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Karyn P. Leible, RN, MD, CMD
Chief Medical Officer
Jewish Senior Life of Rochester, NY
Immediate Past President, AMDA
Quality Assurance and Process Improvement
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: 1) discuss the changes in nursing facility Quality
Assurance and Assessment (QA&A) as outlined in health care reform legislation
2) discuss tools and processes that are associated with best practices for quality assurance and process improvement
3) discuss the role of the facility medical director in the facility Quality Assurance Process Improvement program
Definitions
◦ 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
The Patient Protection and Affordable Care Act (ACA) Signed into law March 23, 2010
Many provisions for which CMS is responsible for implementing
Survey and Certification Group Section 6102
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
Quality and Safety Transforming nursing homesthrough continuous attention toquality of care and quality of life
Quality Assurance and Performance Improvement (QAPI) Overview
Expands current regulations for QAA
Sets expectation for a sound, basic plan for QAPI that will support the systems of care and quality of life in every nursing home
A demonstration project is testing QAPI in 17 nursing homes, and preparing for national implementation
QAPI Nursing Home Demonstration
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
Two year demo began September 2011 Four states
- Florida - Massachusetts
- California - Minnesota Diversity of participating nursing homes Learning Collaborative based on IHI model Tools and resources being developed Extensive evaluation planned
Five Elements of QAPI
Design & Scope Governance & Leadership Feedback, Data Systems and
Monitoring Performance Improvement Projects
(PIPs) Systematic Analysis & Systemic
Action
5 Elements of QAPI
Design and Scope 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
Governance and Leadership Boards/owners and executive leadership
Buy in and support Training and organizational climate
Administration sees value Sufficient resources Sustainability
5 Elements of QAPI
Feedback, Data monitoring Systems, and Monitoring
Multiple sources, including resident and staff Benchmarking and targeting Adverse events
5 Elements of QAPI
Performance Improvement Projects Prioritized topics
Number of PIPs depend on the facility program Team Chartered PDSA Cycle
5 Elements of QAPI
Systematic Analysis and Systemic action Root cause analysis Systems thinking Systematic changes as needed
AMDA Position Paper
The Role of the medical director on the QA committee begins with an awareness of the current program in the facility. (March 2011)
Structure and process of the facility program Role of the IDT participants How issues are identified, addressed and
monitored
Case presentation
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
The facility provided data through monitoring a potential problem is identified.
Next steps will be to evaluate if a true problem exists
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 ABAQIS My InnerView
Facility reports Pressure ulcers Falls Accidents Infection Control
QI/QM data MDS derived
MDS 3.0 data
MDS 3.0
Opportunities to assess quality through the facility own data collection opportunities with 3.0
Assessments are done for OBRA Day 14 then quarterly Annual review Discharge
Assessments are done for PPS Days 5, 14, 30, 60, 90
Quality Measures
Short stay % 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
Short stay % of residents assessed and given, appropriately,
the Seasonal Influenza vaccine % of residents assessed and given, appropriately,
the Pneumococcal Vaccine Long stay
% of residents assessed and given, appropriately, the Seasonal Influenza Vaccine
% of residents assessed and given, appropriately, the Pneumococcal Vaccine
Quality Measures
Long Stay % 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
Long Stay 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
June 2012 Public Reporting Short Stay Measure
Incidence of short stay residents that are given an antipsychotic medication after admission to the nursing home
Quality Measures- Antipsychotics
Long Stay Measure 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
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
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
Potential areas for quality monitoring 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
Facility Reports Pressure ulcers Infection control Falls Antipsychotic use
Incidence
Number of new whateversAverage 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
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 1000 = 1.7
3000 (BDOC)
BDOC = 100 resident x 30 days
Prevalence
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
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
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?
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
41
View a process over time
Give a visual description of what the process has done and is doing
If the process is in control, (random normal variation or random walk), you can predict how the process will perform over time
42
Example Facility Weight Loss > 5 lbs and Below IBW
10%
14%
18%
22%
26%
30%
34%
Mean
UCL
LCL
Control Chart
Process Improvement Projects
Performance Improvement Project (PIP) team to address a question
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
Why is the resident screaming in her room? When she is in the dining room she was trying to
strike out at other residents Why is she 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? The doctor cut back on her risperdone dose 2 days
ago
Root Cause: 5 Whys
Why is cutting back on the risperdone dose important?
She is more alert at meals and is afraid that someone is taking her food
Why is she afraid someone is taking her food?
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
facilityresidents
Policies and proceduresStaff
6 social workers for 362 residents
Independent consultant pharmacist
No monitoring of which residents are on meds
No GDR process
Multiple units all function independently
Geriatric nurse practitioner and psychiatrist round weekly
“Our patients are different”
Secured unit for dementia
Employed physician model
Interventions
Meet with attending physicians Identify barriers to GDR Monthly review of residents on antipsychotics and
GDR Meet with facility psychiatrist and geriatric
psych ANP Require nursing have MD consult request
Meet with pharmacy consultant Request monthly reports regarding psychoactive
medication usage
Interventions
Meet with Director of Nursing Identify potential barriers Address staff education opportunities
Meet with facility administrator Identify barriers Identify potential opportunities
Review of current policies and revise as indicated
Prevalence of Antipsychotic Use: Jan-Oct 2012
1 2 3 4 5 6 7 8 9 100
5
10
15
20
25
30
35
40
45
Series 1
Quality Improvement Process
Three fundamental questions What are we trying to accomplish?
Reduce inappropriate medication use Improve dementia care
How will we know that change is an improvement? 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
START
Plan
Do
Check
Act
QAA Meetings
Agenda Reports prepared in advance
Process Improvement Reports Facility reports
Manage the time of the meeting
QAPI Resource Library & Tools
Web-based Resource Library• Content-rich• User-friendly• Supports diversity of target audiences
Provides Consumers Regulators
• Easy links to tools and resources - relevant to nursing home QAPI
National Rollout: Timeline
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?