Transcript Quality Assurance and Process Improvement

Quality Assurance and Process
Improvement
Karyn P. Leible, RN, MD, CMD
Chief Medical Officer
Jewish Senior Life of Rochester, NY
Immediate Past President, AMDA
Speaker Disclosures:
Dr. Leible has disclosed that she has no relevant financial
relationships.
Learning Objectives:
By the end of the session, participants will be able to:
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1) discuss the changes in nursing facility Quality
Assurance and Assessment (QA&A) as outlined in
health care reform legislation
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2) discuss tools and processes that are associated
with best practices for quality assurance and process
improvement
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3) discuss the role of the facility medical director in the
facility Quality Assurance Process Improvement
program
Definitions
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Quality Assessment- is an evaluation of a process
to determine if a defined standard of quality is
being achieved.
Quality Assurance- is the organizational structure,
processes, and procedures designed to ensure
that care practices are consistently applied
Quality Improvement- (Process or Performance
Improvement) is an ongoing interdisciplinary
process that is designed to improve the delivery
of services and resident outcomes.
Quality Assurance and Process
Improvement
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The Patient Protection and Affordable Care Act
(ACA)
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Signed into law March 23, 2010
Many provisions for which CMS is responsible for
implementing
Survey and Certification Group
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Section 6102
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Establishment of standards relating to quality assurance
and process improvement
Purpose of program is to strengthen current requirements
and promote accountability for resident care
and safety by nursing facilities
Nursing Home QAPI:
A Proactive Approach to Improving
Transforming
Quality
and Safety nursing
homes
through continuous
attention to
quality of care and
quality of life
Quality Assurance and Performance
Improvement (QAPI) Overview
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Expands current regulations for QAA
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Sets expectation for a sound, basic plan
for QAPI that will support the systems of
care and quality of life in every nursing
home
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A demonstration project is testing QAPI in
17 nursing homes, and preparing for
national implementation
QAPI Nursing Home Demonstration
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CMS contracted with University of Minnesota, with
Stratis Health serving as a subcontractor, to
develop the demo and early implementation
strategies
CMS will support stakeholders, providers,
consumer advocates, consumers, and surveyors
through outreach and communication
Technical Expert Panel (TEP) is reviewing QAPI
program materials
QAPI Nursing Home Demonstration
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Two year demo began September 2011
Four states
- Florida
- California
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- Massachusetts
- Minnesota
Diversity of participating nursing homes
Learning Collaborative based on IHI model
Tools and resources being developed
Extensive evaluation planned
Five Elements of QAPI
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Design & Scope
Governance & Leadership
Feedback, Data Systems and
Monitoring
Performance Improvement
Projects (PIPs)
Systematic Analysis & Systemic
Action
5 Elements of QAPI
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Design and Scope
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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
5 Elements of QAPI
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Governance and Leadership
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Boards/owners and executive leadership
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Training and organizational climate
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Buy in and support
Administration sees value
Sufficient resources
Sustainability
5 Elements of QAPI
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Feedback, Data monitoring Systems, and
Monitoring
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Multiple sources, including resident and staff
Benchmarking and targeting
Adverse events
5 Elements of QAPI
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Performance Improvement Projects
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Prioritized topics
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Number of PIPs depend on the facility program
Team Chartered
PDSA Cycle
5 Elements of QAPI
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Systematic Analysis and Systemic action
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Root cause analysis
Systems thinking
Systematic changes as needed
AMDA Position Paper
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The Role of the medical director on the QA
committee begins with an awareness of the
current program in the facility. (March 2011)
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Structure and process of the facility program
Role of the IDT participants
How issues are identified, addressed and
monitored
Case presentation
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You are the medical director/ administrator/
director of nursing of a 100 bed facility just
outside of Denver. During the facility QAA
meeting it is brought to your attention that the
facility use of antipsychotics is above the
state average based on data just released
from the CMS.
QAPI
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The facility provided data through monitoring
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Next steps will be to evaluate if a true problem
exists
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a potential problem is identified.
look at root causes, analyze and interpret data and
develop interventions.
Monitor and re-evaluate
All part of an over all program to proactively
monitor facility processes of care in order to
ensure the highest quality of care and quality of
life
QAA Tools
Proprietary programs/ Corporate programs
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Facility reports
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Pressure ulcers
Falls
Accidents
Infection Control
QI/QM data
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ABAQIS
My InnerView
MDS derived
MDS 3.0 data
MDS 3.0
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Opportunities to assess quality through the
facility own data collection opportunities with
3.0
Assessments are done for OBRA
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Day 14 then quarterly
Annual review
Discharge
Assessments are done for PPS
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Days 5, 14, 30, 60, 90
Quality Measures
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Short stay
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% of residents on a scheduled pain medication
regimen on admission who report a decrease in
pain intensity or frequency
% of residents who self report moderate to severe
pain
% of residents with pressure ulcers that are new
or worsened
Quality Measures
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Short stay
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% of residents assessed and given, appropriately,
the Seasonal Influenza vaccine
% of residents assessed and given, appropriately,
the Pneumococcal Vaccine
Long stay
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% of residents assessed and given, appropriately,
the Seasonal Influenza Vaccine
% of residents assessed and given, appropriately,
the Pneumococcal Vaccine
Quality Measures
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Long Stay
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% of residents experiencing one or more falls with
major injury
% of residents who self report moderate to severe
pain
% of high risk residents with pressure ulcers
% of long stay residents with a urinary tract
infection
% of long stay residents who lose control of
bowels and bladder
Quality Measures
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Long Stay
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Residents who have/had a catheter inserted and
left in their bladder
% of residents who were physically restrained
% of residents who needed help with physical
activities has increased
% of long stay residents who lose to much weight
% of residents who have depressive symptoms
Quality Measures- Antipsychotics
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June 2012 Public Reporting
Short Stay Measure
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Incidence of short stay residents that are given an
antipsychotic medication after admission to the
nursing home
Quality Measures- Antipsychotics
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Long Stay Measure
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Percentage of long stay residents receiving an
antipsychotic who do not have a diagnosis of
Tourette’s, Huntington's or Schizophrenia
Diagnosis of hallucinations, delusions or bipolar
are no longer excluded
Reporting currently last quarters of 2011 and
first 2 of 2012
Quality Measures-Antipsychotics
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National average 23.9% (long stay) goal for
15% reduction would bring the national
prevalence rate to 20.3%
MDS 3.0- Section N Medications
N0400. Medications Received.
Check all medications the resident received at any time
during the last 7 days or since admission/reentry if less
than 7 days.
Antipsychotic.
Antianxiety.
Antidepressant.
Hypnotic.
Anticoagulant (warfarin, heparin, or low-molecular weight
heparin).
Antibiotic.
Diuretic.
Z. None of the above were received.
MDS 3.0- Section I
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In the past 7 days: Check all that apply
Anxiety Disorder
Depression (other than bipolar)
Manic Depression (bipolar)
Psychotic Disorder (other than Schizophrenia)
Schizophrenia (schizoaffective,
schizophreniform disorders)
Post traumatic stress disorder
MDS 3.0
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Potential areas for quality monitoring
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BIMS scores
PHQ-9 scores
Pain management
Late loss ADL (toileting, eating, transfers, bed
mobility)
Urinary incontinence
Weight loss
Prognosis (less than 6 months)
Pressure ulcers
Quality Assurance and Assessment
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Facility Reports
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Pressure ulcers
Infection control
Falls
Antipsychotic use
Incidence
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Number of new whatevers
Average census x time
Average census x time = bed days of care
Assume stable census of 100 elder in month of
September then BDOC= 3000
Multiply incidence by 1000 to get # per 1000
resident days
Incidence
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In September Shady Pines had 5 facility
acquired urinary tract infections. They had a
stable census of 100 residents.
What is the incidence of facility acquired
urinary tract infections?
Incidence
5_UTI
X
3000 (BDOC)
1000 =
BDOC = 100 resident x 30 days
1.7
Prevalence
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Prevalence is defined as the total number of
cases of the disease in the population at a
given time, or total number of cases in the
population
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Number of whatevers that exist
number at risk
Prevalence
Shady Pines has 4 residents with pressure
ulcers. Non of the ulcers are new. What is
the prevalence of pressure ulcers in the
facility?
Prevalence
4 elders with pressure ulcers X 100
100 elders at risk
.04 X 100 = 4 %
Consider unit of measure
number of ulcers versus number of elders
with ulcers
Prevalence
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Sunny Acres has 100 long stay residents. 25
of those residents are receiving an
antipsychotic. 2 residents are schizophrenic
and one resident is bipolar. What is the
prevalence of antipsychotic use in the facility?
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What is the incidence?
Prevalence
23 residents are on antipsychotics without dx
100 long stay residents
.23 X 100 = 23 %
Incidence cannot be determined with the
information given.
Run Charts
Control Chart
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View a process over time
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Give a visual description of what the process
has done and is doing
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If the process is in control, (random normal
variation or random walk), you can predict
how the process will perform over time
41
Example Facility
Weight Loss > 5 lbs and Below IBW
34%
30%
26%
Mean
22%
UCL
18%
LCL
14%
42
O 6
ct
-9
6
D
ec
-9
6
Fe
b97
A
pr
-9
7
Ju
n97
A
ug
-9
O 7
ct
-9
7
D
ec
-9
7
Fe
b98
-9
A
ug
Ju
n
-9
6
10%
Control Chart
Process Improvement Projects
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Performance Improvement Project (PIP) team
to address a question
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Involve staff working closest to the residents
whenever possible
PIP team meets identifies potential root case
Develops action plan/intervention
Monitors and reports back to QAA
Root Cause: 5 Whys
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Why is the resident screaming in her room?
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Why is she trying to strike out at other residents?
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When she is in the dining room she was trying to
strike out at other residents
She is fearful that someone is trying to take her food
Why is she fearful that someone is trying to take
her food?
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The doctor cut back on her risperdone dose 2 days
ago
Root Cause: 5 Whys
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Why is cutting back on the risperdone dose
important?
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She is more alert at meals and is afraid that
someone is taking her food
Why is she afraid someone is taking her
food?
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She grew up in Germany at the end of world war
2 and Russian soldiers used to come through the
village she lived in and steal food
residents
facility
“Our patients are
different”
Multiple units all function
independently
Secured
unit for
dementia
Geriatric nurse
practitioner and
psychiatrist round
weekly
Employed
physician model
6 social
workers for
362 residents
Independent
consultant
pharmacist
Staff
No GDR
process
No monitoring
of which
residents are
on meds
Policies and procedures
Interventions
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Meet with attending physicians
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Meet with facility psychiatrist and geriatric
psych ANP
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Identify barriers to GDR
Monthly review of residents on antipsychotics and
GDR
Require nursing have MD consult request
Meet with pharmacy consultant
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Request monthly reports regarding psychoactive
medication usage
Interventions
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Meet with Director of Nursing
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Meet with facility administrator
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Identify potential barriers
Address staff education opportunities
Identify barriers
Identify potential opportunities
Review of current policies and revise as
indicated
Prevalence of Antipsychotic Use: Jan-Oct 2012
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Series 1
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Quality Improvement Process
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Three fundamental questions
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What are we trying to accomplish?
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How will we know that change is an
improvement?
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Reduce inappropriate medication use
Improve dementia care
There will be an appropriate reduction in medications
There will not be an increase in incidents
What changes can we make that will result in
improvement?
The Model for Continuous
Improvement - PDCA
Plan
START
Act
Do
Check
QAA Meetings
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Agenda
Reports prepared in advance
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Process Improvement Reports
Facility reports
Manage the time of the meeting
QAPI Resource Library & Tools
Web-based Resource Library
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Content-rich
User-friendly
Supports diversity of target audiences
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Provides
Consumers
Regulators
Easy links to tools and resources - relevant to
nursing home QAPI
National Rollout: Timeline
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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 the end of 2012 or early
2013.
QUESTIONS?