QAPI: What Nursing
Home Medical
Directors Should Know
Susan M. Levy, MD, CMD
VPMA Levindale Hebrew Geriatric Center and Hospital
Baltimore, Maryland 21215
VAMDA
September 14, 2013
QAPI: Learning Objectives
• Understand how CMS QAPI initiative developed
• Learn the five components of QAPI
• Know the medical directors role in QAPI
• Update on the CMS Partnership to Improve
Dementia Care
Susan M. Levy, MD, CMD
Disclosure
• CMS Consultant to the Nursing home division
• Legal expert review
• MMDA advisor to the board
• AMDA committees
• Governance
• Transitions of Care
• Public Policy
QAPI and ACA
• Provisions in section 6102
• Secretary shall establish and implement a QAPI program
in facilities that includes the development of standards
related to QAPI through regulations
• The Secretary shall provide technical assistance to facilities
on the development of best practices in order to meet the
standards
QAPI and Other Health
Settings
• Hospitals
• Home Care
• Dialysis
• Ambulatory Care
and now
• Nursing Homes
QA & A F520
• A facility must maintain a quality assessment and
assurance committee consisting of:
• The director of nursing services
• A physician designated by the facility
• At least three other members of the facility’s staff
• The quality assessment and assurance (QA & A)
committee:
• Meets at least quarterly to identify issues with respect to
which QA & A activities are necessary
• Develops and implements appropriate plans of action to
correct identified quality deficiencies
6
QA & A F520, cont.
• The 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 the
requirements of this section.
• Good faith attempts by the committee to
identify and correct quality deficiencies will not
be used as a basis for sanctions .
7
Description: What is QAPI?
• Quality Assurance (QA) and Performance Improvement
(PI) are complementary approaches to quality
management. Both involve seeking and using information,
but they differ in key ways
Description: What is QAPI?
• QA is a process of meeting quality standards and assuring
that care reaches an acceptable level. Nursing homes
typically set QA thresholds to comply with regulations.
• PI is a pro-active and continuous study of processes with
the intent to prevent or decrease the likelihood of problems.
PI identifies areas of opportunity and tests new approaches
to fix underlying causes of persistent/systemic problems.
QA + PI = QAPI
• QA and PI combine to form QAPI, a data-driven, proactive
approach to improving the quality of life, care, and services
in nursing homes. The activities of QAPI involve members
at all levels of the organization to: identify opportunities for
improvement; address gaps in systems or processes; develop
and implement an improvement or corrective plan; and
continuously monitor effectiveness of interventions.
QAPI builds on QA&A
• Committee structure
• Review complaints and concerns
• Conduct audits
• QAPI will go beyond QA&A with
• Prospective approach through comprehensive plan and
leadership engagement
• Greater involvement of all staff, residents, families
• Focus on performance improvement projects (PIPs) and
Systems
Description: What is QAPI?
Quality Assurance
Performance
Improvement
Motivation
Measuring compliance
with standards
Continuously improving
processes to meet
standards
Means
Inspection, review
Prevention, planning
Attitude
Required, defensive
Chosen, proactive
Focus
Outliers, “bad apples,”
individuals
Processes, systems
Scope
Individual provider
Systems for patient care
Responsibility
Few
All
Comparison of QA and QI
Quality Assurance
(QA)
Focus: Catch “bad apples”
or detect serious
problems
Goal: Meet minimal
standards
Who’s Usually 1-2
Involved: individuals
Driven By: Regulation/accredit
13
ation
Quality Improvement
(QI)
Improve processes—
not fault finding
Ongoing process
improvement
Teams
Organizations
CMS QAPI Efforts
 Nursing home quality improvement questionnaire
 Development of QAPI tools and resources
 Development of QAPI website
 QAPI demonstration project:
• Test tools/resources
• Conduct learning collaboratives
• Online resource center for demo participants
14
QAPI FAQs
• Aren’t we already meeting the requirements?
• Formal improvement model
• Ongoing accountability
• When will the QAPI regulations be issued?
• TBA but will have one year to submit written plan
• Will surveyors have access to QAPI documentation?
• Until regulations promulgated remains unclear
AMDA Medical Director
Roles and Responsibilities
• Functions
• Tasks
• Competencies
AMDA Medical Director
Function 3 – Quality Assurance
The medical director participates in
the process to ensure the
appropriateness and quality of
medical care and medically related
care
AMDA Medical Director
Function 3 Tasks
1. The medical director participates in the monitoring
of care within the facility through a quality
assurance program that encourages self-evaluation,
anticipates and plans for change and meets
regulations
2. The medical director maintains knowledge of state
and national standards for nursing home care and
ensures that the facility meets the minimal
acceptable standards of care
AMDA Medical Director
Function 3 Tasks
3. The medical director understands basic research
methods when conducting medical care evaluations
studies, evaluates and reviews the feasibility and goals
of research projects, and fosters a facility wide attitude
that is supportive of research and open to change.
4. The medical director monitors physician
performance and involves the attending physician in
the setting of quality assurance standards.
AMDA Medical Director
Function 3 Tasks
5. The medical director ensures that the quality assurance
program addresses issues germane to the quality of
patient care.
6. The medical director utilizes the quality assurance
program to effect change in policies and procedures.
7. The medical director establishes with the administration
a means for disseminating information gained from the
quality assurance program to residents, family members,
staff members, attending physicians and other
appropriate personnel.
AMDA Medical Director
Function 3 Tasks
8. The medical director serves as chairman of the
institutional committee to review the feasibility and
goals of research projects and disseminates research
findings
9. The medical director participates in the quality
review of care within the facility n those specific
areas mandated by law (e.g. drug level monitoring,
laboratory indicator monitoring)
AMDA Medical Director
Function 3 Tasks
10. The medical director reviews periodically admission
transfers, and discharges of patients.
11. The medical director participates in time
management studies
Framework for Competencies
• Based on ACGME Outcome Project’s General
Domains
• Foundational (Ethics, Professionalism and
Communication)
• Medical Care Delivery Process
• Systems
• Nursing Home Medical Knowledge
• Personal QAPI
Competency Pyramid
AMDA Competencies
Personal QAPI
•
5.1 Develops a continuous professional development plan
focused on post-acute and long-term care medicine, utilizing
relevant opportunities from professional organizations (AMDA,
AGS, AAFP, ACP, SHM, AAHPM), licensing requirements (state,
national, province) and maintenance of certification programs
•
5.2 Utilizes data (e.g. PQRS indicators, MDS data, patient
satisfaction) to improve care of their patients/residents
•
5.3 Strives to improve personal practice and patient/resident
results by evaluating patient/resident adverse events and
outcomes (e.g., falls, medication errors, healthcare acquired
infections, dehydration, return to hospital)
AMDA Position
• HOD resolution A 06 - 2006
• White Paper C 11“Role of the
Medical Director Quality
Assurance and Process
Improvement in Long-Term Care 2011 in
Five Elements of QAPI
• Design and Scope
• Governance and Leadership
• Feedback, Data Systems, and Monitoring
• Performance Improvement Projects (PIPs)
• Systemic Analysis and Systemic Action
Role of the Medical Director
in Each Element
“Beyond the Quick Fix: The Medical Director’s Role in
QAPI” Geriatric Medicine and Medical Direction Vol.
34(4) April 2013-Jane Pederson, MD Stratis Health
Personal Comments
Element #1: Design and Scope
 A QAPI program must be:
• Ongoing and comprehensive
• Dealing with the full range of
services offered by the facility
• Including ALL departments
 It utilizes the best available
evidence to define and
measure goals.
 A written QAPI plan
29
• Address:
•
•
•
•
Clinical care
Quality of life
Resident choice
Care transitions
 Aims for safety and high quality
with all clinical interventions
 Emphasizes autonomy and
choice in daily life for
residents
Design and Scope: Role of the
Medical Director
Should be integrally involved as they can weigh the
balance between quality and safety, and resident quality
of life and individual autonomy
Vision of what is good care for all as well as each
individual
Element #2: Governance and
Leadership
The governing body
and/or administration:
 Develops and leads a
QAPI program
 Involves leadership
 Uses input from facility
staff, residents and their
families and/or
representatives
 Assures the QAPI
program is adequately
resourced
 Designates one or more
persons to be accountable
for QAPI
 Develops leadership and
facility-wide training on
QAPI
 Ensures staff time,
equipment and technical
training as needed for
QAPI
 Responsible for
establishing policies to
sustain the QAPI
program despite changes
in personnel and turnover
Element #2: Governance and
Leadership, cont.
Also responsible for:
 The governing body ensures
that while staff are held
accountable, there exists an
atmosphere in which staff
are not punished for errors
and do not fear retaliation
for reporting quality
concerns.
 Setting priorities for the QAPI
program
 Building on the principles
identified in design and scope
 Setting expectations around:
• Safety, Quality, Resident
Rights, Choice, and
Respect
• Balancing both a culture of
safety and a culture of
resident-centered rights and
choice
32
Governance and Leadership : Role
of the Medical Director
• Educate organizational leaders and
staff
• Help drive data driven decisions
• Support a culture of quality
improvement and safety in all that is
done
• Encourage team problem solving
Element #3: Feedback, Data
Systems and Monitoring
 Put systems in place to monitor care and services,
drawing data from multiple sources.
 Feedback systems actively incorporate input from staff,
residents, families and others as appropriate.
 Use performance indicators to monitor a wide range of
care processes and outcomes
 Review findings against benchmarks and/or targets the
facility has established for performance.
34
Element #3 Feedback, Data
Systems and Monitoring (cont.)
• Tracking, investigating, and monitoring ADVERSE
EVENTS that must be investigated every time they
occur and action plans implemented to prevent
recurrences.
NEVER EVENTS
RCA
Feedback, Data Systems and Monitoring:
Role of the Medical Director
• Help the facility gather data that will evaluate their
current performance
• Use their skills in data management
• Solicit feedback from the medical staff
• Develop process to obtain feedback and monitor
provider performance
Element #4: Performance
Improvement Projects (PIPs)
• Conduct PIPs to examine and improve care or
services in areas identified as needing attention.
• A PIP is:
• A concentrated effort
• On a particular problem in one area of the facility or
facility-wide
• Involves gathering information systematically to clarify
issues or problems
• Intervening for improvements
• Selected in areas important and meaningful for the specific
type and scope of services unique to each facility
37
PIPs: Role of the Medical
Director
• Participate and in some cases lead teams with
facility support
• Review and assist with developing team charters
• Be kept in the loop through updated reports at
facility meetings and/or minutes
• Be available as a consultant to other team leaders
Element #5: Systematic Analysis
and Systemic Action
•
Use a systematic approach to determine when in-depth analysis is
needed to fully understand the problem, its causes and implications
of a change (a.k.a. root cause analysis).
•
Use a thorough and highly organized/structured approach to
determine whether and how identified problems may be caused or
exacerbated by the way care and services are organized/delivered.
•
Develop policies and procedures and demonstrate proficiency in the
use of root cause analysis.
•
Systemic actions look comprehensively across all involved systems to
prevent future events and promote sustained improvement.
•
This element includes a focus on continual learning and continuous
improvement.
39
Systemic Analysis and Systemic
Action: Role of the Medical Director
• Support culture of avoiding individual
blame and focusing on system fixes
• Understand and support RCA
approach to problems that gets to the
long term fix
QAPI at Glance – Step by
Step Guide
41
Implementing QAPI: A 12
Step Program -STEP 1
• Leadership responsibility and accountability
•
•
•
•
•
•
•
•
Availability to staff
Visibility on units
Commit, follow through, lead by example
Recognize staff and give the credit
Involve staff and build leadership skills
Ensure staff have equipment to do their job
Openly admit errors-culture of transparency
Set high expectations
QAPI: STEP 2
• Develop a Deliberate Approach to
Teamwork
• Assess the effectiveness of teamwork in the
organization
• Discuss how PIP teams will work to address
QAPI goals
• Determine how direct care staff, residents, and
families can be involved in PIPs
• Identify communication structures that need to
be developed or enhanced
QAPI: STEP 3
• Take your QAPI “pulse” with a SelfAssessment
• Determine when and who will participate
in the self-assessment
• Complete the baseline self-assessment
• Determine when you will reassess
(annual)
QAPI Self Assessment
45
QAPI: STEP 4
• Identify your organizations guiding
principles
• Review, update and/or develop your
organizations mission and vision statement
• Develop a purpose statement for QAPI
• Establish guiding principles
• Define the scope of your QAPI program
• Assemble the document
Guiding Principles and Scope
47
QAPI: STEP 5
• Develop your QAPI plan
• Determine your timeline for writing the
plan
• Circulate the Guide for Developing a
QAPI plan for all involved in developing
the plan
• Once completed determine time for
review(annual)
QAPI Plan Outline
49
QAPI: STEP 6
• Conduct a QAPI Awareness Campaign
• Share mission, vision, and guiding principles with all staff
• Include the mission, vision, and guiding principles in new
orientation for staff
• Develop communication plans that use multiple
approaches to reach all staff across all shifts
• Hold meetings
• Share performance date openly and transparently with
staff, board, residents, families
• Set up scorecard for staff to monitor progress towards
important goals and post in visible areas
QAPI: STEP 7
• Develop a Strategy for Collecting &
Using QAPI Data
QAPI: STEP 8
• Identify Your Gaps and Opportunities
• Measure important indicators of care that are relevant and
meaningful to the residents you serve
• Guide and empower staff to solve problems
• Hold short stand up meetings across all shifts to identify
concerns
• Establish the nursing home as a learning organization
• Discuss processes and systems to identify areas for
improvement in all meetings
• Empower residents to get involved in identifying areas for
improvement
QAPI: STEP 9
• Prioritize Quality Opportunities and Charter
Performance Improvement Projects (PIPS)
• Get everyone involved in setting goals
• If practices are not making sense or seem
frustrating to staff, residents, and families
challenge and sort out what you have
control over and look for ways to address
improvements
QAPI: STEP 10
• Plan, Conduct, and Document PIPs
• Identify and support a change agent for each
improvement project
• Use an action plan template that defines the who and
when to establish timelines and accountability
• Seek creative ideas from multiple sources within and
outside the organization to foster innovation
• Create a safe environment to test changes
• Include all “voices” that have a stake in what is being
discussed
Goal Setting Worksheet
55
QAPI: STEP 11
• Get to the “Root” of the Problem
• Use the RCA process to look at systems
rather than individuals when something
breaks down.
QAPI: STEP 12
• Taken Systemic Action
• Before initiating a change in the
organization, meet with any staff and
residents that will be impacted by the
change in order to gain their support, buyin, and feedback.
Using QI Tools
There are many tools that can help you meet the goal
of improving your work processes and services
58
Useful QI Tools
 Process Mapping
 Check Sheets
 Pareto Charts
 Cause and Effect Diagrams
 Fishbone Diagrams
 The 5 Whys
 Run Charts
59
What is a Process Map?
A pictorial representation of
the sequence of actions that
describe a process
60
What are the Symbols Used
in Process Mapping?
 Start and End of the Process:
 A process Activity:
 A process Decision:
 A Break in the process:
61
What is the Purpose of a
Check Sheet?
 To turn observational data into numerical data
 From records
 Newly collected
 To find patterns using a systematic approach
that reduces bias
 Use check sheets when data can be observed or
collected from your records
62
Run charts
Tracking Process Performance
63
Individual Facility Quality Improvement
Data: Suburban Pavilion Nursing Home
Root Cause Analysis
• Inter-disciplinary
• Involving experts from
the frontline services
• Continually digging
deeper by asking why,
why, why at each level of
cause and effect
65
Goal of the RCA
• What happened?
• Why did it happen?
• What to do to prevent it
from happening again
66
Root Cause Analysis
• Identifies needs for systems changes
• Is a process that is as impartial as possible
• As well as a tool for
identifying prevention
strategies
• There are various tools
to use
67
Problem Solving & Root
Cause
 When confronted with a problem most people like to tackle
the obvious symptom and fix it
 This often results in more problems
 Using a systematic approach to analyze the problem and
find the root cause is more efficient and effective
 Tools can help to identify problems that aren’t apparent on
the surface (root cause)
68
What is the 5 Whys?
 A question asking method used to explore the
cause/effect relationships underlying a particular
problem
 The goal is to determine the ROOT CAUSE of a
problem
69
5 WHYs Tool
70
71
An Example of the 5 Whys
 My car will not start. (the problem)
 Why? - The battery is dead. (first why)
 Why? - The alternator is not functioning. (second why)
 Why? - The alternator belt has broken. (third why)
 Why? - The alternator belt was well beyond its useful service
life and has never been replaced. (fourth why)
 Why? - I have not been maintaining my car according to the
recommended service schedule. (fifth why, root cause)
72
What is the Purpose of
Fishbone Diagrams?
 To
identify underlying or root causes of
a problem
 To
identify a target for your
improvement that is likely to lead to
change
73
Construction of a Fishbone
Diagram
 Then for each cause identify deeper root causes
Cause 1
Cause 3
Effect/Problem
Cause 2
Cause 4
74
Tips for Using Fishbone
Diagrams
 Find the right problem or effect statement
 Find causes that make sense and that you can
impact
 Make use of your results
75
Summing Up Cause and
Effect
 Use Fishbone and 5 Whys to explore and
graphically display in increasing detail all of
the possible causes related to the problem
 Use Fishbone and 5 Whys to find dominant
causes rather than symptoms
 Use Fishbone and 5 Whys to identify the
root cause of the problem we seek to
improve
76
We Have the Root Cause
Now what?
77
Quality Improvement Models
DMAIC
FMEA
PDCA/PDSA
LEAN
FOCUS
RAPID CYCLE QUALITY
IMPROVEMENT
SIX SIGMA
SMART
JACHO 10 STEP
PDSA and Using QI Tools
 Using tools as part of the PDSA cycle
 Some tools will be useful in the planning
stage
 Others will help you to implement your QI
project
 And/or will help you study the impact of
your process change
79
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act
Plan
Study
Do
80
The PDSA Cycle for Learning and
Improvement
Act
• What changes
are to be made?
• AdApt? AdOpt?
or Abandon?
• Next cycle?
Plan
• Objective
• Questions and
predictions (why)
• Plan to carry out
the cycle (who,
what, where, when)
Study
Do
• Complete the
• Carry out the plan
analysis of the data • Document problems
• Compare data to
and unexpected
predictions
observations
• Summarize what • Begin analysis
was learned
of the data
81
Repeated Use of the Cycle
A P
Changes That
Result in
Improvement
S D
Spread
Implementation of Change
Wide-scale Tests of Change
A P
S D
Hunches
Theories
Ideas
Follow-up Tests
Very Small-scale Test
82
GOAL – Improve
Outcomes
Concept D
Concept A
Concept C
Concept B
Change concepts, theories, ideas
83
84
CMS National Partnership to
Improve Dementia Care
Launched in 2012 with one goal reduction in use of
antipsychotic medications for short and long stay
nursing home residents
Excludes Schizophrenia, Tourette’s and Huntington’s
Disease
Short Stay and Long Stay Measures
CMS Partnership Strategies
• Education and Training at all levels but Hand in
Hand for GNA/CNA level
• PIPs/QA team focus
• Review Individual Cases
• Behavioral Rounds
• Clinical Champion
• Family education
Region III-Results
STATE
%
Rank
%change
MD
17.31
8
12.5
DC
17.42
9
12.84
DE
17.99
12
15.51
WV
19.77
19
3.53
PA
20.49
28
8.14
VA
22.08
31
4.19
THE STATE OF VIRGINIA
Work with your state coalition
Reach out to your area medical directors
Reach out to area mental health providers
Work with industry
Start PIPs in your nursing homes around AP reduction
OR EXPLAIN WHY YOU ARE DIFFERENT!
Levindale and Courtland
Gardens
Q2-4 2011
Q3 2012-Q1 2013
Courtland
14.2%
11.8%(9.7)
Levindale
18.8%
8.5%(7.9)
Courtland
16.9% reduction
Levindale
54.8% reduction
LEVINDALE STRATEGIES
• Oversight team met monthly-Medical director, DON, QA
nurse, psychiatrist, unit managers, consultant pharmacist
(now quarterly)
• Monthly behavioral rounds
• Letter to families about dementia care and antipsychotics
• Consent form
• Neighborhood model/Culture change
Courtland Strategies
• Work with Psychogeriatric services
• NP and CP working on GDR collaboratively
• Track results through QA process
Levindale and Courtland
Strategy
Put your money where
your mouth is!
Post-acute quality PFP
indicator
Role of the Medical Director
 Educational resource
 Quality oversight
 Communicate with providers
 Clinical champion
THEY SHOULD NOT BE PART OF
THE PROBLEM
AMDA (4)
Don’t prescribe antipsychotic medications for
behavioral and psychological symptoms of
dementia (BPSD) individuals with dementia
without an assessment for an underlying cause
of the behavior.
CMS Efforts
• National Calls
• Regional Calls
• Individual Facility/Chain calls
CMS Lessons
• Provider buy in (primary and mental health)
• Provider availability
• Returns from “acute” psych stays
• Reluctant families- “buddy” system
• “creep” of other psychoactive medications-anecdotal
• Letters from state survey agencies to high utilizing
facilities
CMS QAPI Website
http://go.cms.gov/Nhqap
i
Dementia Care Resources
• www.amda.com
• www.nhqualitycampaign.org
• www.cms.gov
• www.pioneernetwork.net
• www.alz.org