
Dementia Drugs
Vitamins/Supp/Herbals
Minerals/Electrolytes
WEIGHT LOSS/
DEHYDRATION
Weight Loss
Dehydration
Health Shakes
T y pe
UTI
RESP
SKIN
WOUND
Me a d o wWo o d s
S u n f l ow er
PRN
RTN
M e a do w W o o ds
Avoid
PRN
S u n f l ow er
Unavoid
Avoid
Unavoid
Prev Mo
PRESSURE SORES
M e a do w W o o ds
Hosp. Acq.
Avoidable
Unavoidable
UNUSUAL OCCURRENCES
Skin Discoloration
Skin Tear
Elopement
Behavior
Aspiration
Other
Caregiver Report
RESTORATIVE
CALL LIGHTS
Total Lights
Over 7 minutes
Over 10 minutes
SURVEYS
# Surveys returned
Overall Rating
Recommend Larksfield
Areas for improvement:
S u n f l ow er
Fac. Acq.
Hosp. Acq. Fac. Acq.
M e a do w W o o ds
S u n f l ow er
Meadow Woods
Sunflower
M e a do w W o o ds
S u n f l ow er
An n u al
Survey Comments:
N e w R e s i de n t
1s t
D i s c ha r g e
2n d
3rd
D ec eas ed
Mo
QI Monitoring Tool
CONTINUOUS QUALITY IMPROVEMENT MONITOR
Topic: Hospitalization and/or Subsequent Death
Date of Audit: _______________________
MET
NOT MET
Data Source
____ Resident Interview
____ Observation
____ Family Interview
____ Chart Review
____ Other
INDICATORS
Use this protocol for:
Hospitalization for other than a planned elective surgery
Death that was not receiving terminal or Hospice Care
1. Did the facility accurately assess the resident’s condition relevant to the
care issues associated with the resident’s hospitalization or death?
YES ________ NO ________ F272
Assessment completed by day 14?
YES ________ NO ________ F281
2. Did the facility care plan meet the resident’s needs?
YES ________ NO ________ F279
Lack of physician orders?
YES ________ NO ________ F271
3. Did the facility implement practices that meet professional standards of
quality?
YES ________ NO ________ F281
Did the facility fail to implement care plan?
YES ________ NO ________ F281
4. Did the facility appropriately consult with the resident and/or resident’s
family and physician?
YES ________ NO ________ F157
5. Did the facility provide the necessary care and services to maintain the
highest level of physical, mental and psychosocial functioning?
Fail to
Fail to
Fail to
Fail to
Fail to
Fail to
Fail to
____ In-service
____ Individual Counseling
prevent accidents?
promote quality of life?
provide dignity?
provide self-determination?
provide sufficient staff?
provide physician supervision?
involve the medical director?
____ Protocol Change
____ Policy Change
YES ________
YES ________
YES ________
YES ________
YES ________
YES ________
YES ________
____ Postings
____ Other
NO ________ F323
NO ________ F309
NO ________ F241
NO ________ F242
NO ________ F353
NO ________ F385
NO ________ F501
____ Staff Meeting
____ Staff Check-in
Comments/Action Plan:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
QA Expanded: Initiatives and Projects
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CMS Requirements: CPR, Disaster Preparedness
Post-Survey Audits: Plans of Correction monitoring and
reporting
Staff Education: “Skills Labs”, identified topics/issues
Internal Reviews: Process audits for admissions,
documentation, various “check- step” audits.
Investigations
Policy, Protocol, Procedural review and updates
IRB: Research body
Audits are Key
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Need to use “outside” resources – can’t audit yourself!
Six standard audits plus focused others;
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Medicare/Billing
Medicare/Clinical Documentation and Careplans
Clinical – careplans, documentation, hospitalizations, care
transitions
Pharmacy – meds, polypharmacy, black box, etc.
Mock Survey
Resident Focus Groups, Surveys, etc.
Audits Drive Improvements, Identify Weaknesses
Audits Drive Education
Where Innovation Arrived!
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QA/QI is about assuring standards of excellence first but
the key is always to drive improvement – doing things
different!
What We Learned and Now Do Different;
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Therapies in-house, not contracted – huge improvement in
falls, dysphasia management, etc.
Moved to automated dispensing – reduce wait times, errors,
staff time, patient cost. Next, fully automated Med Records.
Implementing more protocols and algorithms – disease
management, standing orders, etc.
Focusing in on behavior management using non-pharm
interventions. Implemented TCI training for all staff.
Lessons Learned
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Support and Expectations Must Come from the Top!
Wide Representation of Staff Required – Include CNAs,
Activities, Social Work, Physicians, etc.
Look Beyond Healthcare and the Industry – Best
Practices can be readily gained from like circumstances!
Use Resident/Family Feedback as a Key Source for
Improvements.
Utilize outside resources to audit!
Be Critical! Don’t perceive milestones as a stopping
point for improvement.
Start Your Own Process!
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Best Place to Start – Get Audited! Complete a mock
survey, do a compliance check, conduct focus groups.
Use the above information to identify key outcome gaps
and process flaws.
Build your team! Develop your mission, vision and policy
statements.
Identify roles and responsibilities – build the
organizational components.
Educate – What are we doing? Why are we doing this?
Where are we going? How will get there?
Start slow and track and monitor outcomes - build slow.
Critical Elements: Must Have for
Success
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Support and Participation from Senior Management
Support from Governance – Ideally, Involvement as Well
Participation from all disciplines, all levels of staff
Audit partners – these must be people from the outside!
Education Components
A structure that includes a specific policy, set of tasks,
duties, responsibilities, accountability, etc.
Record keeping functions
A system for data gathering
A system for reporting
QAPI: Simple Start-Up
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Create a Mission Statement
Identify a Committee including all elements/disciplines of
care. Add a community member or two – people with
core healthcare knowledge.
Select a Committee Chair – someone who can run a
meeting and keep things moving!
Develop a record keeping/minute taking function – basic
organization, minutes, agenda, etc.
First Tasks:
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Decide a meeting structure – times, frequency, etc.
Identify key elements to monitor (from surveys, resident input,
identified weaknesses, etc.).
QAPI: Start-Up, Next Step
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Conduct an Audit/Assessment of the Organization: Use
an Outside Resource. Mock Survey always a good start!
Develop a series of indicators based on the audit findings
and two to three areas/findings to QA specifically
(monitor, educate, review)
Assign tasks Committee members and expanded
individuals (other staff, etc.) to find root causes,
recommend improvements, etc. back to the Committee.
Educate the organization at all levels about what the
Committee learned from the audit, what is happening in
terms of improvements, and how feedback can be given
to the process.
Finally: CQI your QAPI
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Plan on continuous repetition of the process: Monitor,
Audit, Review, Re-Educate
Integrate Feedback Loops: Resident/Family Surveys, Focus
Groups, Staff Meetings
Produce Visible Results for All to See – What Matters,
How Things Improved, Etc.
Add Focused Audits on Unique Issues: Issues Generated
via Feedback Loops, Topics in the News, Other Outside
Subjects
Schedule Continuous Outside Audits – Billing, Mock
Surveys, Complaint Mock Surveys, Careplan Audits –
report findings to Committee.
Best Practice QA/QI: Our Take
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Process also reviews and approves, policies and protocols
Process incorporates education at the committee level –
sharing research, articles, conferences, etc.
All other initiatives, committees, roll-up to QA/QI –
credentialing, infection control, behavior management,
P&T, etc.
Starting point for compliance/survey and accreditation
prep and readiness.
Repository and laboratory for issues, ideas, and challenges
where discussions can occur without risk exposure.
Clearing house and library for information and reference.