CREATING A CULTURE OF QUALITY:
Developing the Infrastructure to Meet Quality Improvement Requirements
Identifying Facilities That Are Most At-Risk: Part I
Carolyn E. Latham, R.N., M.S.N., M.B.A., C.N.N.Corporate Vice President, Clinical Quality and UltraCare
Fresenius Medical Care North America
CCQCreating a Culture of
Quality
3/16/2011 A renal community collaboration
CCQCreating a Culture of
Quality
QAPI Impact on Facilities at Most Risk
QAPI
CMS QAPI Requirements• Program Scope• Data driven• Medical Director & IDTNetwork Relationships
Regulatory SurveysMonitoring & ReportingNetwork Relationships
QAPI: Structure, Processes & Oversight
3/16/2011 A renal community collaboration
CCQCreating a Culture of
Quality
QuestionThe most significant driver(s) of effective QAPI at
the local level?
a. Engaged Medical Directorb. Clinical Manager with skill in QAPIc. Team involvement in QId. Quality culturee. Management commitmentf. All of the aboveg. None of the above
3/16/2011 A renal community collaboration
CCQCreating a Culture of
Quality
3/16/2011 A renal community collaboration
FMCNA Facility-BasedQAPI
Quality Improvement, Certification,
& Recognition
Tools:Quality ReportsCalendarMeeting MinutesAction PlansTracking ToolsInterview GuidesAudits• Documentation• Observational
CCQCreating a Culture of
Quality
QuestionThe most common barrier(s) to effective QAPI at
the local level:
a. Insufficient knowledge & skill in QAPIb. Lack of a quality culturec. Inadequate QI tools and resourcesd. Lack of management commitmente. All of the abovef. None of the above
3/16/2011 A renal community collaboration
CCQCreating a Culture of
Quality
Identifying Facilities That Are Most At-Risk
Ongoing Measurement
Periodic Assessments
Ongoing Reporting & Tracking
3/16/2011 A renal community collaboration
CCQCreating a Culture of
Quality
Criteria Used to Identify Facilities That Are Most At-Risk
Poor clinical quality outcomes
• Low total and subtotal quality scores• Quality measures at action threshold• High standard mortality rates
Web-based results are visible to alllevels of organization
3/16/2011 A renal community collaboration
CCQCreating a Culture of
Quality
Criteria Used to Identify Facilities That Are Most At-Risk
Ineffective QAPI processes (internal)
Poor results on in-person audits,assessments, reviews (internal)
3/16/2011 A renal community collaboration
CCQCreating a Culture of
Quality
Criteria Used to Identify Facilities That Are Most At-Risk
Network reviews (external)
CMS condition-level deficiencies (external)
3/16/2011 A renal community collaboration
CCQCreating a Culture of
Quality
Criteria Used to Identify Facilities That Are Most At-Risk
Major Positions Unfilled• Governing Body• Interdisciplinary Care Team• QAI Team
Inadequate Medical Director Support
3/16/2011 A renal community collaboration
CCQCreating a Culture of
Quality
Criteria Used to Identify Facilities That Are Most At-Risk
Adverse Events• Concerns of reporting
(i.e. under or no reporting)• Unusual patterns
Serious Adverse Events
3/16/2011 A renal community collaboration
CCQCreating a Culture of
Quality
Criteria Used to Identify Facilities That Are Most At-Risk
Persistent Physical EnvironmentPlant Concerns
Biomedical Concerns
3/16/2011 A renal community collaboration
CCQCreating a Culture of
Quality
Criteria Used to Identify Facilities That Are Most At-Risk
Complaints or Grievances• Related to poor quality care, clinical performance, staffing, or physical plant issues
• Initiated by patients, patients’ significant others, staff, and/or physicians
3/16/2011 A renal community collaboration
CCQCreating a Culture of
Quality
QuestionThe most important determinant(s) of a facility
at-risk:
a. Poor clinical quality outcomesb. Higher mortality ratesc. Clinical Manager openingd. Ineffective QAPI processese. Lack of Medical Director leadershipf. All of the aboveg. None of the above
3/16/2011 A renal community collaboration