TRUE BLUE

1. TRUE BLUE Quest For Quality

3. Data Sanity Matthew S. Wayne MD, CMD Chief Medical Officer

4. Objectives • Perform an in-depth evaluation of current data analysis processes and how they can be improved to improve the quality of care in your nursing home • Review the 3 steps in proper data analysis • Utilize control charts to analyze data in your nursing home • Distinguish between common cause and special cause variation and discuss specific strategies to address both types of variation

5. QAPI Quality Assurance - Performance Improvement ACA Provision Section 6102(c) of the Affordable Care Act (ACA) directs the Secretary to provide technical assistance and promulgate regulations for each nursing home to implement a QAPI system, and permits the Secretary to sequence these actions so the technical assistance is available prior to the regulations.

6. QA+PI=QAPI Quality Assurance Performance Improvement Continuously improving processes Prevention Proactive Processes/Systems Systemic Involves entire IDT U.S. Department of Health and Human Services, Health Resources and Services Administration. Quality Improvement adapted from http://www.hrsa.gov/healthit/toolbox/HealthITAdoptiontoolbox/QualityImprovement/whatarediffbtwqinqa.html Compliance with standards Inspection Reactive Remove outliers Narrow Involves only a few

7. QA vs QI Balestracci p285

8. 5 Elements of QAPI • Design & Scope • Governance & Leadership • Feedback, Data Systems and Monitoring • Performance Improvement Projects (PIPs) • Systematic Analysis & Systemic Action

9. 5 Elements of QAPI • Design and Scope • Comprehensive and ongoing plan • Includes all departments and functions • Addresses safety, quality of care, QOL, resident choice, transitions • Based on best available evidence • QAPI plan

10. 5 Elements of QAPI • Governance and Leadership • Boards/owners and executive leadership • Buy in and support • Training and organizational climate • Administration sees value • Sufficient resources • Sustainability

11. 5 Elements of QAPI • Feedback, Data monitoring Systems, and Monitoring • Multiple sources, including resident and staff • Benchmarking and targeting • Adverse events

12. 5 Elements of QAPI • Performance Improvement Projects • Prioritized topics • Number of PIPs depend on the facility program • Team Chartered • PDSA Cycle

13. 5 Elements of QAPI • Systematic Analysis and Systemic action • Root cause analysis • Systems thinking • Systematic changes as needed

14. National Rollout: Timeline • By statute, nursing homes will be expected to have QAPI programs in place that meet a defined standard, one year after CMS issues a QAPI rule. CMS expects to issue a draft regulation for comment in 2012. A final rule is likely to be issued by early 2013.

15. Quality Improvement: Case 1 Goal – reduce 10% next year

16. Quality Improvement: Case1 Everybody gets pizza!!!!!!!!!!!!

17. Quality Improvement: Case 1

18. Quality Improvement: Case 2

19. Quality Improvement: Case 2

20. Quality Improvement: Case 2

21. Quality Improvement: Case 2

22. Quality Improvement: Case 2

23. Quality Improvement: Case 2

24. Quality Improvement: Case 2

25. Quality Improvement: Case 2

26. Quality Improvement: Case 2 What if we were to tell you that this was not medication error data but …………………. Coin Flip Data

27. Basic Statistical Lesson 2Key Concept -Variation • Case 2: Coin Flip : 50 people- 25 times- # Heads

28. Key Concept -Variation • We learn nothing of importance by comparing two or three results when they all come from a stable process Most data of importance to management are from stable processes

29. Quality Improvement • Process • Variation • Priority

30. Process Oriented ThinkingSystems Thinking System - Definition A group of interdependent processes A network of functions or activities within an organization that work together for the aim of the organization 30

31. The Big Picture

32. Process Oriented Thinking • Process- Definition • Sequences of tasks aimed at accomplishing a particular outcome • Transformation of inputs into outputs

33. Basic Statistical Lesson 1 • Given two different numbers, one will be larger Or- Two numbers that are not the same : are different

34. Quality Improvement

35. Basic Statistical Lesson 1 • Is the process that produced the second number the same that produced the first number? Real Question 1

36. Basic Statistical Lesson 1 • If this number is different from a desired goal, is this variation from the goal due to common cause or special cause process? • What is common cause? Special cause? Real Question 2

37. Process • First: Your current processes are perfectly designed to get the results they are already getting and designed to get, • with it's corollary: • insanity is doing things the way you have always done them while expecting different results

38. Process • Second, the current process are also perfectly designed to take up more than 100% of people's time working in them, • with it's corollary, • it is amazing how much waste can be disguised as useful work.

39. Process • Third : improving quality = improving process • Problems : Breakdown in current work processes, or, Lack of consistent work process

40. Process • All work is a process • All processes exhibit variation and have measurable values associated with them • The performance of any component process is to be evaluated in terms of its contribution to the aim of the system.

41. 85/15 Process Rule • Individuals have direct control over only 15% of their work problems. • The other 85% are controlled by the processin their work environment. • Deming 4% - 96%

42. Quality Improvement • Change in focus from the 15% to the 85%: • The process • Not people

43. Worker controllable problems • People need to have the means: • For knowing what they were supposed to do • For knowing what they were actually doing • To close the loop between what they were doing and what they should be doing

44. It’s processes not people • While we must still hold individuals responsible for high standards of performance, we now recognize that most errors result from faulty systems, • not faulty people.

45. Process Oriented Thinking • Concentrating on the process inherent in any improvement situation leads to: • Greater cooperation due to a common language • Elimination of blame • Simpler, more effective solutions

46. Quality Improvement • Process • Variation • Priority

47. Basic Statistical Lesson 2Key Concept -Variation

48. Basic Statistical Lesson 2Key Concept -Variation • Walter Shewhart- 1920’s • There is always variation in anything that is being measured • In statistical thinking terms: there are inputs causing variation that are always present and conspire in random ways to affect a process’s output.

49. Basic Statistical Lesson 2Key Concept -Variation • Case 2: Coin Flip : 50 people- 25 times- # Heads

50. Basic Statistical Lesson 2Key Concept -Variation • Questions to ask: • First: Is the process stable? In other words, is the process in statistical control? • Second: What are the causes of variation in the process?