Quality Assurance Performance Improvement: 12 Steps to Excellence!

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Provisions set forth in the Affordable Care Act (ACA) require the Centers for Medicare and Medicaid Services (CMS) to broaden quality improvement activities in nursing homes. Although the mandatory implementation date for nursing homes to provide evidence of a systematic Quality Assurance and Performance Improvement (QAPI) program has been delayed, but facilities should not delay in implementing a detailed and well-documented QAPI program. This presentation moves beyond the five elements of a QAPI and begins to drill down to practical concepts for “beefing up” an existing Quality Improvement program to meet QAPI standards. Learn how to objectively assess where your facility is in the QAPI journey, and gain a deeper insight into how practical implementation of QAPI activities can be a part of the culture of excellence that is part of all successful nursing homes.

1. Learn to detail the five elements of QAPI and correlate the five elements to the twelve step action plan for QAPI implementation.

2. Learn to articulate the steps to evaluating their facilities progress in QAPI efforts.

3. Understand Performance Improvement Projects (PIPs).

4. Learn the five steps of Root Cause Analysis (RCA) and learn how to apply the RCA process to adverse events in their facility routinely.

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Quality Assurance Performance Improvement: 12 Steps to Excellence!

  1. 1. Quality Assurance Performance Improvement: 12 Steps To Excellence! Harmony University The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Beckie Dow, RN, RAC-MT Director of MDS and Nursing Education & Training
  2. 2. Speaker Bio Over 20 Years Experience in Long-term Care Clinical and Reimbursement Accuracy in Assessments Quality Assurance Activities Interrelation between MDS, Care Planning, QA, and Clinical Excellence at the Bedside AANAC Master Teacher Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2
  3. 3. Quality Assurance Performance Improvement: 12 Steps to Excellence Disclosures: The planners and presenter of this educational activity have no relationship with commercial entities or conflicts of interest to disclose Planners: Elisa Bovee, MS, OTR/L Diane Buckley, BSN, RN, RAC-CT Beckie Dow, RN, RAC-MT Presenter: Beckie Dow, RN, RAC-MT Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 3
  4. 4. Harmony Healthcare International, Inc. Criteria for Successful Completion Complete Sign-in and Sign-Out on Attendance Form Attendance for entire session Completion and submission of speaker evaluation form Copyright © 2013 All Rights Reserved 4
  5. 5. Program Objectives Detail the five elements of QAPI and relate the five elements to the twelve action steps of QAPI Discuss the QAPI demonstration project Articulate how existing quality improvement programs in SNFs and other settings can benefit from the QAPI materials Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 5
  6. 6. Program Objectives Discuss problem solving models, including Root Cause Analysis, Directed Plan of Correction, Plan Do Study Act List three tools that the facility can use to prepare for the implementation of QAPI Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 6
  7. 7. “Don’t judge each day by the harvest you reap, but by the seeds you plant” -Robert Louis Stevenson Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 7
  8. 8. The CMS Nursing Home Action Plan: A Three Part Aim Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 8
  9. 9. The CMS Nursing Home Action Plan: Five Approaches Enhance consumer engagement Strengthen survey processes, standards, and enforcement Promote quality improvement Create strategic approaches through partnerships Advance quality through innovation and demonstration Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 9
  10. 10. F520 - Quality Assessment and Assurance (QAA) The facility has an ongoing QAA committee that includes designated key members and that meets at least quarterly; and The committee identifies quality deficiencies and develops and implements plans of action to correct these quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the action plans Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 10
  11. 11. QAPI Timeline March 2010—Affordable Care Act passed April 2011—QAPI announced September 2011—prototype QAPI program launched to test QAPI tools and resources May 2012—QAPI questionnaire July 2012—Panel of experts assembled to discuss the prototype tools and questionnaire results Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 11
  12. 12. QAPI Timeline December 2012—QAPI at a Glance guide introduced in draft form June 2013—Final version of QAPI at a Glance published June 2013—Announced that wave one NHQI questionnaire results would be available “in the near future” TBD—wave two of the NHQI questionnaire Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 12
  13. 13. The QAPI “Elevator Speech” QAPI is a comprehensive program by which an organization identifies problems or issues early on, develops a plan to address the root causes of problems and prevent adverse events throughout the system, and involves the entire team in using data to understand quality and work to improve performance Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 13
  14. 14. What is QAPI? The merger of two complimentary approaches to quality management: Quality Assessment – determining where things are going well and where opportunity to improve exists Performance Improvement – the reaction to the opportunity to improve Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 14
  15. 15. What is QAPI? Quality Assurance Performance Improvement Motivation Measuring compliance with standards Continuously improving processes to meet standards Means Inspection Prevention Attitude Required , reactive Chosen, proactive Focus Outliers: “bad apples” Individuals Processes or Systems Scope Medical provider Resident care Responsibility Few All Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 15
  16. 16. What is QAPI? “QAPI is about critical thinking. It involves figuring out what is causing certain problems, and implementing interventions and solutions that address the root causes of the problems, rather than just the symptoms” Karen Schoeneman Past Technical Director, CMS Division of Nursing Homes Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 16
  17. 17. The Challenge… “Not all change is improvement, but all improvement is change” Donald Berwick, MD Former CMS Administrator Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 17
  18. 18. The Goal of QAPI and/or Other Quality Improvement Models The Goal: Meet or exceed the expectations of our customers Meeting customer expectations = meeting the mission! Who are the customers? External customers: The reason the organization exists Internal customers: Anyone within the organization Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 18
  19. 19. The Goal of QAPI and/or Other Quality Improvement Models Nursing homes are in the best position to assess, evaluate, and improve their care and services, because each home has first-hand knowledge of their own organizational systems, culture, and history Effective QAPI leverages this knowledge to maximize the return on investments made in care improvement Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 19
  20. 20. The Goal of QAPI and/or Other Quality Improvement Models QAPI will take many nursing homes into a new realm in quality: Systematic Comprehensive Data-driven Proactive Performance Management and Improvement Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 20
  21. 21. The Goal of QAPI and/or Other Quality Improvement Models When nursing home leaders promote the QAPI philosophy the results may: Prevent adverse events Promote safety and quality Reduce risk for residents Reduce risk for caregivers Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 21
  22. 22. The Goal of QAPI and/or Other Quality Improvement Models The goal of QAPI is not to merely meet minimum standards—it is about continually aiming HIGHER! Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 22
  23. 23. A Culture of Caring “I take care of my staff, and they take care of the patients,” said one DON. “If I treat them badly, they will treat the patients badly.” Source: Beyond Unloving Care by Susan Eaton, June 2000 Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 23
  24. 24. Are You Already Doing QAPI? QAPI principles are not new to healthcare QAPI builds on our existing QAA regulations Your facility may already be participating in QAPI activities, and can use existing activities as a foundation for QAPI Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 24
  25. 25. Are You Already Doing QAPI? Does your facility… Create systems to provide care and achieve compliance with nursing home regulation? Investigate problems and try to prevent their recurrence? Track and report adverse events? Compare the quality of your home to that of other homes in your state or company? Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 25
  26. 26. Are You Already Doing QAPI? Does your facility… Receive and investigate complaints? Seek feedback from residents and front-line caregivers? Set targets for quality? Strive to achieve improvement in specific goals related to pressure ulcers, falls, restraints, or permanent caregiver assignment, or other areas (Advancing Excellence campaign) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 26
  27. 27. Are You Already Doing QAPI? Does your facility… Have a commitment to balancing a safe environment with resident choice? Strive for deficiency-free surveys? All of these activities are part of QAPI Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 27
  28. 28. Are You Already Doing QAPI…But Could “Take it to the Next Level?” Some QAPI components are new for many nursing homes QAPI emphasizes quality care for residents and an improved work environment for caregivers QAPI uses a systems approach to actively pursue quality, not just respond to external requirements Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 28
  29. 29. Are You Already Doing QAPI…But Could “Take it to the Next Level?” Use data to identify quality problems, opportunities for improvement, and setting priorities for action Building on residents’ own goals for health, quality of life, and daily activities Building meaningful resident and family voices into setting goals and evaluating progress Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 29
  30. 30. Are You Already Doing QAPI…But Could “Take it to the Next Level?” Incorporating caregivers broadly in a shared QAPI mission Developing Performance Improvement Project (PIP) teams with specific “charters” Performing a Root Cause Analysis (RCA) to get to the heart of the reason for a problem Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 30
  31. 31. Are You Already Doing QAPI…But Could “Take it to the Next Level?” Undertaking systemic change to eliminate problems at the source Developing feedback and monitoring systems to sustain continuous improvement Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 31
  32. 32. QAPI: The Five Elements Your QAPI program should contain all five elements, which are closely related Your QAPI plan will be based on your own center’s needs, current programs, and unique residents Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 32
  33. 33. QAPI: The Five Elements 1. Design and Scope 2. Governance and Leadership 3. Feedback, Data Systems and Monitoring 4. Performance Improvement Projects (PIPs) 5. Systematic Analysis and Systemic Action Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 33
  34. 34. The 12 Action Steps to QAPI The 12 steps do not need to be achieved sequentially, but each step builds on other QAPI principles The most important aspect of QAPI is effective implementation Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 34
  35. 35. Step 1: Leadership Responsibility and Accountability Support “from the top” is essential, and that support should foster the active participation of every caregiver Executive leadership sets the tone and provides resources Executive leaders help other leadership flourish in the nursing home Be available for residents & caregivers, tour and meet where they work Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 35
  36. 36. Step 1: Leadership Responsibility and Accountability Develop a steering committee to provide QAPI leadership Provide resources for QAPI— equipment, training, and staff time Climate of open communication and respect (“just culture”) Understand the culture of your home Expect and build effective teamwork Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 36
  37. 37. Step 2: Develop a Deliberate Approach to Teamwork Teamwork is a central concept to an effective QAPI program An effective team has a clear purpose, defined roles for each member to play, and each member is committed to active engagement in the team’s activities Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 37
  38. 38. Step 2: Develop a Deliberate Approach to Teamwork Characteristics of an effective team include the following: Having a clear purpose Having defined roles for each team member to play Having commitment to active engagement from each member The roles of team workers may grow out of their original discipline or their defined job responsibilities Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 38
  39. 39. Step 3: Take your QAPI “pulse” with a Self-Assessment Self-assessment tool is provided in the QAPI at a Glance guide Can be used at the beginning of the QAPI journey, and then for semi- or annual evaluation thereafter The results will direct you to areas you need to work on to effectively establish QAPI in your organization Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 39
  40. 40. Step 3: Take your QAPI “pulse” with a Self-Assessment See Handouts for the Self-assessment Tool This should be an honest assessment and reflection of your organizations progress Helps you to determine how you know whether QAPI is taking hold Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 40
  41. 41. Step 4: Identify your Organization’s Guiding Principles Establishing a purpose and guiding principle will unify the organization Many caregivers do not know the guiding principles of the organization! Taking time to articulate your organizations purpose will assist your organization to develop a written QAPI plan See Handouts for the guide Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 41
  42. 42. Step 4: Identify your Organization’s Guiding Principles 1. Locate or develop your organization’s vision statement 2. Locate or develop your organization’s mission statement 3. Develop a purpose statement for QAPI Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 42
  43. 43. Step 4: Identify your Organization’s Guiding Principles 4. Establish guiding principles 5. Define the scope of QAPI in your organization 6. Assemble the Document Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 43
  44. 44. Step 5: Develop your QAPI Plan Your plan will assist you in achieving what you have identified as your organizations purpose, guiding principles, and scope Tailor-made program that is a living, breathing document Amend or change your plan as your organization changes and grows See Handouts Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 44
  45. 45. Step 6: Conduct a QAPI Awareness Campaign Let everyone know about your QAPI plan - often and in multiple ways Ongoing and varied caregiver training Ensure that consultants and outside agencies that work within your organization are aware of your QAPI program Discuss the hard questions Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 45
  46. 46. Step 6: Conduct a QAPI Awareness Campaign This is your opportunity to convey the positive message of QAPI and let caregivers from all disciplines know that their participation is key to success If systems don’t exist, they may need to be developed If systems impede quality, they must be changed Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 46
  47. 47. Step 6: Conduct a QAPI Awareness Campaign All residents and families should be made aware that their views are sought, valued, and considered in facility decision-making and process improvements Make announcements in resident and family council or other communication venues Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 47
  48. 48. Step 7: Develop a Strategy for Collecting and Using QAPI Data QAPI includes the routine monitoring of data from multiple sources Set targets for performance in the areas you are monitoring Identify benchmarks for performance Develop a plan for the data you collect to ensure it is used, not just collected You are already collecting valuable data Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 48
  49. 49. Step 7: Develop a Strategy for Collecting and Using QAPI Data Data sources you may already have: Clinical care areas (falls, ulcers, infections) Medications (antipsychotics, narcotics) Complaints from residents and families Hospitalizations and other service use Resident satisfaction Caregiver satisfaction Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 49
  50. 50. Step 7: Develop a Strategy for Collecting and Using QAPI Data Data sources you may already have: Resident and caregiver experiences living and working in the setting State survey results and deficiencies Results from MDS assessments Business and administrative processes (finances, caregiver turnover, staffing patterns, sick calls, staff injuries) Admissions and discharges Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 50
  51. 51. Step 7: Develop a Strategy for Collecting and Using QAPI Data Use your data to set benchmarks Every facility is unique, so individual benchmarks based on your own performance are key This data will require systematic organization and interpretation in order to achieve meaningful reporting and action Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 51
  52. 52. Step 8: Identify your Gaps and Opportunities Review your sources of information to determine if gaps or patterns exist These gaps may result in quality problems (“quality themes”) Look for areas where there is opportunity for improvement Take notice of things you are doing well Set priorities for Performance Improvement Projects (PIPs) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 52
  53. 53. Step 9: Prioritize Quality Opportunities and Charter PIPs Prioritizing opportunities for improvement is a key step in the process of translating data to action Consider areas that are high risk, high frequency, and/or problem prone, or may affect the psychological well-being and comfort of residents Charter a PIP team Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 53
  54. 54. Step 9: Prioritize Quality Opportunities and Charter PIPs The term “charter” is used in conjunction with the PIP to indicate that it is more than just a casual effort The PIP will entail a specific written mission to look into a problem area The PIP will include people in a position to explore the problem (caregivers, discipline specific) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 54
  55. 55. Performance Improvement Projects (PIPs) What do we target? Any area – even if things are going well, there may be the opportunity to improve Identify opportunities to optimize: Effectiveness Efficiency Safety Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 55
  56. 56. Performance Improvement Projects (PIPs) Essential steps/elements of a PIP: Define the nature of the problem Develop change ideas Determine your actions Test the actions Determine if change has occurred and if it is an improvement Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 56
  57. 57. Performance Improvement Projects (PIPs) Team activities Meet regularly Develop the pilot study Once the successful change is determined, roll it out organization-wide Continue to monitor and ensure sustained improvement Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 57
  58. 58. Performance Improvement Projects (PIPs) What should the PIP team expect? 3-6 month commitment Management and staff support Be prepared to participate in the organization-wide implementation of the change Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 58
  59. 59. Step 9: Prioritize Quality Opportunities and Charter PIPs Caregivers on a PIP should be empowered to view their participation as a valuable assignment that the team takes seriously Caregivers should have the PIP meetings built into their assignment for the day Make sure floor duties are covered Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 59
  60. 60. Step 10: Plan, Conduct, and Document PIPs Focus your PIP by defining the scope, so the team does not get overwhelmed Identify the information the PIP team needs and a timeline for completion Identify and request any materials or supplies needed Residents’ perspective is key Use a problem-solving model, like PDSA Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 60
  61. 61. The PDSA Model for Improvement Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 61
  62. 62. Step 10: Plan, Conduct, and Document PIPs Plan: The team learns more about the problem, plans for how improvement would be measured, and plans for any changes that might be implemented Do: The plan is carried out, including the measures that are selected Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 62
  63. 63. Step 10: Plan, Conduct, and Document PIPs Study: The team summarizes what was learned Act: The team and leadership determine what should be done next, which could include adapting (and re- studying), adopting (perhaps expanded to other areas), or abandoning Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 63
  64. 64. Step 11: Getting to the “Root” of the Problem No problem can be effectively addressed without thoroughly exploring the problem The problem may involve multiple factors and may affect several departments Root Cause Analysis (RCA) is a systemic process for identifying contributing causal factors that underlie variations in performance Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 64
  65. 65. Step 11: Getting to the “Root” of the Problem There is danger in starting with a solution without thoroughly exploring the problem Multiple factors may have contributed, and/or the problem ma be a symptom of a larger issue What seems like a simple issue may involve a number of departments Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 65
  66. 66. Root Cause Analysis RCA requires a systematic, intensive, and in-depth review to learn the most basic reasons for the adverse event Formal logic and defined methodology Goal is to understand the problem in sufficient depth to effectively eliminate the risk of future injury See Handouts Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 66
  67. 67. Root Cause Analysis Where Traditional Methods will: Root Cause Analysis will: Expected staff to perform flawlessly 24/7 and blamed individuals when they didn’t Encourages the development of systems that are designed to compensate for human limitations and looks to system fixes when an error occurs Expected staff to adapt their practice to available equipment and regular procedures Stresses the development of equipment and procedures that are designed for safety Relied on a chain of command in a facility to investigate errors and impose corrections Relies on teamwork among all staff to analyze problems and to propose and implement solutions Punished errors Stresses learning from errors Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. Source: Oregon Patient Safety Commission 67
  68. 68. Root Cause Analysis RCA also recognizes that adverse events usually result from a number of factors that are all part of the normal process of providing care and service Adverse events are rarely a single error made by one person RCA process examines the various contributing factors that led to the adverse event happening Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 68
  69. 69. Root Cause Analysis RCA helps you look at the safeguards in your systems or process of care to determine how and why and adverse event happened, and helps you plan to improve those systems to decrease the chances of a similar event happening again Identifies how systems have failed to keep the resident safe Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 69
  70. 70. Root Cause Analysis The purpose of RCA event investigation is to indentify which imperfections in your safety systems had a role in the adverse event, and then strengthen the protections so that future providers and resident will not be caught in the same set of circumstances Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 70
  71. 71. Prepare for Success with RCA Make sure that you clearly understand the facts surrounding the issue, complaint, or concern/allegation at hand Suspend any judgment about how or why it may have happened until you have gathered the facts Start with a “clean slate” attitude Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 71
  72. 72. Prepare for Success with RCA Inquire with those that might have information Make a sample list of what you hope to learn from each of these sources Gather documentation that may be relevant and note any personal observations of equipment, general conditions, etc that will contribute to your understanding Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 72
  73. 73. Prepare for Success with RCA Set aside a time and a place to talk to people privately Be clear about what you want to say and how you want to approach them Address fears that the person may have, such as how the information will be used and what may happen as a result of the information they provide Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 73
  74. 74. Prepare for Success with RCA Take time to gather all resources you will need in order to have successful interviews Acknowledge that the RCA process builds on your current investigation approach, but with several key differences Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 74
  75. 75. Root Cause Analysis Step 1 – Gather initial information Step 2 – Fill in the gaps Step 3 – Analysis Step 4 – Action plan development Step 5 – Evaluation of results Source: Oregon Patient Safety Commission Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 75
  76. 76. Root Cause Analysis Step 1 – Gather Initial Information Immediate data gathering; get the facts first Focus on what happened, not “who did it” Keep an open-minded attitude Source: Oregon Patient Safety Commission Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 76
  77. 77. Root Cause Analysis Step 1 – Gather Initial Information What to watch out for: Emotions of grief and fear altering perceptions during interviews Rote responses assigning blame or denying responsibility Making assumptions about the cause Source: Oregon Patient Safety Commission Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 77
  78. 78. Root Cause Analysis Step 2 – Fill in the Gaps Discuss the incidence as a team Identify gaps and reconcile differences of views Gather more information Investigate the scene of the incident and any involved equipment Source: Oregon Patient Safety Commission Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 78
  79. 79. Root Cause Analysis Step 2 – Fill in the Gaps What to watch out for: Leaving gaps in information Rote responses assigning blame or denying responsibility Making assumptions about the cause Source: Oregon Patient Safety Commission Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 79
  80. 80. Root Cause Analysis Step 2 – Fill in the Gaps Create a “safe table” for interview Tell the interviewee you will take notes. These notes can be copied and given to the interviewee if he/she would like a copy. Do not use information obtained during the interview for disciplinary action. This should be a separate process if the RCA identifies it as an actual or contributing cause. Source: Oregon Patient Safety Commission Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 80
  81. 81. Root Cause Analysis Step 2 – Fill in the Gaps Create a “safe table” for interview Be unbiased and nonjudgmental Do not interview more than one person at a time Do not discuss who else will be interviewed or what other interviewees have said Source: Oregon Patient Safety Commission Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 81
  82. 82. Root Cause Analysis Step 3 - Analysis Ask why until you can’t ask it anymore! Review contributing factors Document Conduct the “Common Sense Test” on the conclusions or the investigation Described using specific/objective words? If you eliminate this cause will it go away? Is human error really the cause? If procedure was violated, why? Source: Oregon Patient Safety Commission Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 82
  83. 83. Root Cause Analysis Step 3 - Analysis Focus on finding the most fundamental reasons (the root cause!) for the event Create conclusion or findings statements that link the causes to the effect or result Use statements that lead to strong action plans Source: Oregon Patient Safety Commission Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 83
  84. 84. Root Cause Analysis Step 3 - Analysis What to watch out for: Easy answers that don’t address the fundamental causes Stopping at the first or second answer to the question “why” Omitting findings because “we can’t do anything about that”—create an action plan Source: Oregon Patient Safety Commission Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 84
  85. 85. Root Cause Analysis Step 4 – Action Plan Development Develop an immediate plan as well as (if needed) a long or short term plan Use the S.M.A.R.T.S. system for action plans Document the plan Implement the plan Consider the application of the plan to others Source: Oregon Patient Safety Commission Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 85
  86. 86. A “SMARTS” Action Plan Specific Measurable Attainable Realistic Timely Supported Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. Source: Oregon Patient Safety Commission 86
  87. 87. Root Cause Analysis Step 4 – Action Plan Development Focus on the most fundamental reasons (the root causes!) for the event Develop physical and natural protections/safety systems as much as possible Develop preventative actions that keep a different person from the same or similar adverse event Source: Oregon Patient Safety Commission Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 87
  88. 88. Root Cause Analysis Step 4 – Action Plan Development What to watch out for: Setting policies that rely on individuals “trying harder” or “paying more attention” Trying to change people Source: Oregon Patient Safety Commission Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 88
  89. 89. Root Cause Analysis Step 5 – Evaluation of Results Track the implementation How are other residents affected? Measure how each plan is doing and how you will track and trend Celebrate success Did you identify & solve an organizational/system problem? Source: Oregon Patient Safety Commission Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 89
  90. 90. Root Cause Analysis Step 5 – Evaluation of Results What to watch out for: Slippage over time as people return to their old routine Not providing feedback to staff on progress Tiring of the measurement Source: Oregon Patient Safety Commission Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 90
  91. 91. Step 12: Take Systemic Action Implement changes that will result in improvement or reduce the chance of an event recurring Choose actions that are tightly linked to the root cause and lead to a system or process change Corrective action should target the elimination of the root cause Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 91
  92. 92. Step 12: Take Systemic Action Pilot test the change in one area of your facility before launching facility-wide Pilot testing gives the team the opportunity to correct unintended consequences of the change Choose strong methods of corrective action for facility policy to increase success Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 92
  93. 93. Step 12: Take Systemic Action Weak corrective actions rely on staff to remember their training or what is written in policy Double-checks Warnings/labels New policies/procedures/memoranda Training/education Additional study Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 93
  94. 94. Step 12: Take Systemic Action Intermediate corrective actions are somewhat dependent on staff remembering to do the right thing, but they provide tools to help staff to remember or to promote clear communication Decreased workload Software enhancements/modifications Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 94
  95. 95. Step 12: Take Systemic Action Intermediate corrective actions (Cont.) Eliminate/reduce distraction Checklists/cognitive aids/triggers/prompts Eliminate look alike and sound alike Read back Enhanced documentation/communication Build in redundancy Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 95
  96. 96. Step 12: Take Systemic Action Strong corrective actions do not depend on staff to remember to do the right thing Change or re-design the process Detect and warn so there is an opportunity to correct before the error reaches the patient Hard stops which will not allow the process to continue unless something is corrected Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 96
  97. 97. Step 12: Take Systemic Action Strong corrective actions (Cont.) Physical changes in environment Forcing functions or constraints (different connection ports so only the correct line will connect) Electronic Medical Records (cannot proceed until all fields filled in) Simplifying (unit dose packaging) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 97
  98. 98. Group Activity See Handouts for the Group Activity Scenario Use the Goal Setting Worksheet in your Handouts to make a plan for quality improvement Work in small groups Be creative! There are no wrong answers! Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 98
  99. 99. QAPI Principles Summarized QAPI may not be new for you—build on what you have QAPI leadership starts at the top with executive management, Board of Directors, Owners or Trustees and includes top management in each home Systems, Systems, Systems Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 99
  100. 100. QAPI Principles Summarized Involve the people directly working in a process in order to improve that process Organization-wide inclusion to truly understand what is going on Continuous communication about QAPI throughout the organization, and built-in to an educational effort that involves caregivers, residents, and families Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 100
  101. 101. QAPI Principles Summarized Residents’ perspective is key in setting QAPI priorities for PIPs Two key activities are setting priorities and chartering PIPs, and everyone should have the opportunity to participate in both Create a log of your QAPI activities Celebrate and reward success! Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 101
  102. 102. Benefits of a QAPI Program Competencies that equip you to solve quality problems and prevent their recurrence Competencies that allow you to seize opportunities to reach new goals Fulfillment for caregivers, as they become active partners in performance improvement (“buy in”) Better care and quality of life Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 102
  103. 103. The Demonstration Project States California Florida Massachusetts Minnesota Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 103
  104. 104. Demonstration Activities Develop and implement QAPI plans Participate in virtual and in-person meetings Receive tools and resources Offer feedback Generate best practice ideas Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 104
  105. 105. Demonstration Activities Expectations of the demonstration participants: Implement all elements of QAPI Provide an environment that encourages quality improvement Develop systems to identify problems and address them Conduct quality improvement projects Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 105
  106. 106. Demonstration Activities Benefits to participants: A liaison to assist each facility Technical assistance On-line instruction Learning collaborative Early access to tools Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 106
  107. 107. Getting Ready for QAPI Nursing Homes can use a variety of resources to select their Performance Improvement Goals Many tools are available online, free of charge These tools can be used to develop a facility-specific plan Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 107
  108. 108. Advancing Excellence in America’s Nursing Homes Goals The Advancing Excellence in America’s Nursing Homes campaign is designed to improve the quality of life for both nursing home residents and the staff who serve them To participate, a nursing home will voluntarily pledge to work on three or more goals Goals were updated August 2013 Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 108
  109. 109. Advancing Excellence in America’s Nursing Homes Goals Process Goals: Increasing Use of Consistent Assignment Safely Reducing Hospitalizations Increasing Person-Centered Care Planning and Decision Making Improving Staff Stability Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 109
  110. 110. Advancing Excellence in America’s Nursing Homes Goals Clinical Outcomes Goals: Preventing and Managing Infections Safely (C. diff) Using Medications Appropriately Increasing Resident Mobility Decreasing Symptoms of Pain Reducing the Prevalence of Pressure Ulcers Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 110
  111. 111. Advancing Excellence in America’s Nursing Homes Goals The Advancing Excellence campaign uses a model called The Circle of Success See Handouts Aspects of this model correlate well with the QAPI 12 Steps Facilities can begin their QAPI journey by participating in the Advancing Excellence campaign Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 111
  112. 112. Advancing Excellence in America’s Nursing Homes - Goals for 2012 Check the Excellence in America’s Nursing Homes Web site for updated tools to assist you in your efforts: www.nhqualitycampaign.org Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 112
  113. 113. Consider Quality Indicator Survey (QIS) Tools as QAPI Data Sources Available at www.QTSO.org Use tools consistently and without bias Go beyond Stage I tools Stage II tools help ensure in-depth investigation Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 113
  114. 114. The DPOC Model: Great for Problem Solving DPOC = Directed Plan of Correction Assessment of causative factors Steps/interventions undertaken Triggers/parameters to signal an evolving problem How the facility will measure the success of its efforts Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 114
  115. 115. Final Thoughts… “Excellence is an art won by training and habituation. We do not act rightly because we have virtue or excellence, but we rather have those because we have acted rightly. We are what we repeatedly do. Excellence, then, is not an act but a habit.” -Aristotle Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 115
  116. 116. Final Thoughts… The goal of providing the best possible quality of care and life for those entrusted to our care does not change Success depends on us evolving and always striving to redefine and achieve excellence Successful QAPI will not be a department, it will be a way of life in the organization Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 116
  117. 117. References Nursing Home Quality Assurance & Performance Improvement (CMS) website http://www.cms.gov/Medicare/Provider- Enrollment-and- Certification/QAPI/NHQAPI.html CMS Advancing Excellence In America’s Nursing Homes website http://www.nhqualitycampaign.org/ Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 117
  118. 118. References S&C Letter Quality Assurance and Performance Improvement (QAPI) in Nursing Homes- Activities Related to QAPI Implementation http://www.cms.gov/Medicare/Provider -Enrollment-and- Certification/SurveyCertificationGenInf o/Downloads/Survey-and-Cert-Letter- 12-38.pdf Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 118
  119. 119. References Root Cause Analysis Materials for Long Term Care Facilities http://oregonpatientsafety.org/healthcar e-professionals/nursing-homes/root- cause-analysis-materials-for-long-term- care-facilities/283/ Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 119
  120. 120. References QAPI at a Glance guide http://newsmanager.commpartners.com/fhca/do wnloads/SC13- 05%2002_%20attach_QAPI%20at%20a%20glance %204.pdf S&C Letter dated 12-14-12 http://www.cms.gov/Medicare/Provider- Enrollment-and- Certification/SurveyCertificationGenInfo/Policy- and-Memos-to-States-and-Regions-Items/Survey- and-Cert-Letter-13-05.html Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 120
  121. 121. References Quality Improvement Organization (QIO) http://www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment- Instruments/QualityImprovementOrgs/ index.html?redirect=/qualityimproveme ntorgs/ Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 121
  122. 122. Questions/Answers Beckie Dow, RN, RAC-MT bdow@harmony-healthcare.com Harmony Healthcare International 1 (800) 530 – 4413 www.Harmony-Healthcare.com Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 122
  123. 123. Harmony Healthcare International Have you Considered a Customized Complimentary HARMONY(HHI) MEDICARE PROGRAM EVALUATION or CASE MIX ANALYSIS for your Facility? Perhaps your facility has potential for additional revenue Benchmark your facility against key indicators and national norms Email us at for more information RUGS@harmony-healthcare.com Analysis is cost & obligation free Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 123

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