Transcript Slides to consider for first presentations

Quality Assessment Performance
Improvement
Learning Objectives
• Define Quality Assessment & Performance
Improvement (QAPI)
• State the goal of QAPI
• Describe the key components of a hospice
QAPI program
QAPI Part 1
QAPI Regulation - 2008
• Patient-focused and outcome oriented
• Goal is to monitor quality/performance, find
opportunities for improvement, and improve
• Focus is on achieving patient/family desired
outcomes
• Explicitly related to other regulations
QAPI Part 1
Desired Outcomes in Hospice vs.
Other Healthcare Setting
• Hospice
– Comfortable dying
– Safe dying
– Self-determined life
closure
– Effective grieving
QAPI Part 1
• Other healthcare
settings
– Cure of illness
– Improved functionality
(including ADLs)
QAPI regulation
• Condition of Participation (CoP)
– 42 CFR 418.58
• Five standards
– Program scope
– Program data
– Program activities
– Performance improvement activities
– Executive responsibilities
QAPI Part 1
Other CoPs that integrate QAPI
§418.54 Comprehensive
Assessment of the Patient
§418.60 Infection Control
(e) Standard: Patient outcome measures.
§418.62 Licensed
Professional Services
(c) Licensed professionals must participate
in the hospice’s quality assessment and
performance improvement program …
(g) Standard: Hospice aide assignments
and duties.
(b) Standard: Governing body and
administrator.
§418.76 Hospice aide and
homemaker services.
§418.100 Organization and
administration of services.
QAPI Part 1
(b) Standard: Control.
The QAPI CoP says:
• The hospice must develop, implement, and maintain an
effective, ongoing, hospice-wide, data-driven QAPI program.
• The hospice’s governing body must ensure that the program:
– reflects the complexity of its organization and services;
– involves all hospice services (including those services furnished
under contract or arrangement);
– focuses on indicators related to palliative outcomes; and
– takes actions to demonstrate improvement in hospice
performance.
• The hospice must maintain documentary evidence of its QAPI
program and be able to demonstrate its operation to CMS.
QAPI Part 1
Standard (a): Program Scope
1) The program must at least be capable of
showing measurable improvement in indicators
related to improved palliative outcomes and
hospice services.
2) The hospice must measure, analyze, and track
quality indicators, including adverse patient
events, and other aspects of performance that
enable the hospice to assess processes of care,
hospice services, and operations
QAPI Part 1
Standard (b): Program Data
1) The program must use quality indicator data,
including patient care, and other relevant data, in the
design of its program.
2) The hospice must use the data to do the following:
i.
ii.
Monitor the effectiveness and safety of services and
quality of care.
Identify opportunities and priorities for improvement.
3) The frequency and detail of the data collection must
be approved by the hospice’s governing body
QAPI Part 1
Standard (c): Program Activities
1)
The hospice’s performance improvement activities must
i.
ii.
iii.
Focus on high risk, high volume, or problem-prone areas.
Consider incidence, prevalence and severity of problems in those
areas.
Affect palliative outcomes, patient safety, and quality of care
2)
Performance improvement activities must track adverse patient
events, analyze their causes, and implement preventive actions
and mechanisms that include feedback and learning throughout
the hospice.
3)
The hospice must take actions aimed at performance
improvement and. After implementing these actions, the hospice
must measure its success and track performance to ensure that
improvements are sustained.
QAPI Part 1
Standard (d):
Performance Improvement Projects
Beginning February 2, 2009, hospices must develop, implement and
evaluate performance improvement projects.
1)
The number and scope of distinct performance improvement
projects conducted annually, based on the needs of the hospice’s
population and internal organizational needs, must reflect the
scope, complexity, and past performance of the hospice’s services
and operations.
2)
The hospice must document what performance improvement
projects are being conducted, the reasons for conducting these
projects, and the measureable progress achieved on these
projects.
QAPI Part 1
Standard (e): Executive Responsibilities
The hospice’s governing body is responsible for ensuring the following.
1)
That an ongoing program for quality improvement and patient
safety is defined, implemented and maintained, and is evaluated
annually.
2)
That the hospice-wide quality assessment and performance
improvement efforts address priorities for improved quality of
care and patient safety, and that all improvement actions are
evaluated for effectiveness.
3)
That one or more individual(s) who are responsible for operating
the quality assessment and performance improvement program
are designated
QAPI Part 1
QAPI Functions
QAPI Part 1
Patient-level QAPI
• Collect data on patient status and
outcomes
– Assessment/reassessment (§418.54)
– Care plan (§418.56)
• Use the data to measure and improve
quality of care and outcomes for that
patient (§418.56)
QAPI Part 1
Patient – level
The Cycle of Care
QAPI Part 1
Hospice-level QAPI
• §418.58 (a) Program Scope
– The hospice must measure, analyze, and track
quality indicators, including adverse patient events
and other aspects of performance that enable the
hospice to assess processes of care, hospice
services and operations.
• §418.54 (e) Patient outcome measures
– Assessment must Include data elements to be used
for outcome measurement
– Data must be used in the aggregate for the
hospice’s QAPI program
QAPI Part 1
Hospice-level QAPI
QAPI Part 1