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Operational Benefits to Quality Improvement Benchmarking

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  1. Operational Benefits to Quality Improvement Benchmarking

  2. Learning Objectives: • To increase knowledge of hospice Quality reporting requirements • To increase knowledge of hospice Quality Benchmarking tools • To demonstrate the ability to utilize Quality Benchmarks to improve clinical and operational performance

  3. Bristol Hospice, LLC~Who We Are • Locations in California, Hawaii, Texas, Georgia, and Utah • Services rural and urban areas • Free standing hospice providers which are part of an alliance of services/corporations • Medicare and Medicaid Certified, Licensed and or CON, as indicated • Accredited/deemed status by Community Health Accreditation Program (CHAP) 4

  4. QAPI InitiativesPatient/Family Centered In alignment with • NHPCO Benchmarks • Hospice Program’s Mission • Strategic Plan and Performance

  5. QAPI Overview PDSA How does this cycle fit within the QAPI framework? This process will be effective for agency specific metrics Rapid cycle use of this model has proven to be highly successful for agencies PLAN DO ACT STUDY

  6. Quality Assurance Performance Improvement • Overview: Quality Journey Reflection • Hospice COPS prior to the 2008 revision • Hospice COPS revision 2008 • NHPCO Family Evaluation Hospice Survey • Data collection and outcomes • National Quality Forum • Duke Study Outcomes • Other outcome data tools • Pain Management • Bereavement Survey • Other

  7. Quality Assurance PerformanceImprovement • Why QAPI • Increase focus on QAPI including Outcomes • Health Reform • National Quality Forum Endorsed Measures • Public Reported Measures • Pay for Performance • Institute of Medicine’s Six Aim • Increased focus related to new hospice COPs • Importance of data driven quality management • Utilizing rapid response and QAPI loop • Importance of 360-degree operational review • Health Reform

  8. Initial QAPI Challenges • New QAPI COP and other regulations • Implementation of numerous new regulations • Educating and engaging the hospice team • QAPI Indicator selection and measurement • What should be collected and why • QAPI Tools and data collection • Selection and implementation of tools and data collection • Data Overload • Collecting a large amount of data • Don’t know what to do with the data • Outcome and benchmark selection

  9. Data Resources • Who is behind that curtain? • What internal resources do you have available • Technology i.e. data and reports that can be directly extracted from EMR, financial database, etc. • Internal content experts ~ who has skill sets to evaluate data and summarize information for team/leadership • Information from non-traditional quality improvement focus i.e. Volunteers, Bereavement, Finance, Education/Training, as well as more obvious intake, Risk Management, Billing and Records • Time to ensure it happens • External resources for compiling/analyzing data • Vendors ~ there are several to consider • NHPCO ~ FEHC and QP

  10. Use of Data to Drive Change • Thought: if you are not going to use it ~ don’t collect it • 360 review allows you to identify what is working, where you excel and where you have ‘opportunities for improvement’ • Your QAPI leader and team will need to prioritize the work to be successful - sometimes easier said than done • Keep data manageable ~ Dashboards and other ways of summarizing information

  11. NHPCO Performance Measures • Evaluation of Care Tools • National Data Set (NDS) • End Result Outcome Measures • Family Evaluation of Hospice Care (FEHC) • Family Evaluation of Palliative Care (FEPC) • Family Evaluation of Bereavement Services (FEBS) • Quality Partners • Evaluation of Staff • Survey of Team Attitudes and Relationships (STARS)

  12. Bristol Hospice QAPI Journey • Commitment to the QAPI Program • Education is key for the success of • Leadership • Governing Body • Medical Director and Physicians • Hospice Staff • Hospice Volunteers • Patient/Families • Community

  13. Bristol Hospice’s Strategies for Sustainability • Company wide commitment to QAPI • QAPI Policy reflecting company’s commitment • Direct linkage between QAPI processes and company’s strategic plan and goals • Hard-wire change process ~ set the expectation • Cycle of review established within the operation • Prioritize the PI process driven by outcomes • Utilize the QAPI Feedback Loop • Celebrate the Success and Promote Innovation!

  14. Health Care Quality AtmosphereWHO? • National Quality Forum (NQF) • NQF endorsed standards will be the primary standards used to measure and report on the quality and efficiency of US healthcare • National Priorities Partnership • Institute for Healthcare Improvement (IHI) • Public Reporting • Pay for Performance • PEACE Project

  15. What?Hospice Quality Reporting Program • The Hospice Wage Index for Fiscal Year 202 finalized measures to be submitted for the FY 2012 payment determination • Hospice will report 2 measures to CMS • Structural Measure/QAPI Measure • Hospice must participate in a Quality Assessment and Performance Improvement Program that includes at least three (3) Quality Indicators related to patient care

  16. What?The Structural Measure/QAPI Measure • To Participate in a Quality Assessment and Performance Improvement (QAPI) program that incudes at least tree quality indicators related to patient care • Same as the structural measure collected during the Voluntary Reporting Period that ended 1/31/12

  17. What?The Structural Measures/QAPI Measure • Data submission site and that entry format changes • Hospices will provided details about their patient care-related QAPI indicators in use during the 4th quarter of CY2012 • Hospices are not required to submit any numeric scores for the structural measure

  18. What? To Submit • NQF 2009 / Pain Measure/Comfortable Dying Measure • # of patients who report being uncomfortable because of pain at the initial assessment (after admission to hospice services) who report pain was brought to comfortable level within 48 hours

  19. Comfortable Dying Measure Purpose • Address the needs of patients/families who are living with chronic and often escalting pain. • Measures is meant to provide hospices with information about how well they are addressing pain for newly admitted patients • Successful pain management is a hallmark of hospice quality

  20. Comfortable Dying Measure Data Collection and Reporting Path

  21. When? All data collection will take place during the 4th quarter of 2012 (October 1-December 31, 2012) Submission deadline for the NQF measure is April 1, 2013

  22. How? • Use Vendor Resources for gathering and reporting • NHPCO Quality Reporting Website • www.nhpco.org • CMS • http://www.cms.gov/Hospice-Quality-Reporting • Help.hospicequality@rti.org

  23. NHPCO Benchmarking • Include the NHPCO Benchmarks in quarterly and annual operational reports, board reports, dashboards, and scorecards • Utilize NHPCO benchmarks throughout the operation, i.e. clinical, bereavement, human resources, financial reviews • Compare benchmarking results internally and externally • Utilize the QAPI Loop and process to improve benchmarks

  24. Team-levelDomain Report

  25. Trend Results: Individual Measures Control Trend Chart 27

  26. Analysis for Utilization

  27. Aggregate / Roll-up Reports Overall Agency Division Region Single Location • Flexibility • Customizeeach report • Enhanced ability to drill-down intoyour data

  28. The QAPI Journey Stories

  29. Operationalize QAPI • Select Benchmarks to measure internally and externally • Find a process to improve • FOCUS PDSA and QAPI Loop • Organize a team to implement the process • Understand the causes of process variation/root cause analysis • Select the process improvement • Measure results through outcomes and benchmarks • Recognize the benchmarking results and successes

  30. Cultivating and Sustaining a QAPI Culture • Develop/Sustain a data driven QAPI program • Establish benchmarking to promote QAPI and improved operational performance • Utilize QAPI methodology and benchmarks in all operation processes • Strive to improve efficiencies and effectiveness • Recognize benchmark results and successes • Appreciative Inquiry • Celebrate the Success

  31. Challenges, Success and Innovations • Utilize Phased Implementation Plan • Identify QAPI data and reports to focus organizational plan • Implementation and education of the Quality Program i.e. Quality Partners Initiative • Promote Innovations • Build a sustainable QAPI program to impact the operational performance • Strive to improve operational models and performance i.e. On-Call • Celebrate success • Implement appreciative inquiry • Communicate and Display the success

  32. The QAPI Journey Stories

  33. Resources and Tools • QAPI Forms & Reports ….. • Useful web Links: • www.nhpco.org/research • http://www.healthcarecomm.org • http://www.ihi.org • http://www.nih.gov

  34. Contact Information • Christie Franklin, RN, BA, CHCE President, CEO • Jeanette Dove, RN, MA Vice President/Clinical Quality Management Bristol Hospice, LLC 206 North 2100 West, Ste. 202 Salt Lake City, UT 84116 (801) 325 0175

  35. Questions and Answers