1. Operational Benefits to Quality Improvement Benchmarking
CALVERT HOSPICE: Quality Assurance and Performance improvement(QAPI) PROJECT
Operational Benefits to Quality Improvement Benchmarking

2. Team Members Jean Fleming, RN, BSN,CHCE
Calvert Hospice Executive Director
Sarah E. Simmons RN, BSN, CHCE
Calvert Hospice Director/Clinical Quality Management
Karen Carloni, LSM
Mary Beth Cook, LSM
Jim Gotsch, LSM
Eusebio Quinones “Q”, LSM

3. Calvert Hospice ~Mission Statement
“The mission of Calvert Hospice, a not-for-profit community-based organization, is to provide comprehensive, interdisciplinary services focused on medical care and psychosocial, emotional, and spiritual support to residents of Calvert County who are dying; to promote and support the provision of palliative care to those in need; to provide emotional, psychosocial, and spiritual support to those in Calvert County grieving the loss of a loved one; and, to provide educational services to the entire community about the processes that accompany death and loss. Calvert Hospice promotes quality of life , respect, and dignity for the individual, and recognition of the significance of loss throughout life.”

4. Calvert Hospice ~Who They Are
Located in Prince Fredrick Maryland
Calvert Hospice began serving patients with serious, life-limiting illnesses in Calvert County in 1984.
Calvert Hospice cares for those in Calvert County who are living with a serious, life-limiting illness. They provide expert medical care, which includes pain and symptom management that is personalized for each patient. The hospice team also provides emotional and spiritual support to patients and affected family members
Calvert Hospice focuses on caring, compassion, dignity, and our patients’ quality of life. They support patients in their final months, weeks, and days amid familiar surroundings, pain-free and surrounded by their loved ones and friends
At Calvert Hospice, they understand that the need for support does not end with a patient’s death. After a patient passes, they provide bereavement support for the family and loved ones left behind

5. Calvert Hospice ~Support Services
Burnett-Calvert House: opened in 2010, a 6 bed residential home designed for Calvert County residents in hospice care who require more skilled care than those at home can provide
Shoppe For Hospice - boutique
Support Groups
Drop-In Grief Support Group
Substance Abuse Loss Grief Support Group
Suicide Loss Grief Support Group
Children’s Programs
Bridges
Camp Phoenix
CONNECT: A Grief Support Group for Teens
Education Seminars
Grief Resources & Support Programs
Grief Counseling
Lending Library

6. Hospice Volunteers: Defined Hours to Qualify for Medicare:
Medicare requires “Volunteers to provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum equals 5% of the total patient care hours of all paid hospice employees and contract staff.” Without volunteers, hospice would be unable to meet Medicare standards.
Volunteers must complete:
11 hour classroom training program
11 hours of online training (RELIAS) for Clinical Volunteers (patient/family contact) and for 7.5 for Administrative Volunteers (shoppe/office)
Volunteer Opportunities:
Office Volunteers
Family Service Volunteers
Bereavement Volunteers
Event Volunteers
Burnett Calvert Hospice House Volunteers
Shoppe for Hospice Volunteers
Board of Directors

7. Project Objectives:
Define and document QAPI Process and target goals for:
Pain Management within 48 hours
Falls with Injury
Completion of Post-Admission Surveys within 3-7 days
Hospice Visits when Death is Imminent (2 visits within last 7 days)
Organize staff to implement the process
Select the process improvement
Measure results through outcomes and benchmarks
Recognize the benchmarking results and successes

8. Quality Assurance Performance Improvement (QAPI)
Why QAPI?
Increase focus on QAPI including Outcomes
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

9. Plan of Action: Utilize Phased Implementation Plan Promote Innovations
Identify QAPI data and reports to focus organizational plan
Implementation and education of the Quality Program
i.e. Quality Partners Initiative
Promote Innovations
Build a sustainable QAPI program to impact the operational performance
Strive to improve operational models and performance
i.e. leverage benchmarking opportunities
Celebrate success
Implement appreciative inquiry
Communicate and Display the success

10. Initial QAPI Challenges
New QAPI COP and other regulations
Implementation of numerous new regulations
Educating and engaging the hospice team
Extremely limited personnel resources
QAPI Indicator selection and measurement
What should be collected and why
QAPI Tools and data collection
Selection and implementation of tools and data collection
Data Overload
Collecting a large amount of data
Don’t know what to do with the data
Outcome and benchmark selection

11. Outcome:
The following slides illustrate the Work Flows and Trend Results created for the reporting on “Falls With Injury” and “Pain Management within 48 hours”. Similar Work Flows were created for the other 2 processes.

12. Work Flow

13. Specific Benefits to Calvert Hospice:
Streamline Process Tracking/Measurement
Developed baseline process maps to capture/measure “as is” conditions
Target process areas and track as ‘open actions” until final resolution/compliance
Automatically Trigger Process Review/PDSA Cycle
Developed Process Management Control Model with thresholds for selected Performance Improvement Project (PIP) areas that would “trigger” an in-depth root cause analysis using the PDSA (Plan-Do-Study-Act)/QAPI methodology
Create the ability to utilize Quality Benchmarks to improve clinical and operational performance
Model incorporated a method of visually linking benchmarks to daily process work flow activities at the user input level by using Control Trend Charts (accreditor dictated requirement in adherence to local and state ACA Regulations)

14. Trend Results: Individual Measures Input: Falls Data Input Sheet

15. Trend Results: Individual Measures Output: Falls Data Control Trend Chart

16. Trend Results: Input: Pain Data Measure Sheet

17. Trend Results: Individual Measures Output: Pain Management Control Trend Chart

18. Trend Results: Individual Measures Output: Pain Management 4 Year Control Trend Chart

19. Questions? 21