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Brought to you by Progressive A webinar series that keeps you in the know

QAPI: Making it Meaningful

Regina Boore RN, BSN, MS, CASC Progressive Huddle Tuesday, March 31, 2014 1PM PT/4PM ET

Condition 416.43

•  The ASC must develop, implement and maintain an ongoing, data-driven quality assessment and performance improvement (QAPI) program.

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QAPI

•  CMS defines QAPI as “an initiative that goes beyond Quality Assessment and Assurance and aims to significantly expand the intensity and scope of activities in order not only to correct quality deficiencies (Quality Assurance) but to put practice(s) in place to monitor care and services to continuously improve performance.”

Quality Management Resources

Available on eSupport: Operations/Quality Management/Overview

What is a QAPI Activity?

•  Facility wide effort, to

•  Identify opportunity for improvement, or

•  Address process gaps or system failures

•  Develop and implement a plan for improvement

•  Continuously monitor results and efficacy

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QAPI Activity

•  High risk, high volume, and problem-prone areas

•  Affect health outcomes, patient safety and quality of care

•  Prevent recurrence of incidents (risk management)

•  Financial performance

•  Survey results/compliance issues

•  Infection control

•  Patient/physician satisfaction issues

Quality Indicators

•  Compliance •  Hand hygiene •  Universal Protocol •  P&Ps •  DFUs

•  Medication management •  Adverse medication reaction •  Medication error •  Antibiotic timing

•  Clean and safe environment

•  Surgical efficiency

•  Medical record documentation

Quality Indicators

•  OSHA compliance •  BBPE •  Employee injury

•  Fire/Disaster drill performance

•  Contracted services

•  Complications, patient transfers, falls

•  Medical staff credentialing

•  HAIs

•  “Never events”

•  Hand-off communication

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QAPI Study: Physician Credentialing

Definition: Incomplete physician credentialing files is cited as a deficiency >50% of regulatory and accreditation surveys .

We struggle to get required current documentation from our medical staff members to maintain complete and current files.

Medical Staff Credentialing Guide

Available on eSupport: Operations/Staffing/Credentialing Guide

Standard

Complete and current

medical staff credentialing files

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Data Gathering

•  A random audit of medical 15 staff files found 13 deficiencies (87%)

Problem # of Files GB documentation 5

Expired physician document 5

Missing physician document 3

Missing signature/date 1

Total 13

Action: Positive Reinforcement

•  An incentive program was designed to improve physician cooperation

•  Medical staff was informed of the incentive program by letter

•  Response to first request for documentation or response within 15 days enters name in $50 monthly drawing

•  Monthly winners enter ipad mini annual drawing

Monitoring: Restudy

•  Audit after 1 quarter implementation a random audit of 15 files found 4 deficiencies (27%)

Problem # of files GB documentation 2

Expired physician document 1

Missing physician document 1

Missing signature/date 0

Total 4

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Analysis

•  The physician incentive program was well received and resulted in improvement in capture of documentation to maintain current, complete credentialing files

•  The program saved staff hours and aggravation hounding the physicians and their offices by phone and fax to get documents

•  There is still room for more improvement

Action

•  The physician incentive program will be extended

•  The medical staff will be informed of study results and program extension via letter

•  Restudy in 6 months

Action

•  Staff would like to expand the incentive program to address other physician problem behaviors: •  Chronic late arrivals

•  Incomplete or missing H&Ps

•  Peer review participation

•  Missing health data (flu vaccine, TB)

•  Incomplete medical records

•  Baseline data will be gathered and reported at the next QAPI meeting

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QAPI Study: Hand Hygiene

Definition: A general term that applies to either hand washing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis. CDC, 2010

Hand Hygiene

•  Hand Hygiene is the single most important procedure for preventing Healthcare acquired infections. Underwood Ma. APIC Text 2005

•  Keeping hands clean is one of the best ways to prevent the spread of infection and illness. CDC Text 2010

Standard

•  100% adherence to proper hand hygiene

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Data Gathering

•  All staff members were involved in the activity

•  Glogerm was placed on each employee’s hands before they washed their hands.

•  After washing, their hands were viewed with a black light which detected “glogerms”

Glogerm

Information available on eSupport Resources/Products/Hand Hygiene Monitoring Tools

Results

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Results

•  30% of the staff cleaned their hands effectively

•  Most common places missed were the fingernails, side of hands, between the fingers

Action: Education

•  Staff in-service on hand hygiene •  CDC video

•  Proper hand washing technique demonstrations

•  Review DFUs

•  Review 5 moments of hand hygiene

•  Review criteria for hand hygiene w/soap and H2O

5 Moments of Hand Hygiene

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Action: Raise Awareness

•  Reminders were posted throughout the facility

•  Signs were placed near scrub sinks to remind OR staff to follow facility surgical hand hygiene protocol

Action: Make it Convenient

•  Locations of alcohol based hand rub was increased to include: •  By doorways in and out of the sterile area

•  Patient and family waiting areas

•  At front entrance

•  At nurse station

•  In OR’s near charting areas

•  Antiseptic foam was conveniently placed in the ORs with instructions for use (per DFU’s)

Action: Make it Convenient

•  Cubby’s were set up at each patient bay and included an alcohol based hand rub

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Monitoring: Restudy

•  The next quarter all the employees were re-tested with glogerm

•  100% of employees had effective hand hygiene

Monitoring: Ongoing Surveillance

•  Infection control compliance surveillance is conducted quarterly to assure adherence to infection control standards including proper hand hygiene

•  Conduct another hand hygiene study based on surveillance results and the 5 moments of hand hygiene in 6 months in an effort to continue to raise awareness

QAPI Study: Medication Error

Definition: Any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Institute for Safe Medication Practices

LVNs are utilized in preop/PACU and require RN oversight of medication management

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Standard

•  Our Facility will have NO medication errors.

ERROR

Data

•  Four documented medication errors over two quarters

•  Reported through incident report mechanism (Risk Management program)

Data: Types of Errors

•  Patient given Diamox with allergy to Sulfa

•  Patient not given Diamox per MD order

•  Eye dilated without physician order

•  Patient given Ancef with allergy to PCN in OR

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Analysis: Causes

•  Failure to thoroughly review physician orders

•  Failure to note patient allergies

•  Lack of knowledge/understanding of laser procedures

•  Inadequacy of established systems to prevent medication errors

Action: Increase awareness

•  Every patient will have an allergy band

•  Allergy signs will be hung on IV pole on patients bed to provide a visual que

Action: Increase awareness

•  Every patient who does not get dilated; pterygium, yag PI, Argon Laser, Glaucoma procedures, get a sign on their IV pole and an arm band.

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Action: Increase Awareness

Allergy Sticker on Pt. Chart Pre-printed Allergy Signs

Action: Increase awareness

•  Signs for patients with cipro allergy

Action: Implement scripted hand off communication

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Action: Increase awareness

•  Review and reinforce facilities policy for medication administration on a sterile field

The RN must state the patient’s allergy along with the name, concentration and exp date of the medication being handed to the surgical technician drawing up the medication and the medication label must visible to the technician.

Action: Education

•  Staff education and reading material made available regarding laser procedures. •  Engage physicians to conduct staff education

•  Make books on eye surgery available to staff

•  Use competencies or post-test to validate staff understanding

Re-Study: Success!!

•  The following quarter there were no medication errors!

•  There have been no medication errors since.

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QAPI Study: Environmental Cleaning and Disinfection Definition: Proper environmental cleaning is the second most important thing (after hand hygiene), that can be done to prevent Healthcare Acquired Infections and Surgical Site Infections. Center for Disease Control

Definition: Environmental Cleaning and Disinfection

•  In 2010 The US spent $35B on Healthcare Acquired Infections (HAIs)

•  It is estimated there are over 500,000 Surgical Site Infections (SSIs) annually

•  50% of all SSIs require hospitalization.

Standard

•  Cleaning with an approved germicidal, per manufacturer DFUs, daily, upon opening and closing, and between patients, is a facility standard to ensure disinfection, cleanliness and infection control.

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Data

•  Agar plates were brushed with 20 swabs from “high touch” locations throughout the facility and allowed to grow for 72 hours

•  50% or 10 swabs were positive for bacteria

Analysis

•  Environmental cleaning and disinfection falls short of the goal and expectation

•  Environmental cleaning and disinfection efforts must improve

•  Staff awareness must be raised regarding the importance and significance of diligent environmental cleaning and disinfection

Action: Increase Awareness

•  Create posters regarding the importance of environmental cleaning and disinfection including infection control standards, study results and facts about HAIs and SSIs

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Action: Education

•  Conduct staff education to review: •  Infection control standards

•  Environmental sanitation standards and policies

•  Approved disinfectants and DFUs

•  Individual responsibility for infection control

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Action: Implement changes

•  Trial a different germicidal wipe, (with bleach) for one quarter

•  Implement a system for wiping down frequently touched and high traffic areas as part of the daily closing routine, including anesthesia carts, soiled/clean utility counters, patient beds, patient monitors, thermometers, glucometer

•  Consider replacing housekeeping contractor

Action: Monitoring

•  Increase frequency of infection control compliance monitoring from quarterly to monthly for one quarter

•  Implement monitoring of cleaning and disinfection staff competency – assess each staff member initially and again monthly for one quarter

•  Repeat study in 6 months

Report! Report! Report!

•  Studies must be reported to: •  QAPI Committee

•  Facility staff

•  Medical Advisory Committee

•  Governing Body

•  Document reporting in appropriate meeting minutes

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Quality Management: QI Study

QI Studies available on eSupport Operations/Quality Management/Quality Improvement Study

Questions?

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Current Issues in Ambulatory Infection Surveillance

Monday May 19, 2014 1pm PT/4pm ET

Kelly Podgorny, DNP, MS, CPHQ, RN Joint Commission