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To increase knowledge of hospice Quality
reporting requirements
To increase knowledge of hospice Quality
Benchmarking tools
To demonstrate the ability to utilize Quality
Benchmarks to improve clinical and operational
performance
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Locations in California, Hawaii, Texas, Georgia,
and Utah
Services rural and urban areas
Free standing hospice providers which are part
of an alliance of services/corporations
Medicare and Medicaid Certified, Licensed and
or CON, as indicated
Accredited/deemed status by Community Health
Accreditation Program (CHAP)
4
Agency
Leadership
In alignment with
 NHPCO Benchmarks
 Hospice Program’s
Mission
 Strategic Plan and
Performance
Quality
Partner
Initiative
Governing
Body
Patient/Family
Satisfaction
Agency
Staff
QAPI
Committee
PDSA
How does this cycle fit
within the QAPI
framework?
◦ This process will be
effective for agency
specific metrics
◦ Rapid cycle use of this
model has proven to be
highly successful for
agencies
PLAN
DO
ACT
STUDY
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Overview: Quality Journey Reflection
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Hospice COPS prior to the 2008 revision
Hospice COPS revision 2008
NHPCO Family Evaluation Hospice Survey
Data collection and outcomes
National Quality Forum
Duke Study Outcomes
Other outcome data tools
 Pain Management
 Bereavement Survey
 Other
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Why QAPI
◦ Increase focus on QAPI including Outcomes
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Health Reform
National Quality Forum Endorsed Measures
Public Reported Measures
Pay for Performance
Institute of Medicine’s Six Aim
◦ Increased focus related to new hospice COPs
 Importance of data driven quality management
 Utilizing rapid response and QAPI loop
 Importance of 360-degree operational review
◦ Health Reform
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New QAPI COP and other regulations
◦ Implementation of numerous new regulations
◦ Educating and engaging the hospice team
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QAPI Indicator selection and measurement
◦ What should be collected and why
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QAPI Tools and data collection
◦ Selection and implementation of tools and data collection
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Data Overload
◦ Collecting a large amount of data
◦ Don’t know what to do with the data
◦ Outcome and benchmark selection
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Who is behind that curtain?
What internal resources do you have available
◦ Technology i.e. data and reports that can be directly
extracted from EMR, financial database, etc.
◦ Internal content experts ~ who has skill sets to evaluate data
and summarize information for team/leadership
◦ Information from non-traditional quality improvement focus
i.e. Volunteers, Bereavement, Finance, Education/Training,
as well as more obvious intake, Risk Management, Billing
and Records
◦ Time to ensure it happens
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External resources for compiling/analyzing data
◦ Vendors ~ there are several to consider
◦ NHPCO ~ FEHC and QP
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Thought: if you are not going to use it ~ don’t
collect it
360 review allows you to identify what is
working, where you excel and where you have
‘opportunities for improvement’
Your QAPI leader and team will need to prioritize
the work to be successful - sometimes easier
said than done
Keep data manageable ~ Dashboards and
other ways of summarizing information
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Evaluation of Care Tools
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National Data Set (NDS)
End Result Outcome Measures
Family Evaluation of Hospice Care (FEHC)
Family Evaluation of Palliative Care (FEPC)
Family Evaluation of Bereavement Services (FEBS)
Quality Partners
Evaluation of Staff
◦ Survey of Team Attitudes and Relationships (STARS)
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Commitment to the QAPI Program
◦ Education is key for the success of
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Leadership
Governing Body
Medical Director and Physicians
Hospice Staff
Hospice Volunteers
Patient/Families
Community
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Company wide commitment to QAPI
QAPI Policy reflecting company’s commitment
Direct linkage between QAPI processes and
company’s strategic plan and goals
Hard-wire change process ~ set the
expectation
Cycle of review established within the operation
◦ Prioritize the PI process driven by outcomes
◦ Utilize the QAPI Feedback Loop
Celebrate the Success and
Promote Innovation!
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National Quality Forum (NQF)
◦ NQF endorsed standards will be the primary
standards used to measure and report on the
quality and efficiency of US healthcare
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National Priorities Partnership
Institute for Healthcare Improvement (IHI)
Public Reporting
Pay for Performance
PEACE Project
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The Hospice Wage Index for Fiscal Year 202 finalized
measures to be submitted for the FY 2012 payment
determination
Hospice will report 2 measures to CMS
Structural Measure/QAPI Measure
◦ Hospice must participate in a Quality Assessment and
Performance Improvement Program that includes at least three
(3) Quality Indicators related to patient care
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To Participate in a Quality Assessment and
Performance Improvement (QAPI) program
that incudes at least tree quality indicators
related to patient care
Same as the structural measure collected
during the Voluntary Reporting Period that
ended 1/31/12
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Data submission site and that entry format
changes
Hospices will provided details about their
patient care-related QAPI indicators in use
during the 4th quarter of CY2012
Hospices are not required to submit any
numeric scores for the structural measure
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NQF 2009 / Pain Measure/Comfortable Dying
Measure
◦ # of patients who report being uncomfortable
because of pain at the initial assessment (after
admission to hospice services) who report pain was
brought to comfortable level within 48 hours
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Address the needs of patients/families who
are living with chronic and often escalting
pain.
Measures is meant to provide hospices with
information about how well they are
addressing pain for newly admitted patients
Successful pain management is a hallmark of
hospice quality
Comfortable Dying Measure
Data Collection and Reporting Path
COMFORTABLE
ON ADMISSION
COMFORT NOT
ACHIEVED
WITHIN 48
HOURS
ELIGIBLE
ALL
ADMISSIONS
COMFORT
ACHIEVED
WITHIN 48
HOURS**
NOT ELIGIBLE
UNCOMFORTABLE
ON ADMISSION*
UNABLE TO SELFREPORT AT
FOLLOW-UP*
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All data collection will take place during the
4th quarter of 2012 (October 1-December 31,
2012)
Submission deadline for the NQF measure is
April 1, 2013
FY2012 - 2013
Released: November, 2011
Structural Measure*
Comfortable Dying Measure*
10/1/2013
Begin 2% market basket reduction
for failure to participate in Quality
Reporting
1/31/2013
Deadline for mandatory
submission of Structural
measure data
1/31/2012
Deadline for voluntary
submission of Structural
measure data
4/1/2013
Deadline
For submission of Comfortable Dying measure data
October 2011 January 2012
April 2012
July 2012
October 2012 January 2013
April 2013
July 2013
October 2013
9/1/2011
10/1/2011 - 12/31/2011
Voluntary
data collection for
Structural measure
1/1/2014
10/1/2012 - 12/31/2012
Mandatory data
collection for
Structural measure
and
Comfortable Dying measure
1/1/2013 - 12/31/2013
Data collection
For Structural measure
and
Comfortable Dying measure
* See next page for details on measures, data collection, and data submission.
© NHPCO 2011
www.nhpco.org/quality
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Use Vendor Resources for gathering and
reporting
◦ NHPCO Quality Reporting Website
◦ www.nhpco.org
◦ CMS
◦ http://www.cms.gov/Hospice-Quality-Reporting
◦ Help.hospicequality@rti.org
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Include the NHPCO Benchmarks in quarterly
and annual operational reports, board reports,
dashboards, and scorecards
Utilize NHPCO benchmarks throughout the
operation, i.e. clinical, bereavement, human
resources, financial reviews
Compare benchmarking results internally and
externally
Utilize the QAPI Loop and process to improve
benchmarks
Team-level
Domain
Report
Control Trend Chart
27
•
•
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Flexibility
Customize
each report
Enhanced
ability to
drill-down into
your data
Overall
Agency
Division
Region
Single
Location
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Select Benchmarks to measure internally and
externally
Find a process to improve
◦ FOCUS PDSA and QAPI Loop
Organize a team to implement the process
Understand the causes of process variation/root
cause analysis
Select the process improvement
Measure results through outcomes and
benchmarks
Recognize the benchmarking results and
successes
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Develop/Sustain a data driven QAPI program
Establish benchmarking to promote QAPI and
improved operational performance
Utilize QAPI methodology and benchmarks in
all operation processes
Strive to improve efficiencies and effectiveness
Recognize benchmark results and successes
◦ Appreciative Inquiry
◦ Celebrate the Success
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Utilize Phased Implementation Plan
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Promote Innovations
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Celebrate success
◦ Identify QAPI data and reports to focus organizational
plan
◦ Implementation and education of the Quality Program
i.e. Quality Partners Initiative
◦ Build a sustainable QAPI program to impact the
operational performance
◦ Strive to improve operational models and performance
i.e. On-Call
◦ Implement appreciative inquiry
◦ Communicate and Display the success
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QAPI Forms & Reports …..
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Useful web Links:
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www.nhpco.org/research
http://www.healthcarecomm.org
http://www.ihi.org
http://www.nih.gov

Christie Franklin, RN, BA, CHCE
President, CEO

Jeanette Dove, RN, MA
Vice President/Clinical Quality Management
Bristol Hospice, LLC
206 North 2100 West, Ste. 202
Salt Lake City, UT 84116
(801) 325 0175