QAPI Achieving a Culture of Excellence Objectives To demonstrate an understanding of how to use the elements of QAPI within the performance excellence framework. To verbalize how a SVH can mobilize an organization to create and sustain a culture of excellence. To identify at least one method to involve team members in creating a culture of learning "Change would be easy if it weren't for all of the people" Balestracci and Barlow Baldrige Quality Award All about results and improvement Using a framework A systematic approach Established by congress in 1987 Designed to improve the competitiveness of US businesses Identifies role model organization Internationally recognized and emulated. Baldrige Background Studies done related to industries in the US who were losing market share- such as steel and auto industries. Found a common set of values and process that successful organizations used These process and values are now the framework for performance excellence Why Baldrige Study by Thompson Reuters found that hospitals using the Baldrige criteria were 6X more likely to be in the top 100 hospitals and outperformed nonBaldrige hospitals in: Risk-adjusted mortality index Risk-adjusted complications index Patient safety index CMS core measures score Severity-adjusted average length of stay Adjusted operating profit margin Roadmap Leadership Triad Results Triad Baldrige categories Leadership: How do leaders create a sustainable organization? Strategic Planning: How do you develop strategy? Customer Focus: How do you listen to customers and determine solutions upon feedback from the customer? Measurement, Analysis and Knowledge Management: How do you select and use data to measure and improve performance? Baldrige categories Workforce: How do you assess capacity and capability to meet the needs of the customer and accomplish the plan? Operations: How do you manage key work processes and systems to create long term sustainable value? Results: What results are important to leadership and your customers and how do you share with those that impact performance? Approach Integrate Deploy Learn So what? 12 What’s the Goal? Improvement of some components, processes, or outcomes? OR Complete system transformation to ensure success every time? “Tension for Change” “To leave the comfort of the status quo, most individuals need to believe that change is truly imperative and there is a more attractive alternative.” Silversin, J. & Kornacki M.J, ,(2000) Leading Physicians Through Change QAPI Affordable Care Act A system to provide technical assistance to nursing homes Transformation of how we deliver quality Shift on delivering excellence proactively, not reactively Approach where problems are caught before serious QAPI “The Centers for Medicare & Medicaid Services (CMS) is leading an initiative that could transform the way nursing homes ensure quality. This initiative goes beyond the current QAA provision, and aims to significantly expand the intensity and scope of current activities in order to not only correct quality deficiencies (quality assurance), but also to put practices in place to monitor all nursing home care and services to continuously improve performance.” QAPI A framework of 5 elements: 1. Design and scope 2. Governance and leadership 3. Feedback and monitoring 4. PI projects 5. Analysis and systematic action Governance/ Leadership Feedback, Data Systems/Monitoring Performance Improvement Projects Systematic Analysis and Action Quality of Care, Quality of Life, Resident Choice Design/Scope QAPI: Design and Scope Plan should be comprehensive and include all the care and services your facility provide Balancing safety and quality of care with resident choice and autonomy Not just about nursing or the food in the kitchen— involves every aspect of the care and services provided QAPI: Governance and Leadership Expectation that the executive leadership of your facility must be actively engaged and involved in QAPI It must be real visible involvement at all levels QAPI: Feedback, Data Systems, and Monitoring This element emphasizes the establishment of systems for proactively identifying and using data to measure performance and identifying opportunities for improvement QAPI: Performance Improvement Projects Performance Improvement Projects (PIPs) to improve care Builds on the other elements to ensure that the opportunities for improvement are prioritized and incorporated into PIPs Systemic Analysis and Action Using a systematic formal process for analysis Example: root cause analysis Ensuring that actions taken address changes or improvements to the system Continual improvement and learning Design & Scope Approach Integrate Performance Improvement Projects Deploy (PIP) Systematic Analysis/ Systematic Action Feedback, Data Systems Monitoring Learn 24 “Call the Question” 1. Are you proud of “your” performance? 2. How do your clinical scores compare to your competitors? 3. What did "we" do differently? 4. Does improving quality really matter in your organization? 5. How are quality initiatives prioritized within your organization? 6. Do you “know” how you do what you do to make success repeatable? 25 Developed from AHA Get w/ the Guidelines program (Houston, 2005) QAPI Maine Veterans Homes Journey Converging on Qapi • Silver award applications • Affordable Care Act mandate: QAPI • Hardwire a culture of excellence • Strategic Plan: Direction from the board • Needed a framework Leadership and Governance • Developing the QAPI Workgroup: • Educate board • Obtain senior leadership support • Identified initial membership of the Workgroup • Board steers the QAPI workgroup MVH QAPI Workgroup Representatives from all 6 homes and central office Standardized education to introduce QAPI Charter established and approved by Board Purpose – establish a fact based, data-driven system for improving healthcare, safety, operational performance and competitiveness of Maine Veterans’ Homes Goals: Development of an annual QAPI plan Development of a results dashboard Review of outcome results and identification of opportunities for improvement Charter A Purpose of the Committee Primary Functions The primary function of the Committee is to establish a fact based, data driven system for improving health care, safety, operational performance, and competitiveness of Maine Veterans' Homes. The Committee provides a stabilizing influence so organizational concepts and directions are established and maintained with a visionary view. The Committee provides insight on long-term strategies in support of Quality Assurance and Performance Improvement (QAPI). Members of the Committee ensure the development, oversight, and publication of the annual QAPI Plan. The Committee will establish a Results Dashboard that includes measurements of outcome results in Healthcare Process, Customer Focus, Workforce Focus, Leadership & Governance, and Financial & Market. In practice these responsibilities are carried out by performing the following functions: Develop annual QAPI Plan and Results Dashboard to be formally accepted by the MVH Board Development Committee Identify all current QAPI-related initiatives throughout MVH; Review outcome results to identify opportunities for improvement and strategy sharing; Control project scope as emergent QAPI issues force changes to be considered, ensuring that scope aligns with the agreed requirements of key stakeholder groups (Veterans, Families, and Staff); Resolving project conflicts and disputes, reconciling differences of opinion and approach; Charter Role of a Committee member It is intended that the Committee leverage the experiences, expertise, and insight of key individuals at each facility committed to enhancing the QAPI process. Members will champion the development of a corporate culture of transparency, employee involvement and development, and resident directed care to improve health care, safety, operational performance, and competitiveness. Committee members may not be directly responsible for conducting QAPI efforts, but they provide support and guidance for those who do. Thus, individually, Committee members should: Understand the strategic implications and outcomes of QAPI initiatives being pursued; Appreciate the significance of QAPI for all stakeholders and represent their interests; Be genuinely interested in the initiative and be an advocate for broad support for the outcomes being pursued in the QAPI Plan and Results Dashboard; Have a broad understanding of management issues and approaches being adopted. In practice, this means Committee members: Review the status of QAPI-related efforts within MVH; Ensure the QAPI-related outputs in their respective fields meet the requirements of the Committee and stakeholders; Help balance conflicting priorities and resources; Provide guidance to the facility-level QAPI efforts; Provide feedback on facility-level QAPI efforts to the Committee; Consider ideas and issues raised; Ensure adherence of QAPI activities to standards of best practice both within MVH and in any regulatory manner; and Foster positive communication outside of the Committee regarding the Committee’s progress and outcomes; Design and Scope Reviewed organizational profiles Baldrige definition: What are your key organizational characteristics? What is your organization's strategic situation? Products, vision, mission, workforce, assets, regulatory requirements, organizational structure, customers/stakeholders, suppliers/partners Self Assessment: CMS QAPI tools: QAPI at a Glance Organizationally and at each home QAPI Plan Development: Purpose Statement Development of guiding principles Design and Scope MVH QAPI Purpose Statement The purpose of our Quality Assurance and Performance Improvement (QAPI) Program is to achieve and sustain a culture of excellence by using a fact based, data driven decision making model with a proactive approach to continually improving the way we “Care for Those Who Served”. QAPI Plan Goals QAPI Plan Goals: Utilize a dashboard to monitor key measures and improve organizational performance Establish a framework for performance improvement practices at MVH Promote a culture of safety for residents, families, and staff Enhance quality of life for our resident through culture change activities Design and Scope MVH QAPI Guiding Principles 1. In our organization, QAPI includes all employees, all departments, and all services. 2. QAPI has a prominent role in our management and board functions. 3. Our organization uses QAPI to make informed decisions and guide our day to day operations. 4. The outcome of QAPI in our organization is the quality of care and quality of life of our residents within a framework of resident directed care and recognition that “Veterans are Unique”. 5. QAPI focuses on systems and process. The emphasis is on identifying system gaps rather than blaming individuals. Design and Scope MVH QAPI Guiding Principles 6. Our organization has a culture that supports “Honesty and Integrity” by encouraging employees to identify errors and system breakdown. 7. Our decisions to improve will be guided by data, in conjunction with individual care and choice, which includes to input and experience of residents, families, caregivers, health care practitioners, and other stakeholders. 8. Our organization sets goals for performance and measures progress towards those goals with a focus on “Leading the Way” within our industry and sustaining a culture of “Excellence”. 9. Our organization supports performance improvement by encouraging our employees to “Respect” and support each other as well as be accountable for their own professional performance and practice. 10. MVH encourages “Team” collaboration, sharing of best practices, and celebrating successes across the organization. Development of Measures Measures were reviewed for alignment with: Industry goals and initiatives MVH Strategic Plan Customer Expectations Core Values Performance Excellence Framework for Improving Organizational Quality QAPI elements Tool to determine measures 1. Type of measure: 2. Level of care applied to: 3. Goal of measure, link to strategic plan: Financial Workforce Customer Focus Healthcare and Process Leadership and Governance Domiciliary, SNF, NF, other · · · · · · · Deliver highest quality of care to veterans and their families. Enhance quality of life through person directed care. Attract and retain the best employees. Develop and maintain effective information delivery systems. Expand services to meet the evolving needs for veterans care. Environmental design/ Campus plan Maintain the financial foundation to ensure MVH care to veterans into the future. 4. Objective: What are we looking at to meet our goal (reflective of the indicator). Examples decrease trash by 5% this year, decrease falls by 3% this year, reduce the number of falls. 5. Indicator: Should be a ration or % if at all possible 6. Applied to: Who or what does the indicator apply to? Example- a specific employee group, an apartment or apartment type? 7. Frequency of measurement: This may be daily, weekly, monthly, or more. May also be a one time measurement-example an annual satisfaction survey Dashboard Measures Non-clinical Measures: Workforce – Total facility turnover; Nursing turnover; Days Away Restricted Transferred Duties (DART) Operations – Days in Accounts Receivable; Occupancy Customer – Overall satisfaction; Recommends to others; Culture change Clinical Measures: Healthcare – Hospital Readmissions; Serious Reportable Events; Long-Stay, Short-Stay, & Res Care Antipsychotic Drug Use Results Dashboard Visual representation of organizational performance Displays clinical and nonclinical results called measures Displays MVH target Reflects trends in organizational performance Review of Measures Measures approved by board and senior leaders QAPI Element: Actively involved governing body Standardized training across organization Accountability Measure Freqency Person Responsible Notes Total Facility Turnover Quarterly Ken/Lori 4/20, 7/20, 10/20, 1/20 Nursing Turnover Quarterly Ken/Lori 4/20, 7/20, 10/20, 1/20 Hospital Readmissions Monthly Alain with Rhona backup Data entered by DNS by 15th 20th Culture Change Every 6 months Admistrators to Deb Data due to Deb by 12/30, 6/30 1/20, 7/20 Days in AR Monthly Jeremy with Karen backup 20th Overall Satisfaction Monthly Jeff 20th DART Quarterly Ken/Lori 4/20, 7/20, 10/20, 1/20 Recommend to Others Monthly Jeff 20th Occupancy Monthly Jeremy with Karen backup 20th Serious Reportable Events Monthly Administrators Long Stay Antipsychotics Quarterly Jim with Rob backup 4/20, 7/20, 10/20, 1/20 Short Stay Antipsychotics Quarterly Jim with Rob backup 4/20, 7/20, 10/20, 1/20 Res Care Antipsychotics Every 6 months Jim with Rob backup enter data by 15th RCD to send QIQM report to Jim Post to M-Drive by 20th 5/20, 11/20 Systematic Analysis and action: Root Cause Analysis Developed a root cause analysis tool Reviewed with VAMC liaison Educated clinical leaders Implemented Root Cause analysis Tool What happened? Why did it happen? Policy/procedures/practice Human Factors Communication Factors Equipment Factors Information Factors Environmental Factors Other Root cause analysis tool Root cause analysis tool Cause and effect diagram tool Performance Improvement projects One of our organization-wide PIPs was regarding hospital readmissions We began this PIP by looking at best practices and researching tools to assist us Reviewed data using Trend Tracker Chose to use Interact tools Interfaced with local hospitals Hospital Readmission PIP Next Steps Finalization of MVH QAPI Plan to include: Descriptions of: Scope Guidelines for Governance and Leadership Feedback, Data Systems, and Monitoring Guidelines for Performance Improvement Project Teams Systematic Analysis and Systemic Action Communications Evaluation Board review and Approval of Annual QAPI Plan Standardized training across the organization QAPI: Achieving a Culture of Excellence One Home’s Journey Maine Veterans’ Home, Scarborough The past Reviewing QIQM reports Counting beans Department Measures Each department measuring their own area Narrow focus Functional Measures Transition to functional measures Interdisciplinary Measures across departments for functional groups Engaging and Building Relationship with Stakeholders In the true sense of resident directed and person-centered approach to all that we do, we have developed and/or revised seven teams. Engaging and Building Relationship stakeholders These committees are: Communications Safety Employee Recognition Wellness Public Relations & Marketing Activities and Dining Recycling Engage Staff, residents, and family members agreed to populate them. Where we are now Prior to QAPI we were adding pieces but not building from the foundation Using the Baldrige criteria and the elements of QAPI to hardwire a culture of excellence Not only understand HOW but WHY we have quality assurance and performance improvement activities Engaging and Building Relationship with Staff: Cultivating Excellence & Improve Staff Satisfaction Not easy Persevere Engaging and Building Relationship with Staff: Cultivating Excellence & Improve Staff Satisfaction Hear the negatives Stay focused Don’t overwhelm Make it THE most important Let them do their work, if they do it wrong at least they are doing it. Engaging and Building Relationship with Staff: Cultivating Excellence & Improve Staff Satisfaction Celebrate the successes Acknowledge the failures Thomas Edison said, “I did not fail, I discovered thousands of things that did not work” Contact Information Debra Fournier, Chief Operations Officer Maine Veterans’ Homes dfournier@mainevets.org 207-671-1996 Kevin Warren, Deputy Commissioner Texas State Veterans Homes & Cemeteries Kevin.Warren@GLO.TEXAS.GOV 512-463-8764