Transcript Slide 1

Quality Assessment &
Performance Improvement,
Root Cause Analysis and
the Model for Improvement
Melody Malone, PT, CPHQ
TMF Health Quality Institute
Objectives
The learner will be able to:
 Describe quality assessment & performance
improvement (QAPI)
 Define the three categories of human factor
performance gaps
 Explain root causes
 Understand rapid cycle quality improvement
methodology
2
About TMF
TMF Health Quality Institute focuses on
improving lives by improving the quality
of health care through contracts with federal,
state and local governments, as well as private
organizations. For more than 40 years, TMF has
helped health care providers and practitioners
in a variety of settings improve care for their
patients.
3
About the QIO Program
Leading rapid, large-scale change in health
quality:
 Goals are bolder.
 The patient is at the center.
 All improvers are welcome.
 Everyone teaches and learns.
 Greater value is fostered.
4
About the QIO Program
Leading rapid, large-scale change in health
quality:
 Goals are bolder.
 The patient is at the center.
 All improvers are welcome.
 Everyone teaches and learns.
 Greater value is fostered.
5
Have You Ever Said “HUMMMM”
QM Score
Quality Measure
25
20
15
10
5
0
Facility
Top 10% of TX
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How come I CAN’T:

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
Get my calls returned on time?
Why can’t I document in OmbudsManager?
Stay within budget?
Get my facilities where I want?
Sustain improvements?
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How do I get here??
20.0%
18.0%
Mean proportion of population
16.0%
14.0%
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
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Through Quality Improvement
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“Quality is not an act, it’s a habit.”
- Aristotle
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Current State of Affairs
“How do YOU do
Quality Improvement Now?”
{in your office}
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Current State of Affairs
“We have our QAA meeting every
month… isn’t that QI?”
{Nursing Home}
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Comparison of QA and QI
Quality Assurance (QA)
Quality Improvement (QI)
Focus: Catch “bad apples” or
detect serious problems
Goal: Meet minimal standards
Improve processes—not
fault finding
Ongoing process
improvement
Who’s Involved: Usually 1-2 individuals
Teams
Driven By: Regulation/accreditation Organizations
Occurs: Monthly or quarterly
Continuously
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QA & A F520
 A facility must maintain a quality assessment and
assurance committee consisting of:
• The director of nursing services
• A physician designated by the facility
• At least three other members of the facility’s staff
 The quality assessment and assurance (QA & A)
committee:
• Meets at least quarterly to identify issues with respect to
which QA & A activities are necessary
• Develops and implements appropriate plans of action to
correct identified quality deficiencies
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QA & A F520, cont.
 The state or the Secretary may not require
disclosure of the records of such committee
except insofar as such disclosure is related to the
compliance of such committee with the
requirements of this section.
 Good faith attempts by the committee to identify
and correct quality deficiencies will not be used
as a basis for sanctions .
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Quality Assurance and
Performance Improvement
(QAPI)
16
QAPI Background
 Mandated in the Affordable Care Act, enacted
March 2010
 Legislation requires the Centers for Medicare &
Medicaid Services (CMS) to establish QAPI
program standards and provide technical
assistance to nursing home providers.
 CMS identified training needs for long-term care
surveyors.
 Demonstration projects are ongoing now and tools
are coming.
17
5 Elements of QAPI
• Element 1 – Design and scope
 Element 2 – Governance and leadership
 Element 3 – Feedback, data systems and
monitoring
 Element 4 – Performance improvement projects
 Element 5 – Systematic analysis and systemic
action
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Element #1: Design and Scope
 A QAPI program must be:
• Ongoing and comprehensive
• Dealing with the full range of
services offered by the facility
• Including ALL departments
 It utilizes the best available
evidence to define and
measure goals.
 A written QAPI plan
 Address:
•
•
•
•
Clinical care
Quality of life
Resident choice
Care transitions
 Aims for safety and high
quality with all clinical
interventions
 Emphasizes autonomy
and choice in daily life for
residents
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Element #2: Governance and
Leadership
The governing body and/or
administration:
 Develops and leads a QAPI
program
 Involves leadership
 Uses input from facility staff,
residents and their families
and/or representatives
 Assures the QAPI program is
adequately resourced
 Designates one or more
persons to be accountable
for QAPI
 Develops leadership and
facility-wide training on
QAPI
 Ensures staff time,
equipment and technical
training as needed for QAPI
 Responsible for establishing
policies to sustain the QAPI
program despite changes in
personnel and turnover
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Element #2: Governance and
Leadership, cont.
Also responsible for:
 Setting priorities for the QAPI
program
 Building on the principles
identified in design and scope
 Setting expectations around:
• Safety
• Quality
• Rights
• Choice
• Respect
• Balancing both a culture of
safety and a culture of
resident-centered rights and
choice
 The governing body ensures
that while staff are held
accountable, there exists an
atmosphere in which staff are
not punished for errors and do
not fear retaliation for
reporting quality concerns.
21
Element #3: Feedback, Data
Systems and Monitoring
 Use systems to monitor care and services, drawing data
from multiple sources.
 Feedback systems actively incorporate input from staff,
residents, families and others as appropriate.
 Use performance indicators to monitor a wide range of
care processes and outcomes, and review findings against
benchmarks and/or targets the facility has established for
performance.
 Use tracking, investigating and monitoring adverse events
that must be investigated every time they occur, and
action plans implemented to prevent recurrences. 22
Element #4: Performance
Improvement Projects (PIPs)
 Conduct PIPs to examine and improve care or
services in areas identified as needing attention.
 A PIP is:
• A concentrated effort
• On a particular problem in one area of the facility or
facility-wide
• Involves gathering information systematically to clarify
issues or problems
• Intervening for improvements
• Selected in areas important and meaningful for the
specific type and scope of services unique to each facility
23
Element #5: Systematic Analysis
and Systemic Action
 Use a systematic approach to determine when in-depth analysis is
needed to fully understand the problem, its causes and implications
of a change (a.k.a. root cause analysis).
 Use 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/delivered.
 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 a focus on continual learning and continuous
improvement.
24
CMS QAPI Efforts
 Nursing home quality improvement
questionnaire
 Development of QAPI tools and resources
 Development of QAPI website
 QAPI demonstration project:
• Test tools/resources
• Conduct learning collaboratives
• Online resource center for demo participants
25
National Rollout Plans
 Initial release of QAPI materials on CMS website (late
summer, 2012)
 Continued identification of resources and case examples
 Engagement of state and national stakeholders
 Encouragement of learning collaboratives with partner
organizations
 Development of regulation
 Development of surveyor training materials and survey
worksheet
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LET’S WATCH A MOVIE!
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28
Human Errors in Medicine
“… and the adverse events that may follow,
are problems of psychology and engineering,
not of medicine.”
- J.W. Senders, PhD, Medical Researcher
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Human Error – The Old View
The bad apple theory:
 Complex systems would be fine if it weren’t for
some unreliable people.
 Human errors cause accidents.
 Failures are surprises.
30
What’s wrong with the old view?
 Focusing on individuals does not solve
underlying problems.
 Errors are not intrinsically bad.
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Human Error
 Human error is not the cause of accidents, it
is a symptom of deeper trouble.
 Human error is not random.
 Human error is not the conclusion of an
investigation, it is the beginning.
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What is “Human Factors”?
“Human Factors” is about how features of
our tools, tasks and work environments
continually influence what we do and
how we do it.
33
In Other Words
Human Factors is about how the design of
things impacts how well we do any task.
• Design of our workplace
• Design of the tools we use
• Design of processes (how we do our work)
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What’s wrong with this picture???
35
Human Factors
 How could this happen?
• Distracted sign maker
 What could happen as a result?
• What were conditions and situation like when
driving?
• What are characteristics of the task?
36
Combating Human Error with
Better Designs
Where do we start?
• Assume that people do reasonable things.
• Look at why there is a performance gap.
37
3 Categories of Performance Gaps
 The plan itself was inadequate to achieve
desired outcome (planning error).
 The plan is not executed properly
(execution error).
 There was a deliberate departure from “safe”
practice (violation).
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Planning Errors
 Driving to favorite gas station—run out of gas
 Giving antibiotics to a patient with a viral
infection
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When is it a planning error?
 Don’t know what to do
 Don’t know how to do it
 Don’t know who is supposed to do it
 “I couldn't do it”
 “I used to do it differently”
40
Planning Errors
 Table Talk…
• What sort of planning errors have
you experienced lately?
41
Planning Errors
What may not work:
1. Punishment
2. Rewards
3. Reminders
Why? They believe they are acting correctly
or following the set process.
42
Planning Errors
What may work:
1. Memory aids
2. Training or education
3. Creating/redesigning process
43
Execution Errors
 Turning left instead of right!
 Giving the wrong medicine when distracted
 Forgetting to assess a patient’s pain due to
interruptions
44
When is it an execution error?
 Forgot
 Distracted or interrupted
 Steps look alike
 “It slipped my mind”
 Just “messed up”
45
Execution Errors
 Table Talk…
• What sort of execution errors have
you experienced lately?
46
Execution Errors
What may not work:
1. Punishment
2. Rewards
3. Training or education of skilled
operators/experts
Why? They intended to correctly complete
the task.
47
Execution Errors
What may work:
1. Prompts
2. Reminders
3. Memory aids
48
Violations
 Act itself is deliberate
 Negative consequences are not intended
 Certain conditions more likely to produce
violations
49
When is it a violation?
 Don’t have to do it
 Frustration
 Cumbersome rules, policies
 Perception of being above the rules
 “Saving time if I do it my way”
50
Violations
 Table Talk…
• What sort of violations have you
experienced lately?
51
Violations
What may not work:
1. Training and education
2. Reminders
3. Prompts
4. Memory aids
5. Punishment
Why? Violations are a product of consequences,
and positive consequences are strongest.
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Violations
What may work:
1. Redesign work to eliminate frustrations.
2. Use policies and rules only when
necessary.
3. Give positive feedback for desired
behavior.
4. Simplify processes.
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Possible Solutions in Summary
 Planning errors
• Memory aids
• Training/education
• Process changes
 Execution errors
 Violations
• Redesign work
• Use policies only
when necessary
• Positive feedback
• Prompts
• Reminders
• Memory aids
54
Human Factors vs.
Disciplinary Action
 Human error (a.k.a. human factors):
• Planning errors
• Execution errors
• Violation (intentional and/or recklessness)
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Just Culture vs. Disciplinary Action
 Just culture (safety thinking):
• Promotes a questioning attitude
• Resistant to complacency
• Committed to excellence
• Fosters both personal accountability and
corporate self-regulation in safety matters
• Atmosphere of trust
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Goals of Quality Improvement
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
Identify problem areas
Identify sources of variation
Simplification
Eliminate duplication, rework, extra steps
Improve fragmentation
Remove waits, delays
Eliminate errors
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And Most Importantly, QI…
Is a process to build a
culture of safety and
move beyond the
culture of blame.
Remember :
Human Factors and a
Just Culture!
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Quality Principles
Systems Thinking
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Cyclical─not linear (cause/effect)
System is dynamic in achieving goals
Looks at a system in total, as sum of
its parts, all working together
Encourages communication and
speaking up to break down silos
Depends on feedback to maintain
stability
System at fault versus individual
employee
Promotes understanding of the
patterns of behaviors that lead to
outcomes, positive and negative
Principles of QAPI

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
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Just culture
Ongoing, continuous
5 elements that are interrelated
Learning organization; sustaining
improvements
Culture where staff do not fear
reporting quality concerns
Feedback, data systems and
monitoring
An approach to QI where the
culture is to make continuous
improvement. “It’s just what we
do.”
Feedback, data systems and
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monitoring
Where do we begin?
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Search for the Root Cause
 The most fundamental reason a problem has
occurred.
When performance does not meet expectations
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Root Cause Analysis
 Inter-disciplinary
 Involving experts from
the frontline services
 Continually digging
deeper by asking why,
why, why at each level of
cause and effect
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The Goal of a Root Cause Analysis
is to Find Out:
 What happened?
 Why did it happen?
 What to do to
prevent it from
happening again
63
Root Cause Analysis
 Identifies needs for systems changes
 Is a process that is as impartial as possible
 As well as a tool for
identifying prevention
strategies
 There are various tools
to use.
64
5 WHYs Tool
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Brainstorming
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Brainstorming Rules
 Postpone and withhold your judgment of
ideas.
 Encourage wild and exaggerated ideas.
 Quantity counts at this stage, not quality.
 Build on the ideas put forward by others.
 Every person and every idea has equal
worth.
68
Brainstorming
 Why can't we keep sufficient staff?
69
Silent Brainstorming
70
Silent Brainstorming
 What do you want to change
about the Ombudsman program?
71
Silent Brainstorming
 What should not be changed
about the Ombudsman program?
72
Fishbone Diagram
Materials
Staff
Problem
Statement
Equipment
Education
73
We Have the Root Cause
Now what?
74
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act
Plan
Study
Do
75
The PDSA Cycle for Learning and Improvement
Act
• What changes
are to be made?
• AdApt? AdOpt?
or Abandon?
• Next cycle?
Study
• Complete the
analysis of the data
•Compare data to
predictions
•Summarize what
was learned
Plan
• Objective
• Questions and
predictions (why)
• Plan to carry out
the cycle (who,
what, where, when)
Do
• Carry out the plan
• Document problems
and unexpected
observations
• Begin analysis
of the data
76
Model for Improvement
What are we trying to
accomplish?
Decreasing falls
How will we know that a
change is an improvement?
We are going to measure!
Set a goal: 50% imp. Q1 to Q2
What change can we make that will
result in improvement?
Follow up daily on fall risk
assessments from day before.
77
The PDSA Cycle for Learning and Improvement
Act
• What changes
are to be made?
• AdApt? AdOpt?
or Abandon?
• Next cycle?
Study
• Complete the
analysis of the data
•Compare data to
predictions
•Summarize what
was learned
Plan
• Verify one of
prior day’s fall
risk assessments
• Validate 1
• Observe 1
• By unit manager
• Track results
Do
• Carry out the plan
• Document problems
and unexpected
observations
• Begin analysis
of the data
78
Repeated Use of the Cycle
A P
Changes That
Result in
Improvement
S D
Spread
Implementation of Change
Wide-scale Tests of Change
A P
S D
Hunches
Theories
Ideas
Follow-up Tests
Very Small-scale Test
79
The PDSA Cycle for Learning and Improvement
Act
• What changes
are to be made?
• AdApt? AdOpt?
or Abandon?
• Next cycle?
Study
• Complete the
analysis of the data
•Compare data to
predictions
•Summarize what
was learned
Plan
• Verify prior day’s
fall risk assessments
Done, daily
• Validate 10% of each
• Observe 10% of each
• By unit manager
• Track results
Do
• Carry out the plan
• Document problems
and unexpected
observations
• Begin analysis
of the data
80
Overall Goal:
Implement the Model for Improvement
Concept A
Concept B
Concept C
Concept D
Concept E
Develop strategies for each component of the model.
81
GOAL – Improve Outcomes
Concept D
Concept C
Concept A
Concept B
Change concepts, theories, ideas
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Start Small
 What can you do by Tuesday?
84
85
86
QI Resources:
http://TexasQIO.tmf.org
87
Questions?
88
Contact
Melody Malone, PT, CPHQ
Quality Improvement Consultant
TMF Health Quality Institute
214-632-2238
[email protected]
http://TexasQIO.tmf.org
This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement
Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an
agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect
CMS policy. 10SOW-TX-C7-12-174
89