How to Direct and Produce a
“BLOCKBUSTER”
QAPI Meeting
A learning and action webinar for
the South Dakota Nursing Home
Quality Care Collaborative
October 17, 2013
Presented by:
Holly Beving, RN, hbeving@sdqio.sdps.org, 605-228-9594
Lori Hintz, RN, lhintz@sdqio.sdps.org, 605 354-3187
South Dakota Foundation for Medical Care
This material was prepared by SDFMC, the Medicare Quality Improvement Organization for South Dakota, under
contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health
and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-SD-C7-13-410
The Plot . . . “aka” the objectives
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Learn key strategies that will assist Quality Assurance
Performance Improvement (QAPI) meetings to be more
organized, more effective, and produce results.
Share meeting agenda template designed specifically for QAPI
that incorporates an action and follow-up plan for EVERY
meeting.
Learn when to form a PIP Team. Share PIP documentation tool.
Familiarize participants with the “National Nursing Home Quality
Care Collaborative CHANGE Package” and “QAPI At A Glance”
document.
Hear from three South Dakota DONs related to their QAPI best
practices.
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The Backdrop: F520 Regulation
483.75(o) Quality Assessment and
Assurance
1) A facility must maintain a quality assessment and
assurance committee consisting of: (i) the director of
nursing services; (ii) a physician designated by the facility,
and (iii) at least 3 other members of the facility’s staff.
2) . . . (i) Meets at least quarterly to identify issues with
respect to which quality assessment and assurance
activities are necessary; and (ii) develops and implements
appropriate plans of actions to correct identified quality
deficiencies.
The Long Term Care Survey Manual, AHCA, May 2013 Edition
3
F520 Regulation continued
3) A 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 requirements of this section.
Surveyors will ask for a record of dates of your QAPI meetings and list
of attendee names and titles at each meeting. . .You do not have to
give them your notes unless you choose to do so.
4) Good faith attempts by the committee to identify and
correct quality deficiencies will not be used as a basis for
sanctions.
The Long Term Care Survey Manual, AHCA, May 2013 Edition
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F520 Guidance to Surveyors
Section helpful
QA? QI? QAA? QAPI?
Technically have different meanings but are used
interchangeably. QAA is what is used in F520 now . . .
QAPI will probably be the term used in the sequel.
Root Cause Analysis mentioned frequently in the F520
Surveyor Guidance Section. Are you using this term in
your building with all staff and departments?
Action Plan and Follow Up mentioned frequently
5
Also Helpful:
The Investigative Protocol Under
Guidance to Surveyors in F520
Prior to the Survey Team visit they review:
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CASPER Quality Measure Reports
4 year history of the facilities’ deficiencies from past surveys,
revisits, and complaint surveys
Look for repeat deficiencies
Survey Team will interview QAPI Committee Leader to
determine the PROCESS:
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How committee identifies current and ongoing issues
Methods used to develop action plans
How current action plans are being implemented
Survey Team will be looking that QAPI process is
demonstrated facility wide.
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Behind the Scenes
Get your cast and crew selected
Designate a leader for the QAPI Committee
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Need to BELIEVE in quality improvement
Need to be organized
Need to be given the time, resources, and equipment to do
the “behind the scenes” work
– Education, Long Term Care Survey Manual, CASPER QM
reports, computer, email
•
•
Needs to be a good communicator with a hint of
outspokenness . . . Can he/she lead the Root Cause Analysis
(5 Why’s)?
Needs to drive accountability
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Behind the Scenes
Get your cast and crew selected
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Director of Nursing
Medical Director
Administrator
Board Member(s)
Therapy
Maintenance
Laundry
Housekeeping
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Social Services
Activities
Pharmacist
MDS Coordinator
Infection Control
Coordinator
Recommendation: Every
department is represented at
your QAPI Committee Meeting
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QAPI Committee Roles
•
•
RESPECT - Each discipline brings a UNIQUE
perspective
Each discipline is responsible for a focus area
 Review the federal and state regulations that pertain to
member’s focus area. Know what drives the data on the QM
report.
•
•
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Develops and modifies the QAPI plan
Reviews data measures
Sets benchmarks and goals
Prioritizes focus areas and PIPs
 Target high volume, high risk, problem prone areas first
 Not every focus area requires a PIP
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Meeting Ground Rules
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Meetings start and end on time (may consider having a
timekeeper)
Use a consistent agenda/format
Set a regular time and place for meeting
Recommend MONTHLY QAPI meetings
If need be, post meeting reminders/send members reminders
(email works great, create email data base so easy to send
the group notices)
Avoid distractions and maintain active engagement
Create safe environment to brainstorm and voice concerns
Expectation that everyone is prepared for meeting
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Meeting Ground Rules
continued . . . Best Practice Idea!
All members report on their focus areas in the
Agenda/Meeting Template PRIOR to QAPI meeting
 Why?
• Saves time! Increases efficiency! Promotes action!
• Meeting time is reserved for real discussion of the facts, NOT to
enter the facts.
• Meeting minutes are essentially done with exception of QAPI
leader taking notes of attendance, action plans, and follow-up.
 How?
• Put Agenda/Minutes Template on shared electronic drive – allows for easy
access for members to complete.
• QAPI Leader makes copies available for members at meeting.
11
Action Plans and Follow Up
are the star attractions
Making action
plans and following up
on those action plans at
key to producing results.
EVERY meeting is
“It is not what the latest software or technology does.
It’s what the user does.”
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The Script . . .
QAPI Agenda Meeting Template
QAPI AGENDA/MEETING TEMPLATE
QUALITY OF LIFE/QUALITY OF CARE
QAPI AGENDA/MEETING TEMPLATE
ITEM
Making a difference in the lives we touch through quality assurance and performance improvement.
MISSION STATEMENT: (Print and save on template)
DATE OF MEETING:
ATTENDING (List name and title; save on template)
MEDICAL DIRECTOR
ADMINISTRATOR
DIRECTOR OF NURSING
QAA COORDINATOR
ENVIRONMENTAL SERVICES
PHARMACY
RD/DM
SOCIAL SERVICES
ACTIVITIES
HUMAN RESOURCES
BOARD MEMBER
(INSERT ACTION PLAN TABLE FROM PREVIOUS MEETING)
YES
NO
Quality Measures:
 Quality measures >
75% and identify
trends/causes
Facility Focus:
 Antipsychotic
reduction
 Advancing
excellence
 Activities
 Call lights
 Enhancing resident
centered care
 Advanced care
planning
 Other
Infection Control:
 Resident infection
rate
 Staff infection rate
 Trends by location
and organism
Mock Survey:
 Benchmark set/met
State Survey/Nursing
Home Compare:
 Finds
 Barriers
 Survey readiness
 Benchmarks set/met
 Star rating
EMR:
 Totally rolled out?
 Accurate
 Reports being
utilized
 Case mix
Care Transitions
Rehospitalization/
Discharges:
 30 day discharge
benchmark and
results
 Follow up on
residents discharged
home
Pilot Projects:
 Interact 3
 Others
SYSTEM
CHAMPION
ALL
REPORT
ACTION
PIP
DON
SS
RD/DM
ACT
ALL
ALL
ICN
ALL
ALL
ALL
DON
SS
ALL
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The Script . . .
QAPI Agenda Meeting Template Continued
QAPI AGENDA/MEETING TEMPLATE
ITEM
Policies:
 Current ones
updated
 New ones
implemented
Secured Unit:
 New programs
 Issues that need
attention
Pharmacist Report:
 Physician response
to recommendations
 Tracking and
trending of
medication
Recruitment and
Retention:
 Turnover rate by
department
 Efforts to recruit and
retain
 Trends of exit
interviews
Staff Satisfaction:
 Progression of top
two areas identified
in staff survey
Orientation/Training:
 # of new people
starting per
department
Incident
Reports/Safety:
 Trends and tracking
 Falls
benchmark/trends
 Reportable to the
State
 Work comp trends
Resident Council:
 Recommendation
from Council
Concern Forms:
 Tracking/trending of
staff and family
issues
 24-48 hour follow-up
done?
Family/Resident
Survey:
 Progression of top
two areas identified
SYSTEM
CHAMPION
DON
REPORT
QAPI AGENDA/MEETING TEMPLATE
ACTION
PIP
ITEM
Daily Rounding:
 Items/areas
identified
Other:
SYSTEM
CHAMPION
ADM
DON
REPORT
ACTION
PIP
DON
PHARM
ACTION PLAN
GOAL
ACTION
PROCESS
CHAMPION
TARGET
DATE
COMPLETION
DATE
HR
ALL
ALL
SS
ADM
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Stunt Team aka “PIP Team”
erformance
mprovement
roject
Charter PIP teams with a specific mission to look into a
problem area.
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Select those working closest to the challenge to explore the root cause and
problem solve (i.e. direct caregivers, dietary, housekeeping, even family
and residents in some cases).
PIP team always includes one member from the QAPI Committee.
PIP teams need to be given TIME to work on the issue. Give them a
timeline and a budget.
Need a leader for the PIP team.
Need to report back to the QAPI Committee.
PIP teams must be considered VALUABLE and an important assignment.
15
Easy to Use Documentation
Tool for PIPs
PERFORMANCE IMPROVEMENT PROJECT (PIP) GUIDE
START DATE
REVIEW DATE(S)
COMPLETE DATE
9/1/13
9/15/13, 10/1/13
Projected 11/1/13
Lori Hintz, QAPI Coordinator
1. Lori, QAPI Coordinator
2. Holly, ADM
3. Sarah. DON
Absence of a written QAPI plan.
Incorporate QAPI principles with our current QI program.
4.
PROJECT LEADER:
KEY AREA FOR
IMPROVEMENT:
PIP SQUAD MEMBERS
5.
6.
7.
PIP Squad will have a draft of written QAPI plan to be presented to entire leadership team for their input and/ or
Specific
approval by 11/1/13.
Measureable
.
GOAL: Action Oriented
Realistic
Time Bound
WHAT IS THE ROOT CAUSE(S) FOR THE PROBLEM? Ask “Why is this happening?” 5 times. If you removed this root cause, would the
event have been prevented?
Don’t know where to start - Have attended several QAPI education webinars and have even downloaded CMS, “QAPI At a Glance” doc but haven’t
actually read the doc – time constraints have prevented taking action – it wasn’t a facility priority until now.
BARRIERS:
CMS final regulations for having the written QAPI plan in place not finalized. However, CMS has provided tools for QAPI education and
implementation.
BRAINSTORM POSSIBLE SOLUTIONS and START YOUR PDSA CYCLE (PLAN, DO, STUDY, ACT) – See page 2
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PIP Documentation Tool
Continued
PERFORMANCE IMPROVEMENT PROJECT (PIP) GUIDE
BRAINSTORM:
Read “QAPI At A Glance” . Solicit examples of QAPI plans from peers. Review current QI program. Know the current F520 QAA regs
in the survey manual. Educate entire leadership team and then staff utilizing problem solving models (PDSA’s and RCA’s) .
PLAN
LIST THE TASKS TO BE DONE
DO
RESPONSIBLE
MEMBER
Read QAPI At A Glance, current Lori
facility QI program and F520 reg, Holly
then discuss
Sarah
Review examples of QAPI plans Lori
(Avera Brady & Golden Living)
Holly
then discuss
Sarah
Formulate written draft to be
given to leadership team for
Lori
input / approval
STUDY AND ACT
START DATE
ACTUAL
COMPLETION
DATE
COMMENTS
(RESULTS/LESSONS
LEANRED)
9/1/13
9/15/13
Current QI doesn’t incorp.
QAPI principles; but does
adhere to F520
Adapt QAPI principles in
current QI program/policy
9/15/13
9/30/13
Decided on format and key
QAPI elements to include in
current QI Plan
Adapt
9/30/13
10/15/13
ADOPT/ADAPT/ABANDON
(CHOOSE ONE)
In leadership daily standup,
PIP team informs progress &
solicit ideas as plan written
STUDY AND ACT
BENCHMARKS/METRICS
How will we measure progress
Facility QI program will be
updated to incorporate QAPI
principles in a written format
BASELINE
DATE
Written QI
program only
9/1/13
FIRST
MEASUREMENT
DATE
SECOND
MEASUREMENT
DATE
FINAL
MEASUREMENT
DATE
COMMENTS
1st draft done
10/15/13
This material was prepared by SDFMC, the Medicare Quality Improvement Organization for South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S.
Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-SD-C7-13-405
17
National Nursing Home Quality
Care Collaborative “CHANGE
Package” and “QAPI At A Glance”
“QAPI At A Glance”
“CHANGE Package”
• It is the “nuts and bolts” of QAPI.
• Step by step guide to
implementing QAPI, including the
steps to write a written QAPI plan.
• Excellent problem solving models
outlined in this resource.
• Have copies available.
• Gives a menu of strategies, change
concepts, and actionable items that
will be helpful in finding solutions to
challenge areas.
• It is not the intent that nursing
homes try to attempt every change
concept at the same time.
• Prioritize the areas where you feel
change is needed.
• Have document available at QAPI/
PIP meetings. Refer to the
document when trying to problem
solve and/or looking for ideas.
Both the “Change Package” and
“QAPI At A Glance” can be found
on the CMS, SDFMC websites
(addresses on resource slide)
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Metric / Benchmark
Formula
Date
9/20/13
9/20/13
Chosen Measure
for Evaluation
# of Cases
Reviewed
(A)
# of Cases
w/Positive
Results (B)
(B) out of (A)
New admissions have
completed assessment
forms within 24 hours
10
7
7/10 =
Call lights received
response within 10
minutes
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(B/A)
.70 or 70%
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10/20 =
.50 or 50%
FYI: A Way to Calculate Falls
Falls will be calculated by taking the total number of falls that have occurred
for one month and dividing it by the total number of resident days for that
same month. This figure will then be multiplied by 1000 to give you the
average number of falls per 1000 resident days.
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Best Performances go to . . .
Jenkins Living Center, Watertown, SD - Shawn Gilman, DON
Forming a PIP Squad
Platte Care Center Avera, Platte, SD - Traci Harrington, DON
QAPI and Falls
Firesteel Healthcare Center, Mitchell, SD - Sarah Comp, DON
Using the Connecticut RCA Event Tool
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Credits “aka” resources
South Dakota Foundation for Medical Care:
http://www.sdfmc.org/PatientSafety/SDNursingHomeQualityCareCollaborative/SDNHQCCResources
/Index.cfm
CMS QAPI Webpage: http://go.cms.gov/Nhqapi
CMS QAPI AT A Glance document: http://cms.gov/Medicare/Provider-Enrollment-andCertification/QAPI/Downloads/QAPIAtaGlance.pdf
Advancing Excellence in America’s Nursing Homes: http://www.nhqualitycampaign.org/
Agency for Healthcare Research and Quality, STEPPS program:
http://www.ahrq/gov/professionals/education/curriculum-tools/teamstepps/ltc/index.html
Department of Veterans Affairs, Root Cause Analysis: http://www/patientsafety.gov/CogAids/RCA/
Getting Better All the Time: Working Together for Continuous Improvement:
http://www.susanwehrymd.com/files/gettingbetterall-the-time.pdf
InterAct: www.interact2.net
Oklahoma Foundation for Medical Quality: National Nursing Home Quality Care Collaborative CHANGE
Package: http://www.ofmq.com/nhtoolsandresources
Ohio KePro: Quality Improvement Workbook:
https://www.ohiokepro.com/shopping/pdfs/QualityImprovementWorkbook.pdf
The Long Term Care Survey, AHCA, May 2013 Edition
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Our Offer
Host Open Office Call
9:00 am MT/ 10:00 am CT
Thursday, January 30, 2014
* Purpose: Share how QI/QAPI meetings are going
What is working? What is not?
Contact Information:
Holly Beving: hbeving@sdqio.sdps.org 605-228-9594
Lori Hintz: lhintz@sdqio.sdps.org 605-354-3187
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