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QAPI: What Nursing Home Medical Directors Should Know

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Title: QAPI: What Nursing Home Medical Directors Should Know


1
QAPI What Nursing Home Medical Directors Should
Know
  • Susan M. Levy, MD, CMD
  • VPMA Levindale Hebrew Geriatric Center and
    Hospital
  • Baltimore, Maryland 21215
  • VAMDA
  • September 14, 2013

2
QAPI Learning Objectives
  • Understand how CMS QAPI initiative developed
  • Learn the five components of QAPI
  • Know the medical directors role in QAPI
  • Update on the CMS Partnership to Improve Dementia
    Care

3
Susan M. Levy, MD, CMD Disclosure
  • CMS Consultant to the Nursing home division
  • Legal expert review
  • MMDA advisor to the board
  • AMDA committees
  • Governance
  • Transitions of Care
  • Public Policy

4
QAPI and ACA
  • Provisions in section 6102
  • Secretary shall establish and implement a QAPI
    program in facilities that includes the
    development of standards related to QAPI through
    regulations
  • The Secretary shall provide technical assistance
    to facilities on the development of best
    practices in order to meet the standards

5
QAPI and Other Health Settings
  • Hospitals
  • Home Care
  • Dialysis
  • Ambulatory Care
  • and now
  • Nursing Homes

6
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 facilitys
    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

7
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 .

8
Description What is QAPI?
  • Quality Assurance (QA) and Performance
    Improvement (PI) are complementary approaches to
    quality management. Both involve seeking and
    using information, but they differ in key ways

9
Description What is QAPI?
  • QA is a process of meeting quality standards and
    assuring that care reaches an acceptable level.
    Nursing homes typically set QA thresholds to
    comply with regulations.
  • PI is a pro-active and continuous study of
    processes with the intent to prevent or decrease
    the likelihood of problems. PI identifies areas
    of opportunity and tests new approaches to fix
    underlying causes of persistent/systemic
    problems.

10
QA PI QAPI
  • QA and PI combine to form QAPI, a data-driven,
    proactive approach to improving the quality of
    life, care, and services in nursing homes. The
    activities of QAPI involve members at all levels
    of the organization to identify opportunities
    for improvement address gaps in systems or
    processes develop and implement an improvement
    or corrective plan and continuously monitor
    effectiveness of interventions.

11
QAPI builds on QAA
  • Committee structure
  • Review complaints and concerns
  • Conduct audits
  • QAPI will go beyond QAA with
  • Prospective approach through comprehensive plan
    and leadership engagement
  • Greater involvement of all staff, residents,
    families
  • Focus on performance improvement projects (PIPs)
    and Systems

12
Description What is QAPI?
Quality Assurance Performance Improvement
Motivation Measuring compliance with standards Continuously improving processes to meet standards
Means Inspection, review Prevention, planning
Attitude Required, defensive Chosen, proactive
Focus Outliers, bad apples, individuals Processes, systems
Scope Individual provider Systems for patient care
Responsibility Few All
13
Comparison of QA and QI
Quality Assurance (QA) Quality Improvement (QI)
Focus Catch bad apples or detect serious problems Improve processesnot fault finding
Goal Meet minimal standards Ongoing process improvement
Whos Involved Usually 1-2 individuals Teams
Driven By Regulation/accreditation Organizations
Occurs Monthly or quarterly Continuously
14
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

15
QAPI FAQs
  • Arent we already meeting the requirements?
  • Formal improvement model
  • Ongoing accountability
  • When will the QAPI regulations be issued?
  • TBA but will have one year to submit written plan
  • Will surveyors have access to QAPI documentation?
  • Until regulations promulgated remains unclear

16
AMDA Medical Director Roles and Responsibilities
  • Functions
  • Tasks
  • Competencies

17
AMDA Medical Director
  • Function 3 Quality Assurance
  • The medical director participates in the process
    to ensure the appropriateness and quality of
    medical care and medically related care

18
AMDA Medical Director Function 3 Tasks
  1. The medical director participates in the
    monitoring of care within the facility through a
    quality assurance program that encourages
    self-evaluation, anticipates and plans for change
    and meets regulations
  2. The medical director maintains knowledge of state
    and national standards for nursing home care and
    ensures that the facility meets the minimal
    acceptable standards of care

19
AMDA Medical Director Function 3 Tasks
  • 3. The medical director understands basic
    research methods when conducting medical care
    evaluations studies, evaluates and reviews the
    feasibility and goals of research projects, and
    fosters a facility wide attitude that is
    supportive of research and open to change.
  • 4. The medical director monitors physician
    performance and involves the attending physician
    in the setting of quality assurance standards.

20
AMDA Medical Director Function 3 Tasks
  1. The medical director ensures that the quality
    assurance program addresses issues germane to the
    quality of patient care.
  2. The medical director utilizes the quality
    assurance program to effect change in policies
    and procedures.
  3. The medical director establishes with the
    administration a means for disseminating
    information gained from the quality assurance
    program to residents, family members, staff
    members, attending physicians and other
    appropriate personnel.

21
AMDA Medical Director Function 3 Tasks
  1. The medical director serves as chairman of the
    institutional committee to review the feasibility
    and goals of research projects and disseminates
    research findings
  2. The medical director participates in the quality
    review of care within the facility n those
    specific areas mandated by law (e.g. drug level
    monitoring, laboratory indicator monitoring)

22
AMDA Medical Director Function 3 Tasks
  1. The medical director reviews periodically
    admission transfers, and discharges of patients.
  2. The medical director participates in time
    management studies

23
Framework for Competencies
  • Based on ACGME Outcome Projects General Domains
  • Foundational (Ethics, Professionalism and
    Communication)
  • Medical Care Delivery Process
  • Systems
  • Nursing Home Medical Knowledge
  • Personal QAPI

24
Competency Pyramid
25
AMDA Competencies Personal QAPI
  • 5.1 Develops a continuous professional
    development plan focused on post-acute and
    long-term care medicine, utilizing relevant
    opportunities from professional organizations
    (AMDA, AGS, AAFP, ACP, SHM, AAHPM), licensing
    requirements (state, national, province) and
    maintenance of certification programs
  • 5.2 Utilizes data (e.g. PQRS indicators, MDS
    data, patient satisfaction) to improve care of
    their patients/residents
  • 5.3 Strives to improve personal practice and
    patient/resident results by evaluating
    patient/resident adverse events and outcomes
    (e.g., falls, medication errors, healthcare
    acquired infections, dehydration, return to
    hospital)  

26
AMDA Position
  • HOD resolution A 06 - 2006
  • White Paper C 11Role of the Medical Director
    Quality Assurance and Process Improvement in
    Long-Term Care - 2011 in

27
Five Elements of QAPI
  • Design and Scope
  • Governance and Leadership
  • Feedback, Data Systems, and Monitoring
  • Performance Improvement Projects (PIPs)
  • Systemic Analysis and Systemic Action

28
Role of the Medical Director in Each Element
  • Beyond the Quick Fix The Medical Directors
    Role in QAPI Geriatric Medicine and Medical
    Direction Vol. 34(4) April 2013-Jane Pederson, MD
    Stratis Health
  • Personal Comments

29
Element 1 Design and Scope
  • 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  
  • 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

30
Design and Scope Role of the Medical Director
  • Should be integrally involved as they can weigh
    the balance between quality and safety, and
    resident quality of life and individual autonomy
  • Vision of what is good care for all as well as
    each individual

31
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

32
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, Resident Rights, Choice, and
    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.

33
Governance and Leadership Role of the Medical
Director
  • Educate organizational leaders and staff
  • Help drive data driven decisions
  • Support a culture of quality improvement and
    safety in all that is done
  • Encourage team problem solving

34
Element 3 Feedback, Data Systems and Monitoring
  • Put systems in place 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
  • Review findings against benchmarks and/or targets
    the facility has established for performance.

35
Element 3 Feedback, Data Systems and Monitoring
(cont.)
  • Tracking, investigating, and monitoring ADVERSE
    EVENTS that must be investigated every time they
    occur and action plans implemented to prevent
    recurrences.
  • NEVER EVENTS
  • RCA

36
Feedback, Data Systems and Monitoring Role of
the Medical Director
  • Help the facility gather data that will evaluate
    their current performance
  • Use their skills in data management
  • Solicit feedback from the medical staff
  • Develop process to obtain feedback and monitor
    provider performance

37
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

38
PIPs Role of the Medical Director
  • Participate and in some cases lead teams with
    facility support
  • Review and assist with developing team charters
  • Be kept in the loop through updated reports at
    facility meetings and/or minutes
  • Be available as a consultant to other team leaders

39
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.

40
Systemic Analysis and Systemic Action Role of
the Medical Director
  • Support culture of avoiding individual blame and
    focusing on system fixes
  • Understand and support RCA approach to problems
    that gets to the long term fix

41
QAPI at Glance Step by Step Guide
42
Implementing QAPI A 12 Step Program -STEP 1
  • Leadership responsibility and accountability
  • Availability to staff
  • Visibility on units
  • Commit, follow through, lead by example
  • Recognize staff and give the credit
  • Involve staff and build leadership skills
  • Ensure staff have equipment to do their job
  • Openly admit errors-culture of transparency
  • Set high expectations

43
QAPI STEP 2
  • Develop a Deliberate Approach to Teamwork
  • Assess the effectiveness of teamwork in the
    organization
  • Discuss how PIP teams will work to address QAPI
    goals
  • Determine how direct care staff, residents, and
    families can be involved in PIPs
  • Identify communication structures that need to be
    developed or enhanced

44
QAPI STEP 3
  • Take your QAPI pulse with a Self-Assessment
  • Determine when and who will participate in the
    self-assessment
  • Complete the baseline self-assessment
  • Determine when you will reassess (annual)

45
QAPI Self Assessment
46
QAPI STEP 4
  • Identify your organizations guiding principles
  • Review, update and/or develop your organizations
    mission and vision statement
  • Develop a purpose statement for QAPI
  • Establish guiding principles
  • Define the scope of your QAPI program
  • Assemble the document

47
Guiding Principles and Scope
48
QAPI STEP 5
  • Develop your QAPI plan
  • Determine your timeline for writing the plan
  • Circulate the Guide for Developing a QAPI plan
    for all involved in developing the plan
  • Once completed determine time for review(annual)

49
QAPI Plan Outline
50
QAPI STEP 6
  • Conduct a QAPI Awareness Campaign
  • Share mission, vision, and guiding principles
    with all staff
  • Include the mission, vision, and guiding
    principles in new orientation for staff
  • Develop communication plans that use multiple
    approaches to reach all staff across all shifts
  • Hold meetings
  • Share performance date openly and transparently
    with staff, board, residents, families
  • Set up scorecard for staff to monitor progress
    towards important goals and post in visible areas

51
QAPI STEP 7
  • Develop a Strategy for Collecting Using QAPI
    Data

52
QAPI STEP 8
  • Identify Your Gaps and Opportunities
  • Measure important indicators of care that are
    relevant and meaningful to the residents you
    serve
  • Guide and empower staff to solve problems
  • Hold short stand up meetings across all shifts to
    identify concerns
  • Establish the nursing home as a learning
    organization
  • Discuss processes and systems to identify areas
    for improvement in all meetings
  • Empower residents to get involved in identifying
    areas for improvement

53
QAPI STEP 9
  • Prioritize Quality Opportunities and Charter
    Performance Improvement Projects (PIPS)
  • Get everyone involved in setting goals
  • If practices are not making sense or seem
    frustrating to staff, residents, and families
    challenge and sort out what you have control over
    and look for ways to address improvements

54
QAPI STEP 10
  • Plan, Conduct, and Document PIPs
  • Identify and support a change agent for each
    improvement project
  • Use an action plan template that defines the who
    and when to establish timelines and
    accountability
  • Seek creative ideas from multiple sources within
    and outside the organization to foster innovation
  • Create a safe environment to test changes
  • Include all voices that have a stake in what is
    being discussed


55
Goal Setting Worksheet
56
QAPI STEP 11
  • Get to the Root of the Problem
  • Use the RCA process to look at systems rather
    than individuals when something breaks down.

57
QAPI STEP 12
  • Taken Systemic Action
  • Before initiating a change in the organization,
    meet with any staff and residents that will be
    impacted by the change in order to gain their
    support, buy-in, and feedback.

58
Using QI Tools
  • There are many tools that can help you meet the
    goal of improving your work processes and services

59
Useful QI Tools
  • Process Mapping
  • Check Sheets
  • Pareto Charts
  • Cause and Effect Diagrams
  • Fishbone Diagrams
  • The 5 Whys
  • Run Charts

60
What is a Process Map?
  • A pictorial representation of the sequence of
    actions that describe a process

61
What are the Symbols Used in Process Mapping?
  • Start and End of the Process
  • A process Activity
  • A process Decision
  • A Break in the process

62
What is the Purpose of a Check Sheet?
  • To turn observational data into numerical data
  • From records
  • Newly collected
  • To find patterns using a systematic approach that
    reduces bias
  • Use check sheets when data can be observed or
    collected from your records

63
Run charts
  • Tracking Process Performance

64
Individual Facility Quality Improvement Data
Suburban Pavilion Nursing Home
65
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

66
Goal of the RCA
  • What happened?
  • Why did it happen?
  • What to do to prevent it from happening again

67
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

68
Problem Solving Root Cause
  • When confronted with a problem most people like
    to tackle the obvious symptom and fix it
  • This often results in more problems
  • Using a systematic approach to analyze the
    problem and find the root cause is more
    efficient and effective
  • Tools can help to identify problems that arent
    apparent on the surface (root cause)

69
What is the 5 Whys?
  • A question asking method used to explore the
    cause/effect relationships underlying a
    particular problem
  • The goal is to determine the ROOT CAUSE of a
    problem

70
5 WHYs Tool
71
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72
An Example of the 5 Whys
  • My car will not start. (the problem)
  • Why? - The battery is dead. (first why)
  • Why? - The alternator is not functioning. (second
    why)
  • Why? - The alternator belt has broken. (third
    why)
  • Why? - The alternator belt was well beyond its
    useful service life and has never been replaced.
    (fourth why)
  • Why? - I have not been maintaining my car
    according to the recommended service schedule.
    (fifth why, root cause)

73
What is the Purpose of Fishbone Diagrams?
  • To identify underlying or root causes of a
    problem
  • To identify a target for your improvement that is
    likely to lead to change

74
Construction of a Fishbone Diagram
  • Then for each cause identify deeper root causes

75
Tips for Using Fishbone Diagrams
  • Find the right problem or effect statement
  • Find causes that make sense and that you can
    impact
  • Make use of your results

76
Summing Up Cause and Effect
  • Use Fishbone and 5 Whys to explore and
    graphically display in increasing detail all of
    the possible causes related to the problem
  • Use Fishbone and 5 Whys to find dominant causes
    rather than symptoms
  • Use Fishbone and 5 Whys to identify the root
    cause of the problem we seek to improve

77
We Have the Root Cause
  • Now what?

78
Quality Improvement Models
DMAIC FMEA PDCA/PDSA LEAN FOCUS
RAPID CYCLE QUALITY IMPROVEMENT SIX
SIGMA SMART JACHO 10 STEP
79
PDSA and Using QI Tools
  • Using tools as part of the PDSA cycle
  • Some tools will be useful in the planning stage
  • Others will help you to implement your QI project
  • And/or will help you study the impact of your
    process change

80
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?
81
The PDSA Cycle for Learning and Improvement
Act
Plan
  • Objective
  • Questions and
  • predictions (why)
  • Plan to carry out
  • the cycle (who, what, where, when)
  • What changes are to be made?
  • AdApt? AdOpt?
  • or Abandon?
  • Next cycle?

Study
Do
  • Complete the
  • analysis of the data
  • Compare data to
  • predictions
  • Summarize what
  • was learned
  • Carry out the plan
  • Document problems
  • and unexpected
  • observations
  • Begin analysis
  • of the data

82
Repeated Use of the Cycle
Changes That Result in Improvement
DATA
Spread
Implementation of Change
Wide-scale Tests of Change
Hunches Theories Ideas
Follow-up Tests
Very Small-scale Test
83
GOAL Improve Outcomes
Concept D
Concept C
Concept B
Concept A
Change concepts, theories, ideas
84
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85
CMS National Partnership to Improve Dementia Care
  • Launched in 2012 with one goal reduction in use
    of antipsychotic medications for short and long
    stay nursing home residents
  • Excludes Schizophrenia, Tourettes and
    Huntingtons Disease
  • Short Stay and Long Stay Measures

86
CMS Partnership Strategies
  • Education and Training at all levels but Hand in
    Hand for GNA/CNA level
  • PIPs/QA team focus
  • Review Individual Cases
  • Behavioral Rounds
  • Clinical Champion
  • Family education

87
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88
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89
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90
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91
Region III-Results
  • STATE Rank change
  • MD 17.31 8 12.5
  • DC 17.42 9 12.84
  • DE 17.99 12 15.51
  • WV 19.77 19 3.53
  • PA 20.49 28 8.14
  • VA 22.08 31 4.19

92
THE STATE OF VIRGINIA
  • Work with your state coalition
  • Reach out to your area medical directors
  • Reach out to area mental health providers
  • Work with industry
  • Start PIPs in your nursing homes around AP
    reduction
  • OR EXPLAIN WHY YOU ARE DIFFERENT!

93
Levindale and Courtland Gardens
  • Q2-4 2011 Q3 2012-Q1 2013
  • Courtland 14.2 11.8(9.7)
  • Levindale 18.8 8.5(7.9)
  • Courtland 16.9 reduction
  • Levindale 54.8 reduction

94
LEVINDALE STRATEGIES
  • Oversight team met monthly-Medical director, DON,
    QA nurse, psychiatrist, unit managers, consultant
    pharmacist (now quarterly)
  • Monthly behavioral rounds
  • Letter to families about dementia care and
    antipsychotics
  • Consent form
  • Neighborhood model/Culture change

95
Courtland Strategies
  • Work with Psychogeriatric services
  • NP and CP working on GDR collaboratively
  • Track results through QA process

96
Levindale and Courtland Strategy
  • Put your money where your mouth is!
  • Post-acute quality PFP indicator

97
Role of the Medical Director
  • Educational resource
  • Quality oversight
  • Communicate with providers
  • Clinical champion
  • THEY SHOULD NOT BE PART OF THE PROBLEM

98
  • AMDA (4)
  • Dont prescribe antipsychotic medications for
    behavioral and psychological symptoms of dementia
    (BPSD) individuals with dementia without an
    assessment for an underlying cause of the
    behavior.

99
CMS Efforts
  • National Calls
  • Regional Calls
  • Individual Facility/Chain calls

100
CMS Lessons
  • Provider buy in (primary and mental health)
  • Provider availability
  • Returns from acute psych stays
  • Reluctant families- buddy system
  • creep of other psychoactive medications-anecdota
    l
  • Letters from state survey agencies to high
    utilizing facilities

101
CMS QAPI Website
  • http//go.cms.gov/Nhqapi

102
Dementia Care Resources
  • www.amda.com
  • www.nhqualitycampaign.org
  • www.cms.gov
  • www.pioneernetwork.net
  • www.alz.org
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