Transcript QAPI in Action

QAPI in Action
Lessons Learned, Results Achieved
A Brief History
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Before QAPI Came to Be: In 1990, the process started to
create accreditation compliance with JCAHO.
The basic principles: Measure Quality Indicators, Measure
Customer Satisfaction, Audit for Opportunities, Revise
Processes
Initial Indicators: Falls, Pressure Sores, Medication Errors,
Infections, Hospitalizations, Staff Turnover/Retention,
Resident/Family Satisfaction.
Added: Physician Performance, Polypharmacy,
Psychoactive Drugs, Food Temps/Dining Satisfaction,
Service Wait Times (call lights)
What Was Achieved?
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First organization in the nation to achieve all three (back
then) JCAHO long-term care accreditations with
commendation (skilled nursing, sub-acute, dementia).
Throughout the Years….
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Falls = 5% or less of average census in all facilities (over 300
SNF beds)
Medication Errors = less than .05% of all meds passed and
dispensed (over 200,000 administrations per month!)
Staff turnover = less than 10% (1,000 FTEs total) annually,
average length of service = 10+ years
Resident/Family Satisfaction = 98% rated the organization as 5
(excellent)
How Did this Happen?
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Less About Data, More About Analyzing the Data
Set Expectations High and Measured Progress
Audit, Improve, Re-Teach
Integrated Disciplines
Staff, Residents, Administration all Directly Tied to Quality
Outcomes
Compensation and Gain Sharing Tied to Quality
Outcomes
We Marketed Results
Business Model Driven by Quality Innovations –
Improvements Identified Equaled Business Opportunities.
Now In Kansas: A Current Example
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Fast Forward to 2011: Real Facility
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No Formal QA/QI Program
72 bed SNF Averaging 50 plus Falls per Month
Call Light Response Times – 40% longer than 7 minutes with
an average of 10% longer than 10 minutes
Psychoactive/Anti-Psychotic Meds = 50% plus
Weight Loss/Supplement Use = 50% of residents
No resident satisfaction measures
No monitoring of hospitalizations
No audits
Annual Survey 2011 – 3 Gs, 2 Fs, 2 Es, multiple Ds
Shifting the Paradigm – Putting QA/QI in
Action
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Build the Foundation – Audit the “GAP”
Set Expectations/Targets
Build the Team – all disciplines
Build the Tools and Processes
Gradually, add and monitor, Indicators
Focus on the Data – Weekly Clinical Review, Monthly
QA/QI meeting
Build core competency – staff education, training,
accountability
Audit more, identify more, re-direct processes
What Happened
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Actual Results – 2011 to 2012 – about 15 months postsurvey
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Falls – from an average of 50 or more to an average of 10 or
less
Anti-Psychotics/Psychoactive Medications – 5 residents total,
each with a history of mental illness – none used for dementia
Supplements – gone, except for one or two hospice residents.
Weight Loss – gone!
Dehydration – gone!
Total Meds – reduced by over 1/3 and falling
Survey in 2012 – deficiency free!
Today and Going Forward
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Today, they monitor falls, med errors, infections, care
transitions, drugs, weight loss/dehydration, CASPER,
skin/wound, ADL decline, call light response times,
aspiration/dysphasia risk, unusual occurrences (bruises, theft,
unusual behaviors, skin tears, etc.), resident satisfaction.
View and analyze trends, discuss monthly, target improvement,
focus on education and information.
Target audits for gaps, compliance and process improvement.
QA Committee – chaired by CEO, board participation, all
disciplines, CNA representation, senior management.
Reports to Board Quality and Compliance committee
Audits are Key
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Need to use “outside” resources – can’t audit yourself!
Six standard audits plus focused others;
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Medicare/Billing
Medicare/Clinical Documentation and Careplans
Clinical – careplans, documentation, hospitalizations, care
transitions
Pharmacy – meds, polypharmacy, black box, etc.
Mock Survey
Resident Focus Groups, Surveys, etc.
Audits Drive Improvements, Identify Weaknesses
Audits Drive Education
Where Innovation Arrived!
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QA/QI is about assuring standards of excellence first but
the key is always to drive improvement – doing things
different!
What We Learned and Now Do Different;
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Therapies in-house, not contracted – huge improvement in
falls, dysphasia management, etc.
Moving to automated dispensing – reduce wait times, errors,
staff time, patient cost
Implementing more protocols and algorithms – disease
management, standing orders, etc.
Focusing in on behavior management using non-pharm
interventions. Implemented TCI training for all staff.
Lessons Learned
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Support and Expectations Must Come from the Top!
Wide Representation of Staff Required – Include CNAs,
Activities, Social Work, Physicians, etc.
Look Beyond Healthcare and the Industry – Best
Practices can be readily gained from like circumstances!
Use Resident/Family Feedback as a Key Source for
Improvements.
Utilize outside resources to audit!
Be Critical! Don’t perceive milestones as a stopping
point for improvement.
Start Your Own Process!
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Best Place to Start – Get Audited! Complete a mock
survey, do a compliance check, conduct focus groups.
Use the above information to identify key outcome gaps
and process flaws.
Build your team! Develop your mission, vision and policy
statements.
Identify roles and responsibilities – build the
organizational components.
Educate – What are we doing? Why are we doing this?
Where are we going? How will get there?
Start slow and track and monitor outcomes - build slow.
Critical Elements: Must Have for
Success
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Support and Participation from Senior Management
Support from Governance – Ideally, Involvement as Well
Participation from all disciplines, all levels of staff
Audit partners – these must be people from the outside!
Education Components
A structure that includes a specific policy, set of tasks,
duties, responsibilities, accountability, etc.
Record keeping functions
A system for data gathering
A system for reporting
Best Practice QA/QI: My Take
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Process also reviews and approves, policies and protocols
Process incorporates education at the committee level –
sharing research, articles, conferences, etc.
All other initiatives, committees, roll-up to QA/QI –
credentialing, infection control, behavior management,
P&T, etc.
Starting point for compliance/survey and accreditation
prep and readiness.
Repository and laboratory for issues, ideas, and challenges
where discussions can occur without risk exposure.
Clearing house and library for information and reference.