QAPI: What Nursing Home Medical Directors Should Know

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QAPI What Nursing Home Medical Directors Should
Know

• Susan M. Levy, MD, CMD
• VPMA Levindale Hebrew Geriatric Center and
  Hospital
• Baltimore, Maryland 21215
• VAMDA
• September 14, 2013

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QAPI Learning Objectives

• Understand how CMS QAPI initiative developed
• Learn the five components of QAPI
• Know the medical directors role in QAPI
• Update on the CMS Partnership to Improve Dementia
  Care

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Susan M. Levy, MD, CMDDisclosure

• CMS Consultant to the Nursing home division
• Legal expert review
• MMDA advisor to the board
• AMDA committees
• Governance
• Transitions of Care
• Public Policy

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QAPI and ACA

• Provisions in section 6102
• Secretary shall establish and implement a QAPI
  program in facilities that includes the
  development of standards related to QAPI through
  regulations
• The Secretary shall provide technical assistance
  to facilities on the development of best
  practices in order to meet the standards

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QAPI and Other Health Settings

• Hospitals
• Home Care
• Dialysis
• Ambulatory Care
• and now
• Nursing Homes

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QA A F520

• A facility must maintain a quality assessment and
  assurance committee consisting of
• The director of nursing services
• A physician designated by the facility
• At least three other members of the facilitys
  staff
• The quality assessment and assurance (QA A)
  committee
• Meets at least quarterly to identify issues with
  respect to which QA A activities are necessary
• Develops and implements appropriate plans of
  action to correct identified quality deficiencies

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QA A F520, cont.

• The state or the Secretary may not require
  disclosure of the records of such committee
  except insofar as such disclosure is related to
  the compliance of such committee with the
  requirements of this section.
• Good faith attempts by the committee to identify
  and correct quality deficiencies will not be used
  as a basis for sanctions .

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Description What is QAPI?

• Quality Assurance (QA) and Performance
  Improvement (PI) are complementary approaches to
  quality management. Both involve seeking and
  using information, but they differ in key ways

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Description What is QAPI?

• QA is a process of meeting quality standards and
  assuring that care reaches an acceptable level.
  Nursing homes typically set QA thresholds to
  comply with regulations.
• PI is a pro-active and continuous study of
  processes with the intent to prevent or decrease
  the likelihood of problems. PI identifies areas
  of opportunity and tests new approaches to fix
  underlying causes of persistent/systemic
  problems.

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QA PI QAPI

• QA and PI combine to form QAPI, a data-driven,
  proactive approach to improving the quality of
  life, care, and services in nursing homes. The
  activities of QAPI involve members at all levels
  of the organization to identify opportunities
  for improvement address gaps in systems or
  processes develop and implement an improvement
  or corrective plan and continuously monitor
  effectiveness of interventions.

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QAPI builds on QAA

• Committee structure
• Review complaints and concerns
• Conduct audits
• QAPI will go beyond QAA with
• Prospective approach through comprehensive plan
  and leadership engagement
• Greater involvement of all staff, residents,
  families
• Focus on performance improvement projects (PIPs)
  and Systems

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Description What is QAPI?
Quality Assurance Performance Improvement
Motivation Measuring compliance with standards Continuously improving processes to meet standards
Means Inspection, review Prevention, planning
Attitude Required, defensive Chosen, proactive
Focus Outliers, bad apples, individuals Processes, systems
Scope Individual provider Systems for patient care
Responsibility Few All
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Comparison of QA and QI
Quality Assurance (QA) Quality Improvement (QI)
Focus Catch bad apples or detect serious problems Improve processesnot fault finding
Goal Meet minimal standards Ongoing process improvement
Whos Involved Usually 1-2 individuals Teams
Driven By Regulation/accreditation Organizations
Occurs Monthly or quarterly Continuously
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CMS QAPI Efforts

• Nursing home quality improvement questionnaire
• Development of QAPI tools and resources
• Development of QAPI website
• QAPI demonstration project
• Test tools/resources
• Conduct learning collaboratives
• Online resource center for demo participants

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QAPI FAQs

• Arent we already meeting the requirements?
• Formal improvement model
• Ongoing accountability
• When will the QAPI regulations be issued?
• TBA but will have one year to submit written plan
• Will surveyors have access to QAPI documentation?
• Until regulations promulgated remains unclear

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AMDA Medical Director Roles and Responsibilities

• Functions
• Tasks
• Competencies

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AMDA Medical Director

• Function 3 Quality Assurance
• The medical director participates in the process
  to ensure the appropriateness and quality of
  medical care and medically related care

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AMDA Medical Director Function 3 Tasks

1. The medical director participates in the
   monitoring of care within the facility through a
   quality assurance program that encourages
   self-evaluation, anticipates and plans for change
   and meets regulations
2. The medical director maintains knowledge of state
   and national standards for nursing home care and
   ensures that the facility meets the minimal
   acceptable standards of care

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AMDA Medical Director Function 3 Tasks

• 3. The medical director understands basic
  research methods when conducting medical care
  evaluations studies, evaluates and reviews the
  feasibility and goals of research projects, and
  fosters a facility wide attitude that is
  supportive of research and open to change.
• 4. The medical director monitors physician
  performance and involves the attending physician
  in the setting of quality assurance standards.

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AMDA Medical Director Function 3 Tasks

1. The medical director ensures that the quality
   assurance program addresses issues germane to the
   quality of patient care.
2. The medical director utilizes the quality
   assurance program to effect change in policies
   and procedures.
3. The medical director establishes with the
   administration a means for disseminating
   information gained from the quality assurance
   program to residents, family members, staff
   members, attending physicians and other
   appropriate personnel.

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AMDA Medical Director Function 3 Tasks

1. The medical director serves as chairman of the
   institutional committee to review the feasibility
   and goals of research projects and disseminates
   research findings
2. The medical director participates in the quality
   review of care within the facility n those
   specific areas mandated by law (e.g. drug level
   monitoring, laboratory indicator monitoring)

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AMDA Medical Director Function 3 Tasks

1. The medical director reviews periodically
   admission transfers, and discharges of patients.
2. The medical director participates in time
   management studies

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Framework for Competencies

• Based on ACGME Outcome Projects General Domains
• Foundational (Ethics, Professionalism and
  Communication)
• Medical Care Delivery Process
• Systems
• Nursing Home Medical Knowledge
• Personal QAPI

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Competency Pyramid
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AMDA Competencies Personal QAPI

• 5.1 Develops a continuous professional
  development plan focused on post-acute and
  long-term care medicine, utilizing relevant
  opportunities from professional organizations
  (AMDA, AGS, AAFP, ACP, SHM, AAHPM), licensing
  requirements (state, national, province) and
  maintenance of certification programs
• 5.2 Utilizes data (e.g. PQRS indicators, MDS
  data, patient satisfaction) to improve care of
  their patients/residents
• 5.3 Strives to improve personal practice and
  patient/resident results by evaluating
  patient/resident adverse events and outcomes
  (e.g., falls, medication errors, healthcare
  acquired infections, dehydration, return to
  hospital)  

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AMDA Position

• HOD resolution A 06 - 2006
• White Paper C 11Role of the Medical Director
  Quality Assurance and Process Improvement in
  Long-Term Care - 2011 in

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Five Elements of QAPI

• Design and Scope
• Governance and Leadership
• Feedback, Data Systems, and Monitoring
• Performance Improvement Projects (PIPs)
• Systemic Analysis and Systemic Action

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Role of the Medical Director in Each Element

• Beyond the Quick Fix The Medical Directors
  Role in QAPI Geriatric Medicine and Medical
  Direction Vol. 34(4) April 2013-Jane Pederson, MD
  Stratis Health
• Personal Comments

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Element 1 Design and Scope

• Address
• Clinical care
• Quality of life
• Resident choice
• Care transitions
• Aims for safety and high quality with all
  clinical interventions
• Emphasizes autonomy and choice in daily life for
  residents  

• A QAPI program must be
• Ongoing and comprehensive
• Dealing with the full range of services offered
  by the facility
• Including ALL departments
• It utilizes the best available evidence to define
  and measure goals.
• A written QAPI plan

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Design and Scope Role of the Medical Director

• Should be integrally involved as they can weigh
  the balance between quality and safety, and
  resident quality of life and individual autonomy
• Vision of what is good care for all as well as
  each individual

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Element 2 Governance and Leadership

• The governing body and/or administration
• Develops and leads a QAPI program
• Involves leadership
• Uses input from facility staff, residents and
  their families and/or representatives
• Assures the QAPI program is adequately resourced
• Designates one or more persons to be accountable
  for QAPI

• Develops leadership and facility-wide training on
  QAPI
• Ensures staff time, equipment and technical
  training as needed for QAPI
• Responsible for establishing policies to sustain
  the QAPI program despite changes in personnel and
  turnover

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Element 2 Governance and Leadership, cont.

• Also responsible for
• Setting priorities for the QAPI program
• Building on the principles identified in design
  and scope
• Setting expectations around
• Safety, Quality, Resident Rights, Choice, and
  Respect
• Balancing both a culture of safety and a culture
  of resident-centered rights and choice

• The governing body ensures that while staff are
  held accountable, there exists an atmosphere in
  which staff are not punished for errors and do
  not fear retaliation for reporting quality
  concerns.

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Governance and Leadership Role of the Medical
Director

• Educate organizational leaders and staff
• Help drive data driven decisions
• Support a culture of quality improvement and
  safety in all that is done
• Encourage team problem solving

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Element 3 Feedback, Data Systems and Monitoring

• Put systems in place to monitor care and
  services, drawing data from multiple sources.
• Feedback systems actively incorporate input from
  staff, residents, families and others as
  appropriate.
• Use performance indicators to monitor a wide
  range of care processes and outcomes
• Review findings against benchmarks and/or targets
  the facility has established for performance.

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Element 3 Feedback, Data Systems and Monitoring
(cont.)

• Tracking, investigating, and monitoring ADVERSE
  EVENTS that must be investigated every time they
  occur and action plans implemented to prevent
  recurrences.
• NEVER EVENTS
• RCA

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Feedback, Data Systems and Monitoring Role of
the Medical Director

• Help the facility gather data that will evaluate
  their current performance
• Use their skills in data management
• Solicit feedback from the medical staff
• Develop process to obtain feedback and monitor
  provider performance

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Element 4 Performance Improvement Projects
(PIPs)

• Conduct PIPs to examine and improve care or
  services in areas identified as needing
  attention. 
• A PIP is
• 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
• Intervening for improvements
• Selected in areas important and meaningful for
  the specific type and scope of services unique to
  each facility

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PIPs Role of the Medical Director

• Participate and in some cases lead teams with
  facility support
• Review and assist with developing team charters
• Be kept in the loop through updated reports at
  facility meetings and/or minutes
• Be available as a consultant to other team leaders

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Element 5 Systematic Analysis and Systemic
Action

• Use a systematic approach to determine when
  in-depth analysis is needed to fully understand
  the problem, its causes and implications of a
  change (a.k.a. root cause analysis).
• Use a thorough and highly organized/structured
  approach to determine whether and how identified
  problems may be caused or exacerbated by the way
  care and services are organized/delivered.
• Develop policies and procedures and demonstrate
  proficiency in the use of root cause analysis.
• Systemic actions look comprehensively across all
  involved systems to prevent future events and
  promote sustained improvement.
• This element includes a focus on continual
  learning and continuous improvement.

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Systemic Analysis and Systemic Action Role of
the Medical Director

• Support culture of avoiding individual blame and
  focusing on system fixes
• Understand and support RCA approach to problems
  that gets to the long term fix

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QAPI at Glance Step by Step Guide
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Implementing QAPI A 12 Step Program -STEP 1

• Leadership responsibility and accountability
• Availability to staff
• Visibility on units
• Commit, follow through, lead by example
• Recognize staff and give the credit
• Involve staff and build leadership skills
• Ensure staff have equipment to do their job
• Openly admit errors-culture of transparency
• Set high expectations

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QAPI STEP 2

• Develop a Deliberate Approach to Teamwork
• Assess the effectiveness of teamwork in the
  organization
• Discuss how PIP teams will work to address QAPI
  goals
• Determine how direct care staff, residents, and
  families can be involved in PIPs
• Identify communication structures that need to be
  developed or enhanced

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QAPI STEP 3

• Take your QAPI pulse with a Self-Assessment
• Determine when and who will participate in the
  self-assessment
• Complete the baseline self-assessment
• Determine when you will reassess (annual)

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QAPI Self Assessment
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QAPI STEP 4

• Identify your organizations guiding principles
• Review, update and/or develop your organizations
  mission and vision statement
• Develop a purpose statement for QAPI
• Establish guiding principles
• Define the scope of your QAPI program
• Assemble the document

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Guiding Principles and Scope
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QAPI STEP 5

• Develop your QAPI plan
• Determine your timeline for writing the plan
• Circulate the Guide for Developing a QAPI plan
  for all involved in developing the plan
• Once completed determine time for review(annual)

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QAPI Plan Outline
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QAPI STEP 6

• Conduct a QAPI Awareness Campaign
• Share mission, vision, and guiding principles
  with all staff
• Include the mission, vision, and guiding
  principles in new orientation for staff
• Develop communication plans that use multiple
  approaches to reach all staff across all shifts
• Hold meetings
• Share performance date openly and transparently
  with staff, board, residents, families
• Set up scorecard for staff to monitor progress
  towards important goals and post in visible areas

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QAPI STEP 7

• Develop a Strategy for Collecting Using QAPI
  Data

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QAPI STEP 8

• Identify Your Gaps and Opportunities
• Measure important indicators of care that are
  relevant and meaningful to the residents you
  serve
• Guide and empower staff to solve problems
• Hold short stand up meetings across all shifts to
  identify concerns
• Establish the nursing home as a learning
  organization
• Discuss processes and systems to identify areas
  for improvement in all meetings
• Empower residents to get involved in identifying
  areas for improvement

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QAPI STEP 9

• Prioritize Quality Opportunities and Charter
  Performance Improvement Projects (PIPS)
• Get everyone involved in setting goals
• If practices are not making sense or seem
  frustrating to staff, residents, and families
  challenge and sort out what you have control over
  and look for ways to address improvements

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QAPI STEP 10

• Plan, Conduct, and Document PIPs
• Identify and support a change agent for each
  improvement project
• Use an action plan template that defines the who
  and when to establish timelines and
  accountability
• Seek creative ideas from multiple sources within
  and outside the organization to foster innovation
• Create a safe environment to test changes
• Include all voices that have a stake in what is
  being discussed

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Goal Setting Worksheet
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QAPI STEP 11

• Get to the Root of the Problem
• Use the RCA process to look at systems rather
  than individuals when something breaks down.

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QAPI STEP 12

• Taken Systemic Action
• Before initiating a change in the organization,
  meet with any staff and residents that will be
  impacted by the change in order to gain their
  support, buy-in, and feedback.

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Using QI Tools

• There are many tools that can help you meet the
  goal of improving your work processes and services

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Useful QI Tools

• Process Mapping
• Check Sheets
• Pareto Charts
• Cause and Effect Diagrams
• Fishbone Diagrams
• The 5 Whys
• Run Charts

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What is a Process Map?

• A pictorial representation of the sequence of
  actions that describe a process

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What are the Symbols Used in Process Mapping?

• Start and End of the Process
• A process Activity
• A process Decision
• A Break in the process

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What is the Purpose of a Check Sheet?

• To turn observational data into numerical data
• From records
• Newly collected
• To find patterns using a systematic approach that
  reduces bias
• Use check sheets when data can be observed or
  collected from your records

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Run charts

• Tracking Process Performance

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Individual Facility Quality Improvement Data
Suburban Pavilion Nursing Home
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Root Cause Analysis

• Inter-disciplinary
• Involving experts from the frontline services
• Continually digging deeper by asking why, why,
  why at each level of cause and effect

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Goal of the RCA

• What happened?
• Why did it happen?
• What to do to prevent it from happening again

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Root Cause Analysis

• Identifies needs for systems changes
• Is a process that is as impartial as possible
• As well as a tool for identifying prevention
  strategies
• There are various tools to use

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Problem Solving Root Cause

• When confronted with a problem most people like
  to tackle the obvious symptom and fix it
• This often results in more problems
• Using a systematic approach to analyze the
  problem and find the root cause is more
  efficient and effective
• Tools can help to identify problems that arent
  apparent on the surface (root cause)

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What is the 5 Whys?

• A question asking method used to explore the
  cause/effect relationships underlying a
  particular problem
• The goal is to determine the ROOT CAUSE of a
  problem

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5 WHYs Tool
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An Example of the 5 Whys

• My car will not start. (the problem)
• Why? - The battery is dead. (first why)
• Why? - The alternator is not functioning. (second
  why)
• Why? - The alternator belt has broken. (third
  why)
• Why? - The alternator belt was well beyond its
  useful service life and has never been replaced.
  (fourth why)
• Why? - I have not been maintaining my car
  according to the recommended service schedule.
  (fifth why, root cause)

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What is the Purpose of Fishbone Diagrams?

• To identify underlying or root causes of a
  problem
• To identify a target for your improvement that is
  likely to lead to change

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Construction of a Fishbone Diagram

• Then for each cause identify deeper root causes

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Tips for Using Fishbone Diagrams

• Find the right problem or effect statement
• Find causes that make sense and that you can
  impact
• Make use of your results

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Summing Up Cause and Effect

• Use Fishbone and 5 Whys to explore and
  graphically display in increasing detail all of
  the possible causes related to the problem
• Use Fishbone and 5 Whys to find dominant causes
  rather than symptoms
• Use Fishbone and 5 Whys to identify the root
  cause of the problem we seek to improve

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We Have the Root Cause

• Now what?

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Quality Improvement Models
DMAIC FMEA PDCA/PDSA LEAN FOCUS
RAPID CYCLE QUALITY IMPROVEMENT SIX
SIGMA SMART JACHO 10 STEP
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PDSA and Using QI Tools

• Using tools as part of the PDSA cycle
• Some tools will be useful in the planning stage
• Others will help you to implement your QI project
• And/or will help you study the impact of your
  process change

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Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
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The PDSA Cycle for Learning and Improvement
Act
Plan

• Objective
• Questions and
• predictions (why)
• Plan to carry out
• the cycle (who, what, where, when)

• What changes are to be made?
• AdApt? AdOpt?
• or Abandon?
• Next cycle?

Study
Do

• Complete the
• analysis of the data
• Compare data to
• predictions
• Summarize what
• was learned

• Carry out the plan
• Document problems
• and unexpected
• observations
• Begin analysis
• of the data

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Repeated Use of the Cycle
Changes That Result in Improvement
DATA
Spread
Implementation of Change
Wide-scale Tests of Change
Hunches Theories Ideas
Follow-up Tests
Very Small-scale Test
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GOAL Improve Outcomes
Concept D
Concept C
Concept B
Concept A
Change concepts, theories, ideas
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CMS National Partnership to Improve Dementia Care

• Launched in 2012 with one goal reduction in use
  of antipsychotic medications for short and long
  stay nursing home residents
• Excludes Schizophrenia, Tourettes and
  Huntingtons Disease
• Short Stay and Long Stay Measures

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CMS Partnership Strategies

• Education and Training at all levels but Hand in
  Hand for GNA/CNA level
• PIPs/QA team focus
• Review Individual Cases
• Behavioral Rounds
• Clinical Champion
• Family education

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Region III-Results

• STATE Rank change
• MD 17.31 8 12.5
• DC 17.42 9 12.84
• DE 17.99 12 15.51
• WV 19.77 19 3.53
• PA 20.49 28 8.14
• VA 22.08 31 4.19

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THE STATE OF VIRGINIA

• Work with your state coalition
• Reach out to your area medical directors
• Reach out to area mental health providers
• Work with industry
• Start PIPs in your nursing homes around AP
  reduction
• OR EXPLAIN WHY YOU ARE DIFFERENT!

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Levindale and Courtland Gardens

• Q2-4 2011 Q3 2012-Q1 2013
• Courtland 14.2 11.8(9.7)
• Levindale 18.8 8.5(7.9)
• Courtland 16.9 reduction
• Levindale 54.8 reduction

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LEVINDALE STRATEGIES

• Oversight team met monthly-Medical director, DON,
  QA nurse, psychiatrist, unit managers, consultant
  pharmacist (now quarterly)
• Monthly behavioral rounds
• Letter to families about dementia care and
  antipsychotics
• Consent form
• Neighborhood model/Culture change

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Courtland Strategies

• Work with Psychogeriatric services
• NP and CP working on GDR collaboratively
• Track results through QA process

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Levindale and Courtland Strategy

• Put your money where your mouth is!
• Post-acute quality PFP indicator

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Role of the Medical Director

• Educational resource
• Quality oversight
• Communicate with providers
• Clinical champion
• THEY SHOULD NOT BE PART OF THE PROBLEM

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• AMDA (4)
• Dont prescribe antipsychotic medications for
  behavioral and psychological symptoms of dementia
  (BPSD) individuals with dementia without an
  assessment for an underlying cause of the
  behavior.

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CMS Efforts

• National Calls
• Regional Calls
• Individual Facility/Chain calls

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CMS Lessons

• Provider buy in (primary and mental health)
• Provider availability
• Returns from acute psych stays
• Reluctant families- buddy system
• creep of other psychoactive medications-anecdota
  l
• Letters from state survey agencies to high
  utilizing facilities

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CMS QAPI Website

• http//go.cms.gov/Nhqapi

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Dementia Care Resources

• www.amda.com
• www.nhqualitycampaign.org
• www.cms.gov
• www.pioneernetwork.net
• www.alz.org