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1. ESRD Network 6: QAPI Development for Dialysis Providers
3. Is this how you feel when you see that envelope?Is this how you feel when you see that envelope?
4. Think Warm Happy Thoughts! And complete the task at hand!And complete the task at hand!
5. Fact or Fiction The Network collects endless information from the dialysis facility for no good reason
7. Lets Explore the Role of the Network
ESRD Network 6
Incorporated Name Southeastern Kidney Council
1 of 18 Networks in the Country
Legislation that Networks exist
8. What We Do - Network 6 CMS Contractors
Clinical Performance Measures
Complaints and Grievances
ESRD data forms
Patient and Provider Education
9. What does that mean for the facility? Participation in
Quality Improvement Projects
Complaints and Grievances
10. Current Quality Improvement Initiatives Focus On
Increasing AV Fistulas in South Carolina
Increasing AVF in Network 6 overall
Decreasing Complaints and Grievances
Decreasing Involuntary Discharges
11. Developing a Quality Assessment Performance Improvement (QAPI) Program
12. V626 Condition statement The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team.
13. V627 Condition statement Effective QAPI
(V627) an ongoing program that achieves :
Measurable improvement in health outcomes
Reduction of medical errors
14. V627 Condition statement The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS
15. V638 Monitoring Improvement The facility must:
Continuously monitor its performance
Take actions that result in performance
Track to assure improvements are sustained over time
16. What is QAPI? Quality Assessment Performance Improvement (QAPI)
Under QAPI, the focus is on assessing outcomes to see whether good results are being achieved.
More proactive approach to quality and to improvement.
17. Difference between QI and QAPI? Quality Improvement focuses on structure and process
Quality Assessment Performance Improvement focuses on assessing outcomes
18. QAPI Elements The professional members of the facilitys interdisciplinary team (IDT), which must participate in QAPI activities, consist of a physician, registered nurse, masters-prepared social worker, and registered dietitian.
19. QAPI Elements There must be an operationalized, written plan describing the QAPI program scope including:
Responsibilities of all participants
Procedures for overseeing the effectiveness of monitoring, assessing, and problem-solving activities.
20. QAPI Elements Within the facilities QAPI program, facilities are expected to use the community-accepted standards and values associated with clinical outcomes as referenced on the MAT (measures assessment tool).
22. QAPI Elements If a facility has areas of that do not meet target levels (per MAT) or areas where the facility performance is below average (per data reports), the facility is expected to take action toward improving those outcomes.
23. QAPI Elements QAPI requires the use of aggregate patient data to evaluate the facility patient outcomes.
Hemodialysis and peritoneal dialysis patients should be reviewed separately since factors affecting their clinical outcomes may be different; both groups of patients must be reviewed on an ongoing basis.
24. QAPI Elements Data related to patient outcomes, complaints, medical injuries, and medical errors (clinical variances, occurrences and adverse events) should be used to identify potential problems and to identify opportunities for improving care.
25. QAPI Performance Measures include:
26. Available Data Elements CMS Dialysis Facility Reports (DFR)
Facility Specific Data Outcomes Report
Facility Produced Data
Clinical Variance Reports
Trending Reports from various facility systems
27. How to do it Identify the problem
28. Now What? Develop Plan that results in improvement of care
Identify Opportunity for Improvement
Set Specific goal for Improvement
Define and Measure Root Causes PRIORITIZE!
Identify Person(s) responsible
Date Process began
Date/Frequency of Re-measurement
29. Then what? Work together entire IDT
Write clear statement identifying problem
Use numerical measurable goal
Set specific time range to meet goal
Assure goal is obtainable within specified time range
Use smaller goals in step by step fashion until ultimate goal is reached
30. And more Identify Root Causes:
For Example: If a data report shows that the facilitys ranking for hemodialysis adequacy is below the expected average
Facility must demonstrate QAPI review of global factors that might affect adequacy
Brainstorming with IDT
Data/Spreadsheets to measure barriers
31. Develop Action and Interventions Focus on process
What process can you change or create that will have a positive impact?
Make actions barrier-specific
How will changes impact the root cause?
Choose one or two actions which will have the greatest impact (Rapid cycle improvement)
Review available best practices
Will they work in your facility?
Discuss how you will monitor new processes
How will you know if changes are an improvement?
32. Change Processes Example:
Facility determines inadequate BFRs are highest priority root cause for patients not achieving adequacy
Facility reviews current process and determines new process is needed
NEW PROCESS >
Daily audit checksheet:
Nurse rounds after initiation of each shift to assure BFR and other prescription parameters are met
Allows action to be taken immediately rather than waiting for monthly lab review to reveal a problem
33. Evaluate Graph monthly data
Review trends for improvement
Discuss and document changes in monthly QAPI meetings
Whats not working?
35. Food for thought
Data reported is only as good as the data entered in the electronic or hard copy collection tools. This takes participation and cooperation of all staff.
36. Quality is NOT One Size Fits All individualize!
37. Where do you get DATA for your QAPI?
48. Comments, Questions, Ideas email them to email@example.com