The Quality Improvement Partnership

1. The Quality Improvement Partnership Name Facility Date

2. Learning Objectives • Understand the regulatory requirement of the quality assurance and performance improvement (QAPI) program • Understand the facility team role in QAPI •  Understand the resident’s and family’s role in QAPI •  Identify ways and methods for engaging in QAPI

3. Overview of Regulatory Guidance • Nursing Facility • §483.75(a) Quality Assessment and performance improvement (QAPI) program [F-865] • §483.75(c) Program feedback, data systems and monitoring[F-866] • §483.75(d) Program systematic analysis and systemic action [F-867] • §483.75(g) Quality Assessment and Assurance [F-868]

4. F-865 Each LTC facility, including a facility that is part of a multi-unit chain, must develop, implement and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life.

5. F-866 A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring.

6. F-867 The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained. The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas.

7. F-868 A facility must maintain a quality assessment and assurance committee consisting at a minimum of: • The director of nursing services; • The Medical Director or his/her designee; • At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and • The infection preventionist.

8. Maintaining Compliance • Keeping systems functioning satisfactorily and consistently, including maintaining current practice standards • Preventing deviation from care processes to the extent possible • Discerning issues and concerns with facility systems and determining if they are identified • Correcting inappropriate care processes

9. Expectations of Stakeholders Surveyors Organization / Staff Consumers

10. Surveyor Expectations • 100% compliance with certification and state licensure requirements • QA&A Committees provide points of accountability for ensuring quality of care and quality of life in nursing homes • QA&A Committees allow organizations opportunities to deal with quality deficiencies in a confidential manner

11. Organization / Staff Expectations • Reduced adverse outcomes for residents, families and staff • Good survey results/good ratings • Staff compliance • Resident/family and staff satisfaction • Financial solvency

12. Consumer Expectations • Prevention of avoidable decline or unexpected poor outcomes • Facility responsiveness • Consistency of care • Compliance with requirements • Person-centered care

13. QAPI at a Glance • Detailed guide outlining QAPI principles and how to incorporate them into systems of care • Illustrates QAPI in action • Details the five elements of QAPI • Action steps for implementing QAPI principles • Tools and resources to further develop systems

14. What is QAPI? Merges two complementary approaches to quality management: quality assurance (QA) and performance improvement (PI)

15. Definitions

16. Quality Assurance • A process of meeting quarterly standards and ensuring care reaches an acceptable level. • Thresholds set to comply with regulations and/or organizational standards that go beyond the regulations. • A retrospective effort to examine why a facility did not meet certain standards.

17. Performance Improvement • A proactive and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems. • Aims to improve processes involved in healthcare delivery and resident quality of life. PI can make good quality even better.

18. QAPI as a Foundation • Person-centered care • Relies on the input of residents and families • Encourages feedback and ideas from front line staff • Measurement of not only process but also outcomes • For defining quality as “how work is done” • Broad scope – entire organization (all staff and all departments) • Leadership expected to be a model • For systems thinking • Proactive analysis • Data and measurement driven • Supported by tools

19. 5 Elements of QAPI

20. Element 1: Design and Scope • Must be ongoing and comprehensive, dealing with the full range of services offered by the facility, including the full range of departments. • Should address clinical care, non clinical issue, quality of life, resident choice, and care transitions. • Aims for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents (or residents’ agents).

21. Element 2: Governance and Leadership The governing body and/or administration of the nursing facility develops and leads a QAPI program. • Input from facility staff, residents and their families and/or representatives. • Assures the QAPI program is adequately (e.g. uninterrupted time to participate, training/education and equipment) to conduct its work. • Sets the expectation around safety, rights, and choice.

22. Element 3:Feedback, Data Systems, and Monitoring • The facility puts in place systems to monitor care and services, drawing data from multiple sources. • Feedback systems actively incorporate input from staff, residents, families, and others as appropriate.

23. Element 4: Performance Improvement Projects (PIPs) The facility conducts PIPs to examine and improve care or services in areas that are identified as needing attention. • Typically a concentrated effort on a particular problem in one area of the facility or facility wide. • Involves gathering information systematically to clarify issues or problems, and intervening for improvements.

24. Element 5: Systematic Analysis and Systemic Action • Used to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. • A thorough approach shows whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered. • Looks comprehensively across all involved systems to prevent future events and promote sustained improvement.

25. Features of QAPI • QAPI emphasizes improvement that will: • Improve quality of life, elevate care and experience of all residents • Improve the work environment for caregivers

26. Features of QAPI • Use of Data • Identifies your quality problems • Identifies opportunities for improvements • Assists in establishing priority for action

27. Features of QAPI Builds on the resident’s own goals for health, quality of life and daily activities.

28. Features of QAPI Facilitates meaningful resident and family voices into setting goals and evaluating progress.

29. Features of QAPI • Incorporates staff in a shared QAPI mission • Develops teams with specific charters, or mission

30. Features of QAPI • Performing a root cause analysis to get to the heart of the reason for the concern. • Undertaking systemic change to eliminate problems at the source.

31. Features of QAPI Developing a feedback and monitoring system to sustain continuous improvement

32. Partnership in Quality Improvement • Communication • Resident preferences, life style, likes/dislikes • Changes in resident condition • Compliments and concerns • General feedback

33. Partnership in Quality Improvement • Collaboration • New admission orientation • Care plan meetings • Resident/family council meetings • Performance improvement opportunities/projects

34. Partnership in Quality Improvement • Engagement • Special events • Customer satisfaction surveys (both internal and external) • Recognition programs • Review and discuss quality reports

35. Nourish Teamwork and Communication • Share information in a complete, consistent and timely manner. • Strong communication links people and builds relationships between staff and residents. • High-functioning teams respect one another and work interdependently toward common goals.

36. NNHQIC http://www.nhqualitycampaign.org/

37. Health Quality Innovators (HQI) www.hqi.solutions/resource-center

38. What Can You Do? • Get to know the point of contact for the QAPI program and ask how you can become involved • Educate yourself on the facility’s QAPI atmosphere by reviewing the most recent survey report, attending council meetings, participating in care plan meetings, and attending special events • Communicate regularly with the staff about any positives, as well as about any concerns • Do not be afraid to ask questions about the care, the facility, or the QAPI initiatives

39. THANK YOU Insert Facility Key Contacts For Example: - Administrator - Director of Nurses - Quality Improvement Nurse and/or Point of Contact This material was prepared by Health Quality Innovators (HQI), the Medicare Quality Innovation Network-Quality Improvement Organization for Maryland and Virginia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. HQI|11SOW|20180619-203350