QAPI Part 2 Learning Objectives

1
QAPI- Part 2Learning Objectives

• List key hospice QAPI activities
• Describe elements of a good tracking and trending
  report
• Identify the critical components of a performance
  improvement project

2
QAPI Activities

• Quality Assessment
• Collect quality data across both clinical and
  non-clinical operational
  areas
• Use data to track quality measures over time
• Monitor of quality indicators at regular
  intervals
• Performance Improvement
• Use industry benchmarks and/or internal targets
  (and patient-identified goals at the
  patient-level) to identify opportunties to
  improve
• Take action when performance falls below target
  for two periods or more
• Implement performance improvement projects as
  needed

3
Selecting Measures

• Have a plan or framework for quality measurement
• Clinical quality
• Non-clinical operations
• Have a rationale for each measure
• Why are you tracking?
• What will you do with the information?
• Consider using industry-vetted measures

4
Hospice Data Sources for QAPI

• Patient charts
• Incident reports
• Infection reports
• Satisfaction surveys

• Billing Records
• Human resources files
• Financial Reports
• Volunteer Records

5
Important Points About Data Collection

• Incorporate data collection for QAPI into
  existing processes and procedures
• Example Patient elements incorporated into
  assessments and/or care plan
• SYSTEMATIC Collect the same way every time
• Process measures are a good way to start
• Frequency of data collection
• Approved by governing body
• Based on timeframe that indicator is expected to
  change

6
Using the Data - Actionable Reporting

• Graphs or tables
• Track and trend over time
• Relative to a benchmark or target

7
Identify Opportunities for Improvement When to
take action

• Quality assessment indicates a gap between
  actual and desired performance
• Survey deficiencies
• Management want to improve
• Staff suggestions

8
What action to take

• Individual patient
• Change interventions
• Revisit goal
• Continue to monitor
• Hospice-level
• Investigate causes
• Consider a Performance Improvement Project (PIP)
• Assure that improvement is sustained

9
PIP Overview

• Conducted by a team
• Include all relevant disciplines
• Different people for each project
• Designed to
• Investigate the reasons for the current level of
  performance
• Determine the best way to improve performance
• Measure improvements and assure they are sustained

10
Performance Improvement Projects

• Appoint a PIP team
• Investigate causes of current outcomes or
  performance
• Develop and implement plan for improvement
• Pilot testing with small of cases or limited
  time
• Document the project activities and results

11
Abbreviated PIP How they work

• Smaller team
• Review literature or best practice information
• Write a plan for improving performance
• Implement the plan
• Monitor results for one month (or two)
• Tweak the process if necessary and continue to
  monitor

12
Pt.-level example Symptom Management

• Collect symptom severity data on each assessment
• Collect patient goal
• Monitor severity over time and relative to the
  goal
• Adjust interventions to reach goal and/or assist
  patient in refining the goal

Patient Goal 3
13
Hospice-level example Aggregated clinical data
National Average 82
14
Hospice-level example Non-clinical operations