Quality Assessment Performance Improvement Learning Objectives

1. Quality Assessment Performance ImprovementLearning Objectives Define Quality Assessment & Performance Improvement (QAPI) State the goal of QAPI Describe the key components of a hospice QAPI program QAPI Part 1 Process of IJ determination is covered in Appendix Q, Tab __ of Resource Manual; take along on every survey (regardless of provider type) Need to be familiar in advance! Read separately from survey. Mark page 13 “3 components.”Process of IJ determination is covered in Appendix Q, Tab __ of Resource Manual; take along on every survey (regardless of provider type) Need to be familiar in advance! Read separately from survey. Mark page 13 “3 components.”

2. 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

3. Desired Outcomes in Hospice vs. Other Healthcare Setting Hospice Comfortable dying Safe dying Self-determined life closure Effective grieving Other healthcare settings Cure of illness Improved functionality (including ADLs) QAPI Part 1

4. 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

5. Other CoPs that integrate QAPI QAPI Part 1

6. 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

7. Standard (a): Program Scope The program must at least be capable of showing measurable improvement in indicators related to improved palliative outcomes and hospice services. 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

8. Standard (b): Program Data The program must use quality indicator data, including patient care, and other relevant data, in the design of its program. The hospice must use the data to do the following: Monitor the effectiveness and safety of services and quality of care. Identify opportunities and priorities for improvement. The frequency and detail of the data collection must be approved by the hospice’s governing body QAPI Part 1

9. Standard (c): Program Activities The hospice’s performance improvement activities must 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 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. 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

10. Standard (d): Performance Improvement Projects Beginning February 2, 2009, hospices must develop, implement and evaluate performance improvement projects. 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. 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

11. Standard (e): Executive Responsibilities The hospice’s governing body is responsible for ensuring the following. That an ongoing program for quality improvement and patient safety is defined, implemented and maintained, and is evaluated annually. 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. That one or more individual(s) who are responsible for operating the quality assessment and performance improvement program are designated QAPI Part 1

12. QAPI Functions QAPI Part 1

13. 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

14. Patient – levelThe Cycle of Care QAPI Part 1

15. 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

16. Hospice-level QAPI QAPI Part 1