1. Tanishah Nellom MSPH, MHA, CPHQ SCAHQ September 9, 2016
Hospital QAPI
Tanishah Nellom MSPH, MHA, CPHQ
SCAHQ
September 9, 2016

2. Presentation Objectives
Introduction to hospital QAPI standards and worksheets
Understanding the regulatory requirements of QAPI
Planning a system level QAPI program
Implementation journey at Palmetto Health

3. Introduction to Hospital QAPI

4. What is QAPI?
QAPI is the merger of two complementary approaches to quality, Quality Assurance (QA) and Performance Improvement (PI).
Overarching Goal: Data-driven, proactive approach to improving the quality of life, care, and services in healthcare settings.
Forward-thinking, preventive, proactive.

5. QAPI Process
Facilitates a multidisciplinary, systematic performance improvement approach to identify and pursue opportunities to improve patient outcomes and reduce the risks associated with patient safety in a manner that embraces the mission of your hospital.

6. Purpose of QAPI
Provide a formal mechanism that utilizes objective measures to monitor and evaluate the quality of services provided to patients.
Closes identified gap in current PI project documentation process
Formal, ongoing source of system level PI process information for leadership
Meets CMS and JCO regulatory requirements

7. Worksheet History
October 14, 2011 CMS issues a 137 page memo in the survey and certification section that was pilot tested in hospitals in 11 states
Memo discusses surveyor worksheets for hospitals by CMS during a hospital survey
Addresses discharge planning, infection control, and QAPI (performance improvement)
May 18, 2012 CMS published a second revised edition and pilot tested each of the 3 in every state over summer 2012
November 9, 2012 CMS issued the third revised worksheet
Final ones issued November 26, 2014

8. Final Surveyor Worksheets Made Public 11/26/2014:
Day before thanksgiving
“Via this memorandum we are making the worksheets publicly
available. The hospital industry is encouraged, but not required,
to use the worksheets as part of their self-assessment tools to
promote quality and patient safety.”
Worksheet Memo

9. QAPI Worksheet QAPI worksheet is 15 pages (CMS), JCO 14 pages
Used for validation survey or certification survey in hospitals by CMS
Used by State and federal surveyors on all survey activity in assessing compliance with the CoP
Hospitals are encouraged to use the worksheet as part of their survey self-assessment toolkit

10. QAPI Worksheet Recommendations
Some of the questions asked on the worksheet might not be apparent from reading of CoPs
Use the worksheets as a communication device
helps to clearly communicate to hospitals what is going to be asked in these 3 important areas
Identify and communicate gaps
Pull together a team to complete the form in advance as a self assessment
Attaching the completed assessment documentation and P&P to the worksheet

11. CMS Resources Regulations were first published in 1986
Tag number 0001 through 1164 and PI starts at tag 263
QAPI
Questions: to CMS at
CMS regulations are first published in the Federal Register then the Interpretive Guidelines and Survey Procedures
Hospitals should check this website once a month for changes
Survey and Certification Info

12. System Level QAPI Implementation

13. QAPI CoP
“The hospital must develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS.”
(Rev. 105, Issued: , Effective: , Implementation: )

14. Conditions of Participation
The hospital must develop, implement, and maintain an effective, ongoing, hospital‐wide, data‐driven quality assessment and performance improvement program
Scoring Procedure: The QAPI program covers each of the following elements:
Development (6.1, 6.3)
Implementation (6.2.a, 6.3)
Maintenance (6.2.a-b)
Effectiveness (3.1.k-m, 5.10.d-f)
Ongoing (5.2.a-d, 5.3, 5.5)
Data‐driven (3.1.a-j, 4.1, 4.2, 4.5, 5.5, 5.8)
Hospital wide (4.2, 4.3, 4.4, 5.5, 5.10.a-c)
Contract services
Improved outcomes (5.1.a-c, 5.5, 5.6, 5.8)
Reduction of medical errors (5.1.a-c, 5.5, 5.6, 5.8)

15. Executive Responsibilities
§482.21(e) Standard: The hospital’s governing body, medical staff, and
administrative officials are responsible and accountable for ensuring
the following:
An ongoing program for quality improvement and patient safety is defined, implemented, evaluated, and maintained;
That the hospital‐wide QAPI efforts address priorities for improved quality of care and patient safety
The annual determination of the number of distinct improvement projects
That clear expectations for safety are established
That adequate resources are allocated for improving and sustaining the hospital's performance and reducing risk to patients.

16. Executive Requirements
Evidence for Review
Determine priorities regarding which processes to monitor with data collection and the subsequent development of planned improvement efforts
Review the governing body mission, bylaws,
annual report and meeting minutes to determine the requirement was met.
GB must provide clear expectations for safety and for allocating adequate resources for measuring, assessing, improving, and sustaining hospital’s QAPI and patient safety program
The hospital has staff trained to perform QAPI activities.
The hospital ensures adequate time is devoted to the quality program.
The facility has a multidisciplinary, hospital‐wide Quality Committee w/ representatives from the Med Staff and hospital leadership.
QAPI related education is provided to staff, leadership, Med Staff, and the Governing Body
The medical staff and administrative officials must be held accountable for the implementation of an effective QAPI program consistent with GB direction that demonstrates a sustained improvement in patient outcomes and a reduction in medical errors.
The Quality Committee is responsible for the
development and implementation of an ongoing QAPI program that measures performance, analyzes data, and implements strategies for the purpose of improving health outcomes and reducing risk.
The hospital‐wide QAPI activities identify and
implement strategic actions to improve the quality of care and patient safety. These strategic actions are periodically evaluated to ensure the strategies implemented have been effective
The Quality Committee reviews reports from
all departments and services, discusses opportunities for improvement, and recommends corrective actions.
Quality Committee minutes memorialize quality activities and corrective actions.

17. Data‐Driven Processes
Ongoing program that shows measurable improvement in evidence-based indicators for improved health outcomes and reduction of medical errors. §482.21(a)(1)
Measure, analyze, and track quality indicators, adverse patient events, and performance metrics that assess processes of care, hospital service and operations. §482.21(a)(2)
The program must incorporate quality indicator data including patient care data, and other relevant data (QIO, Premier, Navient)

18. Data Requirements Evidence for Review
The goal of the QA program is to identify and reduce medical errors and improve outcomes.
The documented scope of the QAPI program is to identify and reduce medical errors and improve health outcomes.
Specifies the quality indicators that will be measured, analyzed, and tracked on an ongoing basis.
The documented focus of the QAPI program is to identify high‐risk opportunities and take action to
reduce errors.
Performance indicators and data collection activities for:
Every department and service
Every contracted service
All departments and service lines have performance indicators
All contracted services that impact patient care have performance indicators in the contract
Frequency and detail of data collection activities
The governing body has specified the frequency and detail of data collection
Methods to monitor the effectiveness and safety of services and quality of care
The hospital has a process for measuring, analyzing, and tracking quality, adverse patient events, and other aspects of performance
The plan to use data collected to monitor the effectiveness and safety of services
Data is analyzed to identify patterns and trends.
Data is used to monitor the effectiveness of services provided.
Approval of the annual Quality Plan by the governing body.
The annual Quality Plan has been approved by the governing body and documented in GB minutes and Quality Committee minutes.

19. Performance Improvement Projects
§482.21(d) Standard: As part of its quality assessment and performance improvement program, the hospital must conduct performance improvement projects.
All departments, service lines, and contract services that impact patient care should participate in PIP
System level Information Technology projects that are intended to improve patient care, safety, or outcomes can be used as a QAPI project.
The hospital must document PI projects, the reason for implementation, and associated performance metrics
A QIO cooperative project, or the hospital’s own projects are required to be of comparable effort.

20. PIP Requirements Evidence for Review
The number and scope of the distinct performance
improvement projects is proportional to the scope
and complexity of services provided
The annual Quality Plan identifies the data‐driven, distinct performance improvement projects to be addressed during the current year
The hospital has evidence that it has conducted annual performance improvement projects
The hospital has a process to document each performance project, including:
1. Reason for selecting the project
2. Initial baseline data to support the project
3. Ongoing data that demonstrates progress
for each project
4. Timelines for each phase of the project
5. Data to support sustained improvement
The hospital documented the required elements for each distinct performance improvement project
Documentation of the progress of installation and implementation of Information Technology (IT)
Systems as a hospital‐wide QAPI activity
If the facility implemented an Information
Technology (IT) project, determine why it was considered a priority.
Is the project monitored to ensure desired outcome
A hospital is not required to participate in a QIO cooperative project but its own projects are required to be of comparable effort.
Determine if the hospital works with the QIO or they have a similar project that meets the requirement

21. Patient Safety
Standard §482.21(a)(1) : The program must include, but not be limited
to, an ongoing program that shows measurable improvement in
indicators for which there is evidence that it will improve health
outcomes and identify and reduce medical errors.
The hospital must measure, analyze, and track quality indicators
The hospital must measure, analyze, and track adverse patient events
Other aspects of performance that assess processes of care, hospital service and operations.
Standard §482.21(a)(2): Patient Safety activities must
Track medical errors and adverse patient events
Analyze their causes
Implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

22. Patient Safety Requirements
Evidence for Review
The facility implements a database for tracking
medical errors and adverse patient events by
category.
Determine that the hospital measures,
analyzes, and tracks:
Quality and performance indicators
Medical errors
Adverse patient events
Through data analysis, the facility
determines patterns, implements strategies, and
monitors the effectiveness of corrective actions
implemented.
Determine that the hospital has implemented
improvement mechanisms, based on data analysis, to reduce medical errors and adverse patient events.
The review of errors shall involve the individual(s)
directly involved as well as representatives of any involved hospital services
There is documented evidence of event reviews of adverse patient events and medical errors
The annual QAPI Plan, which clearly establishes
expectations for safety, is approved by the governing
body.
The governing body has clearly established
expectations for safety.

23. Contract Services
Standard: Is there evidence of PI review for contracted services
for clinical care
Services performed under contract are performed in a safe and efficient manner
Contractors furnish services that meet the hospital CoPs and standards for contracted services
Includes shared services and joint ventures
Includes services related to patient care such as environmental cleaning, sterilization, laundry, lab, pharmacy
Identify quality problems and ensure monitoring and correction of any problems ensure corrections sustained

24. Contract Services Requirements
Evidence for Review
The same level of care must be provided to patients whether you provide the service directly or through contract services
Governing Body must make sure the contractors furnish services that meet the hospital CoPs and standards for contracted services
Services performed under contract are performed in a safe and efficient manner
Documented evidence of PI monitoring and review of contract services
For each contract placed under corrective action, the hospital has a process to document each improvement project, including:
1. Reason for selecting the project
2. Initial baseline data to support the project
3. Ongoing data that demonstrates progress
for each project
4. Timelines for each phase of the project
5. Data to support sustained improvement
The hospital documented the required elements for each distinct performance improvement project
Track and monitor all contractors that provide services that impact patient care
List of all contractors providing services that impact patient care along with current PI metrics

25. The Palmetto Health Journey

26. QAPI Implementation to Date
December 2014
Aware of QAPI worksheet
Started inventory of QA and PI tools currently in use
March 2016
Submit draft of QAPI program to QC that reflect TJC standards
Introduce A3 documentation concept
January 2015
Started inventory of all QI/PI projects at PH
Started self-assessment process using CMS surveyor worksheet
May 2016
Prepare for presentation to the PH BOD for official endorsement of QAPI plan
Update QAPI inventory
March 2015
Initial presentation to Quality Committee to introduce changes to QAPI requirements
June 2016
QAPI plan officially endorsed by the BOD quality subcommittee and system level BOD
April 2015
Had a baby
July 2016
Presented to and endorsed by Operations Cabinet, Executive Cabinet, Nursing Leadership
Recommendations made to QC on contracts management standards
Distribute A3s
August 2015
Started initial QAPI program draft
Began earliest drafts of QAPI tools
August 2016
Begin contracts management QAPI work
Continue to train team members on A3 template use
December 2015
Submitted first draft of QAPI Plan to SQIC
Next Steps
Build comprehensive PI education plan integrating QAPI tools with LEAN processes
Getting newly formatted annual quality report approved by the BOD
Assisting PI teams with developing and completing A3s
Knock the next survey out of the ballpark!
January 2016
Julie gives me a copy of TJC QAPI worksheet
Life is now complete

27. Path to Implementation
Committee
QAPI Role (CMS/JCO)
Requested Action
Quality Subcommittee of PH BOD
Governing Body, accountable for creation of QAPI program
Endorsement of formal QAPI management plan
CEO and Executive Cabinet
Accountable for QAPI program effectiveness
Set and communicate clear expectations for safety and quality for the system
Senior Quality Integration Council
Managing Body
Develop, implement, and evaluate QAPI management plan
Medical Executive Committee
Medical Staff Leadership
Assist in planning and implementation of QAPI
Patient Care and Safety
Physician PI
Participation on PI project teams
Patient Safety Leadership-Quality and Safety Council
Nursing PI
Patient and Family Advisory Council
Patient Representation

28. Palmetto Health Board of Directors’ Quality and Patient Safety Committee
Senior Quality Integration Council
Corporate Quality and Patient Safety
Performance Improvement Teams
Authorizes the establishment of this performance improvement program as the Governing Body Assures:
Program for quality improvement and patient safety is defined, implemented, and maintained
That clear expectations for safety are established
Adequate resources are allocated
That a determination of the number of distinct improvement projects is conducted annually
Empowered by the Governing Body to development, implementation, and evaluation of this program
Responsible for monitoring and improving the quality of care, safety and service provided by its medical staff
May delegate to existing entities in their respective organizational structure(s)
CQPS aids in the facilitation for improving the quality of care, safety, and service provided by medical and organizational staff.
Develops structures and processes to carry out this responsibility
The organization will undertake efforts to improve existing processes and outcomes by forming interdisciplinary PI Teams to manage change
Improvement teams will utilize the IHI Performance Improvement Model to design, implement, manage, and sustain improvement

29. Questions?