1. QAPI- Part 2 Learning Objectives List key hospice QAPI activities Describe elements of a good tracking and trending report Identify the critical components of a performance improvement project QAPI Part 1

2. 2 QAPI Activities Quality Assessment – Collect quality data across both clinical and non-clinical operational areas – Use data to track quality measures over time – Monitor of quality indicators at regular intervals Performance Improvement – Use industry benchmarks and/or internal targets (and patient-identified goals at the patient-level) to identify opportunties to improve – Take action when performance falls below target for two periods or more – Implement performance improvement projects as needed

3. Selecting Measures Have a plan or framework for quality measurement – Clinical quality – Non-clinical operations Have a rationale for each measure – Why are you tracking? – What will you do with the information? Consider using industry-vetted measures QAPI Part 1

4. Hospice Data Sources for QAPI Patient charts Incident reports Infection reports Satisfaction surveys Billing Records Human resources files Financial Reports Volunteer Records 4

5. Important Points About Data Collection Incorporate data collection for QAPI into existing processes and procedures – Example: Patient elements incorporated into assessments and/or care plan SYSTEMATIC: Collect the same way every time – Process measures are a good way to start Frequency of data collection – Approved by governing body – Based on timeframe that indicator is expected to change 5

6. 6 Using the Data - Actionable Reporting Graphs or tables Track and trend over time Relative to a benchmark or target

7. Identify Opportunities for Improvement When to take action Quality assessment indicates a “gap” between actual and desired performance Survey deficiencies Management want to improve Staff suggestions 7

8. What action to take Individual patient – Change interventions – Revisit goal – Continue to monitor Hospice-level – Investigate causes – Consider a Performance Improvement Project (PIP) – Assure that improvement is sustained 8

9. PIP Overview Conducted by a team – Include all relevant disciplines – Different people for each project Designed to: – Investigate the reasons for the current level of performance – Determine the best way to improve performance – Measure improvements and assure they are sustained 9

10. 10 Performance Improvement Projects Appoint a PIP team Investigate causes of current outcomes or performance Develop and implement plan for improvement – Pilot testing with small # of cases or limited time Document the project activities and results

11. 11 Abbreviated PIP – How they work Smaller team Review literature or best practice information Write a plan for improving performance Implement the plan Monitor results for one month (or two) “Tweak” the process if necessary and continue to monitor

12. Pt.-level example: Symptom Management Patient Goal: 3 Collect symptom severity data on each assessment Collect patient goal Monitor severity over time and relative to the goal Adjust interventions to reach goal and/or assist patient in refining the goal Symptom3/2/083/3/0 8 3/6/08 AnxietyModerateMild DyspneaMildNoneMild QAPI Part 1

13. National Average 82% QAPI Part 1 Hospice-level example: Aggregated clinical data

14. QAPI Part 1 Hospice-level example: Non-clinical operations