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Choosing a Performance Improvement Project NNHQCC Learning Session #1
Webinar 2 of 4
Donna Beebe
Quality Improvement Coordinator
LSQIN
May 2015
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Objectives
• Identify how to utilize Quality Assurance Performance Improvement (QAPI) resources to assist in choosing a Performance Improvement Project (PIP)
• Describe how to use the National Nursing Home Quality Care Collaborative (NNHQCC) Change Package as a resource and foundation for quality initiatives
• Identify how to develop PIP teams with specific “charters”
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Lead with Purpose
Focus on systems for change
• Proactively look for opportunities to improve the
system
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What is a Performance Improvement Project (PIP)?
• A Performance Improvement Project (PIP) is a concentrated
effort on a particular problem in one area of the facility or
facility wide
• It involves gathering information systematically to clarify
issues or problems, and intervening for improvements
• The facility conducts PIPs to examine and improve care or
services in areas that the facility identifies as needing
attention
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Getting Started
All identified problems need attention—and usually
from more than one person, but they do not all
require PIPs
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Getting Started
Two important components of your QAPI (PIP) plan will be setting priorities and chartering PIP teams
• Everyone should have an opportunity to participate in these activities
• Support staff in being effective PIP team members. Use tools that support effective teamwork
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Getting Started
Convey the message that any and every caregiver is
expected to raise quality concerns, that it is safe to
do so, and that everyone is encouraged to think
about systems
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Additional factors to take into account
1. What existing standards or guidelines are available
to provide direction for this initiative?
2. What measures can be used to monitor progress?
3. Is the topic publicly reported on Nursing Home
Compare and/or is it a goal of the Advancing
Excellence in America’s Nursing Homes
campaign?
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Additional factors to take into account
3. Which type of changes primarily will be involved
(i.e., system changes, environmental changes,
staffing changes)?
4. Which staff will be most affected by the initiative?
What training needs will this initiative present?
5. Is there an identified champion(s) for this initiative?
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Implementing a Performance Improvement Project
• Involve the people directly working in a process in
order to improve that process
• It is crucial to focus on organization-wide inclusion,
not for the sake of inclusion, but to truly understand
what is going on in any given process
• Residents’ perspectives need to be considered in
setting QAPI priorities
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Communicate with Residents & Families
• Ask residents and family members to tell you about
their quality concerns
• Focus on topics that are meaningful and address
the needs of residents and staff
• Make sure all residents and families know that their
views are sought, valued, and considered in facility
decision-making and process improvements
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Prioritization Tool
Purpose: objectively prioritize which projects you
want to work on
Who uses it? The QAPI team
When is it used? Depends on how many projects are
ongoing and how many improvement opportunities
exist
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Prioritization Worksheet for Performance Improvement Projects
http://www.cms.gov/Medicare/
Provider-Enrollment-and-
Certification/QAPI/downloads/
PIPPriorWkshtdebedits.pdf
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Prioritization Tool – Tips
• Should be completed by a team, representing
multiple disciplines
• Don’t be overly concerned about the rating scale
• Team discussion is most important
• Be as specific as possible in how you describe PI
opportunities
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Potential Sources of Data
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Dashboard
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QAPI Relies on Teamwork: Your PIP Team
• Task-oriented teams may be specially formed to look into a particular problem and their work may be limited and focused
• PIP teams are formed for longer-term work on an issue
• PIP teams need to plan for sufficient communication—including face-to-face meetings to get to know each other and plan the work
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Why Teams?
• No one works alone in health care
• No one of us are as smart as we are when we
come together
• Each team member becomes an owner of the
change
• Everyone learns, everyone teaches
• Teamwork begins to break down walls and
barriers between departments
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Create a Performance Improvement Project Charter
http://www.cms.gov/Medicare/Provid
er-Enrollment-and-
Certification/QAPI/downloads/PIPCh
arterWkshtdebedits.pdf
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Prioritize Quality Opportunities and Charter PIPs
As you continue to implement QAPI, you and your team
will:
• Prioritize opportunities for more intensive improvement
work
• Choose problems or issues that you consider important
(consider if the issue is high risk, high frequency, and/or
problem prone)
• Consider which problems will become the focus for a
PIP
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Additional CMS QAPI Tools for
Performance Improvement
Projects
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PIP Launch Check List
http://www.cms.gov/Medicare/
Provider-Enrollment-and-
Certification/QAPI/downloads/
PIPLaunchChecklistdebedits.
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Resources
Resources to assist you in your QAPI efforts to choose a PIP:
• CMS QAPI website: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/qapitools.html
• A Process Tool Framework: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/ProcessToolFramework.pdf
• QAPI at a Glance: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/QAPIAtaGlance.pdf
• NNHQCC Change Package: http://www.qioprogram.org/resources/content/nnhqcc-nursing-home-change-package
• Guide for Developing a QAPI Plan: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/QAPIPlan.pdf
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OPEN CALL
We will have an Open Call for Q & A and assistance
after nursing homes have reviewed both Webinar 1
and 2 recorded webinars, and completed their
activities, on 05/19/15, 1-2 PM CT, 2-3 PM ET
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Contact the Lake Superior Quality Innovation Network
Michigan: MPRO
Donna Beebe
248-465-7354 dbeebe@mpro.org
Minnesota: Stratis Health
Kristi Wergin
952-583-8561 kwergin@stratishealth.org
Wisconsin: MetaStar
Liz Dominguez
608-441-8266 ldomingu@metastar.com
For information on how to join the NNHQCC go to:
https://www.lsqin.org/initiatives/nursing-home-quality/join/
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Thank you.
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