Joseph Ouslander, MD Florida Atlantic University

1. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Joseph Ouslander, MD Florida Atlantic University Gerri Lamb, PhD, RN, FAAN Arizona State University Laurie Herndon, GNPMass Senior Care Ruth Tappen, EdD, RN, FAAN Florida Atlantic University Jo Taylor, RN, MPHThe Carolinas Center for Medical Excellence

2. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Why Start with the Acute Care Transfer Log and QI Review Tool? • The Affordable Care Act contains a new federal requirement for NHs: Quality Assurance and Performance Improvement (“QAPI” programs) • Knowing your baseline, tracking outcomes, and performing root cause analysis are fundamental to improving care for your residents and instituting a QAPI program

3. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Quality Assurance and Performance Improvement “QAPI” Requirement under the ACA • The Affordable Care Act: Section 6102 (c) requires the Centers for Medicare & Medicaid Services (CMS) to establish QAPI standards and provide technical assistance to nursing homes on the development of best practices in order to meet such standards.

4. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Five Elements of QAPI Element 1:Design and Scope Element 2:Governance and Leadership Element 3:Feedback, Data Systems, and Monitoring Element 4: Performance Improvement Projects (PIPs) Element 5:Systematic Analysis and Systemic Action

5. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool QAPI Element 1: Design and Scope Quality Assurance • Reactive • Single episode • Organizational mistake • Sometimes anecdotal • Retrospective • Monitoring based on audit • Sometimes punitive Process Improvement • Proactive • Aggregate Data • Organizational process • Always measureable • Concurrent • Monitoring is continuous • Positive change

6. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool QAPI Element 3: Feedback, Data Systems, and Monitoring • Use multiple data sources • Feedback incorporates staff, families, and residents • Set care processes and outcomes • Benchmark performance with internal and external goals • Track and trend adverse events • Full investigation for each incident or event every time

7. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool • Tracking hospital transfers allows you to: • Determine your baseline, set goals for improvement, and follow your progress • Identify situations that commonly result in transfers of your residents to the hospital Why Start By Tracking Transfers?

8. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

9. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Tracking Hospital Transfers: What Do You Track?

10. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool • Many factors may be involved • Discovering situations that might have been safely treated in the facility may be uncomfortable when you start reviewing them Decisions to Transfer are Complicated

11. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool • Most incentives in the current system favor hospital transfer rather than managing acute changes in condition in the facility Incentives in the Current System of Care

12. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Why Do Unnecessary Hospital Transfers Occur? • Financial incentives in the Medicare fee-for-service program incentivize overuse of diagnostic tests and procedures that do not benefit many elderly people, and can result in morbidity and costs • By far, the most costly examples in the geriatric population are unnecessary ER visits, observation stays, hospitalizations , and readmissions

13. Hospital reimbursement NH Capabilities Physician reimbursement Qualification for skilled nursing facility stay Liability Patient and family preferences What are the Incentives to Hospitalize? Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

14. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool • Incentives are going to change over the next few years • NHs and other health care providers will have incentives to manage acute changes in condition in the facility whenever feasible • You need to be prepared! Incentives in the Current System of Care

15. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool The INTERACT Quality Improvement Tool is meant to identify opportunities to improve management of changes in condition through a root cause analysis process

16. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool QAPI Process: Address Adverse Events Through Root Cause Analysis • Utilize standardized investigation form • Interview staff involved • Interview those who may have witnessed event • Has this event ever happened before? • Investigate contributing factors • How does this event tie into the overall PI plan?

17. Root Cause Analysis (1) Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool • An analytic tool that can be used to perform a comprehensive, system-based review of critical incidents and adverse health events • Goal is to determine: • What happened? • Why did it happen? • What can be done to reduce the likelihood of recurrence?

18. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Root Cause Analysis (2) • Systematic approach to problem solving • Identify issue as a team • Repeatedly asking at least 5 “why?” questions • Don’t stop at symptoms • Get to deeper layers to find the root cause • Identify relationships between different root causes

19. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool • Designed to assist you to review situations that commonly result in transfers in your facility through systematic root cause analysis The Quality Improvement Tool

20. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool • Integrate into the facility’s regular quality and educational processes • Look for common situations that you can work on together to improve • Avoid blaming individuals The Quality Improvement Tool

21. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

22. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool • Background Information • Change in Condition • Evaluation and Management • Transfer Information • Opportunities for Improvement The QI Review Tool: 5 Sections

23. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool The Quality Improvement Review Tool Section 1: Background Info

24. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool The Quality Improvement Review Tool Section 2: Change in Condition

25. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool The Quality Improvement Review Tool Section 3: Evaluation and Management

26. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool The Quality Improvement Review Tool Section 4: Transfer Information

27. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool The Quality Improvement Review Tool Section 5: Opportunities for Improvement

28. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool • Use trends in the data to focus your improvement and educational efforts Tracking and Reviewing Hospital Transfers

29. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool The Transfer Log and QI Tool Will Help Your Facility: • Look for patterns in transfers and the clinical situations that result in them • Identify situations you believe can be managed safely and effectively without transfer • Work together to develop strategies to manage these situations • Develop education on specific topics

30. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool • Each of the INTERACT II tools you will learn about in upcoming sessions is designed to help identify and manage situations that commonly lead to hospital transfers

31. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool What is Your Experience? • What are the most important incentives related to hospital transfer at your facility? • Can you identify the types of change in condition that can be managed safely and effectively without transfer at your facility?

32. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Common Reasons for Transfers Identified in QI Tools • Acute change in condition with unstable vital signs • Family expectations • Lack of availability or communication problems with primary care physicians • Services required are unavailable in the facility • Lack of advance care planning and advance directives

33. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Ratings of Avoidability in QI Tools Lamb, G, Tappen, R, Diaz, S, et al: .J Am Geriatr Soc 59:1665–1672, 2011

34. Changing Perceptions of Avoidability Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool “ There’s been a culture change here. We started out thinking if they’re sent to the hospital, it’s not avoidable. Now we recognize we missed early warning signs.” An INTERACT Champion

35. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Let’s Review Some Sample QI Tools