Kenneth Daily, LNHA
Elder Care Systems Group
Kenn@qissurvey.com
MyCare Ohio Implementation
• MyCare Ohio program will be delayed for one
month, with the earliest effective date for
coverage to be May 1, 2014.
• Several other changes and clarifications:
• A dual eligible beneficiary’s ability to sign up
for MyCare voluntarily and get coverage one
to three months early (depending on region) is
being eliminated.
• Coverage effective date will be July 1 for west
central Ohio
Enrollment
• Importantly, passive enrollment into MyCare
initially will be for Medicaid only. Dual eligible
beneficiaries may choose to join the program
for Medicare as well ("opt in") but will not be
passively enrolled. Previously, passive
enrollment applied to both programs from the
beginning.
• The department is not issuing new “friendly
letters,” but the 60 day enrollment letter will
be pushed back to February 28 or later,
depending on region.
Quality Pressures
Value
Culture Change
Use of
Technology
Accountability
SNFs
Aging
Population
Quality
and
Transparency
Quality Care or
Compliance?
The Five Erroneous Assumptions
Quality means goodness,
elegance
Quality is conformance to
requirements
Quality is intangible, not
measurable
Quality is measured by the
cost of nonconformance
The “economics of quality”
are prohibitive, not
relevant
It is cheaper to do things
right the first time
Quality problems originate
with the workers
Most problems start in
planning -development
Quality is the responsibility
of the quality department
Quality is shared by every
function and department
Quality Assurance
Performance Improvement
S&C Memo
13-05-NH
December 14, 2012
Comparison of QA and QI
Quality Assurance (QA)
Focus: Data of compliance
items but often not
changes
Goal: Meet minimal
standards
Who’s Usually small group of
Involved: individuals
Quality Improvement (QI)
Improve processes—not
fault finding
Ongoing process
improvement
Teams
Driven By: Regulation/accreditatio Organizations
n
Occurs: Monthly or quarterly
Continuously
QAPI as a Foundation
• For person-centered care
– Relies on the input of residents and families
– Measurement of not only process but also
outcomes
• For defining quality as ‘how work is done’
– Broad scope – entire organization (all staff and all
depts)
– Leadership expected to be a model
• For systems thinking
– Proactive analysis
– Data and measurement driven
– Supported by tools
QAPI Background
 Mandated in the Affordable Care Act, enacted March 2010
 Legislation requires the Centers for Medicare & Medicaid
Services (CMS) to establish QAPI program standards and
provide technical assistance to nursing home providers.
 CMS identified training needs for long-term care
surveyors.
 Demonstration projects are ongoing now and tools are
coming.
QAPI
• According to CMS, this initiative “significantly
expands the level and scope of required QAPI
activities to ensure that facilities continuously
identify and correct quality deficiencies as
well as sustain performance improvement”
• QA is a process of meeting quality standards
and typically set 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. Fix
underlying causes of persistent/systemic
problems.
QAPI Must…
According to CMS, this initiative “significantly expands the
level and scope of required QAPI activities to ensure that
facilities continuously identify and correct quality
deficiencies as well as sustain performance improvement”
• Involve all NH services
• Prove that “priorities”
were identified and chosen
for PI activities
• Focus on indicators
• Take actions to
demonstrate improvement
and are sustainable
• Maintain documentary
evidence of it’s operation
and be able to
demonstrate this to CMS
• Developed, implemented
and maintained
• Effective, ongoing,
nursing facility-wide –
that is both clinical and
non clinical indicators of
quality to be measured
• Data driven
5 Elements of QAPI
• Element 1 – Design and scope
• Element 2 – Governance and leadership
• Element 3 – Feedback, data systems and
monitoring
• Element 4 – Performance improvement
projects
• Element 5 – Systematic analysis and systemic
action
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
Phase 3 Roll-Out
• Provider Materials
– Process & Topic Tools
– Online Learning Sessions
– Focused Webinars
• Surveyor Training Needs:
– Understanding Systems Thinking
– Evaluating Plans of Correction
• Surveyor Worksheet
– Prompts surveyors throughout survey process
– Helps identify systems issues to be
investigated during QAPI review
• Consumer Information
Root Cause Analysis
• Finding the real cause of the problem and dealing
with it rather than simply continuing to deal with
the symptoms
• Asks why, why, why at each level
• Interdisciplinary- involves those closest to the
situation
• Identifies changes that need to be made
• Identifies risks and how they contributed
• Leads the team to potential process
improvements
• Move beyond a culture of blame
Tools for RCA
WHY Analysis
Resident fell last night
It was dark and tripped
going to bathroom
No staff member helped
Resident pushed called light
Resident always just gets up
even though not steady
Therapist told resident to be
more independent
1.
2.
3.
Dark bathroom
Staffing
Toileting
Now What???
• Have active and effective QAPI
program
• Auditing, rounding and accountability
• William Deming
– Plan, Do, Study and Act
• Planning is the identifying of hazards and risk
• Do is the implementing of interventions to
reduce risks and hazards
• Study is the monitoring of effectiveness
• Act is the effectiveness and modifying as
necessary
Y-ers
X-ers
Boomers
Matures
F Tags
Quality
Disasters
Quality Measures
K Tags
Audits
Culture Change is More Than
• Eden Alternative, Green Houses, Small Houses and
Pioneer initiatives
• Or the superficial displays of culture change:
– Having mailboxes and front doors yet no one knocks
or takes seriously the privacy it is meant to offer
– Fin, fur and feathers
– Food line buffet
– Memory boxes
– Brag board
• All these efforts are important but these do not deliver
culture change
Culture Change
Health
Promotion
Institutional
Care
Old
Practice
New
Practice
Individualized
Care
Risk
Prevention
Quality Improvement is Key
• The QIS offers each facility
with the tools and concepts
necessary to maintain and
enhance each facility
• Do the QIS
– Conduct sample interviews,
record reviews and observations
– Conduct resident, family and
staff satisfaction surveys
• Improve communications with
staff
• Recognize that the process
relies a lot on empowerment
and satisfaction
The QIS Process
• The Quality Indicator Survey process is a revised
survey process that changes how surveyors determine
a facility's compliance
– Phase I
• Collected comprehensive set of resident sampling data
consisting of standardized questionnaires, specific
observations and record reviews which is used to
determine a facilities Quality Indicators
– Phase II
– Once the quality indicators are determined surveyors
investigate items which exceed CMS thresholds
– Goes beyond previous traditional survey process by
measuring quantifying quality of life aspects of care
Citations and Survey Time
Nat’l QIS
Average Number of
Citations/ Survey
7.8
Deficiency free
6.9%
OH QIS
4.9
9.6%
“Trigger” Responses
QIS rates for:
• Resident Observation
• Resident Interview
• Family Interview
• Staff Interview
• Census Clinical Record
• Admission Clinical Record
16.6%
19.4%
19.6%
18.6%
15.2%
17.8%
Triggered Care Areas
• Frequently Triggered (> 60% of surveys)
– Accidents and Falls, Pressure Sores, Community
Discharge
• Commonly triggered (30%-59% of surveys)
– Dental status, personal property, ROM, activities,
Abuse/Abuse Prohibition, Environment, ADLs,
Death, Sufficient staffing, personal funds, choices
dignity
• Less Frequently Triggered (< 20% of surveys)
– Incontinence, participating in care planning, food
quality, pain, skin (non-pressure), privacy,
restraints, notification of change, positioning and
social services
Deficiency Rates – Mandatory Tasks
•
•
•
•
•
•
•
•
•
Unnecessary Med Use
Kitchen
Infection Control
Dining
Med Storage
Med. Admin
Liability Notices
Resident Council
QA & A
39%
36.2%
35.8%
25.5%
23.7%
14.3%
11%
7.5%
6.7%
Rates = # cited divided by # investigated (not total # of surveys)
Deficiency Rates
TRIGGERED Tasks
•
•
•
•
•
Environment
Abuse Prohibition
Adm, Transfer, Discharge
Personal Funds
Sufficient Nursing Staff
69%
23.9%
22.4%
24.6%
9.4%
Rates = # cited divided by # investigated
(not total # of surveys)
Frequency of Citations
• High frequency when
investigated in stage
II (>50%)
– Positioning (F309)
– Environmental
conditions (F253)
– Physical restraints
(F221)
Frequency of Citations
• Commonly cited (25%-49%)
– ADLs (F312-13)
– Pain (F309)
– Catheter (F315)
– Accidents and falls (F323)
– Social services (F250)
– Pressure sores (F314)
– ROM (F312-13)
– Dental (F411-12)
– Food Quality (F365)
– Nutrition (F325)
Leading Deficiencies
• Assessment F272
• Care Planning F279
• Professional Standards of
Care F281
• Accident/ Hazards F323
• Quality of Care F309
• Unnecessary Medications
F329
• Infection Control F441
• Bowel/Bladder function
F315
• Dignity F241
• Food Handling F371
• Pressure Sores F314
• Environment F253
• Notify of change F157
• Resident Abuse F223-26
• Staffing F353
Disasters
CMS Actions
• On December 31st CMS released draft rules
related to CMS covered facilities to develop
comprehensive disaster management
program.
• Mitigation, Preparedness, Response and
Recovery
• Policies, Hazard Vulnerability, Incident
Command, Training, table top exercise
Disaster Cycle
Mitigation - Minimizing the effects
of disaster. Examples:
building/LSC: risk/vulnerability
analyses
Preparedness - Planning how to
respond including preparedness
plans; emergency
exercises/training; warning systems
Response - Efforts to minimize the
hazards; Examples: search and
rescue; emergency relief
Recovery - Returning the
community to normal; providing
care, rebuilding, return to normal or
better
Mitigation
 Create an All Hazards Plan to consider various hazards
and disaster scenarios
 Risk/Hazards Analysis is the possibility of loss,
damage or any other undesirable event.
 Process used to identify hazards
 Which hazards get attention
 Priorities
 Resources
 Maintaining Life Safety Code requirements
 People – Assigned to the right tasks including
 Triage
 Tracking
 Transport
 Treatment
Emergency Management
Program ???
Prepare for disruption of essential
services
Heating and cooling
Medications
Shelter
Utilities
Food
Supplies
Equipment
What is an
All Hazards Approach?
• SNF’s plan addressing a wide variety of
disasters through the implementation of a
unified approach and Incident Command
• Top potential events which could activate
the Disaster Plan:
– Fire
– Utility Failure
– Severe weather
– Flood
WHY DO WE BOTHER TO
TRAIN?
• Because we are
required to!
• A plan on paper is
meaningless
• Must be useable,
realistic, applicable
• How do you know it
works?
• Because people react
the way they were
trained
• Partner with others to
obtain grants, share
costs
• Look for consultants and
training programs that
“Train the Trainer”
• Command
(management) needs to
“buy in”
• If you don’t make
improvements from
“lessons learned’’,
don’t bother
NHICS
• System for managing emergent and
non-emergent situations
• Provides SNFs with required tools to
address the event
• NHICS initiated by an
internal/external event and is
scalable and flexible
• Every disaster assumes an Incident
Commander
NH Incident Command
System
• A standardized, all-hazard
approach to incident
management; usable to manage
all types of emergencies, routine
or planned events, by establishing
a clear chain of command
• Organization
• Safety
• Achievement of objectives
• Effective use of resources
NHICS Functions
• Identified Command
structure
• Management by
objectives
– Command (Leader)
– Operations (Doers)
– Planning (Planners)
– Logistics (Getters)
– Finance/Administration
(Money)
• Common terminology
• Resource management
• Integrated
communications
Incident Command
The Quality Puzzle
• When should the pursuit for quality
begin?
• Cannot wait for the government
regulation or customer
expectations to change before
paying attention to quality
management
• We must put quality management
procedures into place to improve
quality in spite of imperfect
specification.
Start Small
What can you do by next Tuesday?
Kenneth Daily, LNHA
Elder Care Systems Group
kenn@qissurvey.com
• Consulting and education focusing on quality
improvement, survey compliance, and facility
management.
• Comprehensive Traditional and QIS technical
assistance, Mock surveys and audits
– Standard/traditional and QIS preparation
– Directed Plan of Correction development and
implementation
• Immediate Jeopardy Assistance
• Quality/Performance Improvement Program
development and implementation
• Corp Compliance Plans