1. QAPI – Performace Improvement for Long Term Care

2. Why does this matter in long term care?

3. Office of Inspector General Findings
1:3 Skilled Nursing Facility residents were harmed by an adverse event or temporary harm event within first 35 days of their stay
60% were preventable
79% resulted in an extended nursing home stay or required hospital transfer
50% of those were re-hospitalized costing Medicare $208 million dollars
…in one month!

4. 37% Medication Related 37% Care Related 26% Infection Related
Adverse Events
37% Medication Related 37% Care Related 26% Infection Related

5. F-520 Regulation QAA: Quality Assessment and Assurance regulation
Quarterly meetings to include the director of nursing, a physician, and three other staff members
The committee identifies quality deficiencies and develops and implements plans of action to correct with quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the action plans
Root cause identification with corrective action plans
Survey
Facility is not required to release the records of QAA committees related to being an internal process
If facility does release information, the topics discussed in QAA committees may not be used to cite deficiencies not identified prior to QAA review that are unrelated to the QAA regulation
Staff members will be interviewed about the QAA team and how they would bring up concerns to be investigated for improvement

6. QA—Quality Assurance PI—Performance Improvement
What is QAPI?
QA—Quality Assurance PI—Performance Improvement

7. QA vs PI Quality Assurance (QA)
QA is a process of meeting quality standards and assuring that care reaches an acceptable level. Nursing homes typically set QA thresholds to comply with regulations. They may also create standards that go beyond regulations. QA is a reactive, retrospective effort to examine why a facility failed to meet certain standards. QA activities do improve quality, but efforts frequently end once the standard is met.
Performance Improvement (PI)
PI (also called Quality Improvement - QI) is a pro-active and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems. PI in nursing homes aims to improve processes involved in health care delivery and resident quality of life. PI can make good quality even better.

8. What???
QAPI is a data-driven, proactive approach to improving the quality of life, care, and services in nursing homes. The activities of QAPI involve members at all levels of the organization to:
identify opportunities for improvement;
address gaps in systems or processes;
develop and implement an improvement, or corrective plan;
and, continuously monitor effectiveness of interventions.

9. 5 Elements of QAPI Leadership and Governance Design and Scope
Feedback, Data Systems, and Monitoring
Performance Improvement Projects
Systematic Analysis and Systematic Action

10. 12 Action Steps to QAPI Leadership Responsibility and Accountability
Develop a Deliberate Approach to Teamwork
Take your QAPI Pulse with a Self Assessment
Identify Your Organization's Guiding Principles
Develop your QAPI Plan
Conduct a QAPI Awareness Campaign
Develop a strategy for Collecting and Using QAPI Data
Identify your Gaps and Opportunities
Prioritize Opportunities and Charter PIPs
Plan, Conduct, and Document PIPs
Getting to the Root of the Problem
Take a Systematic Action

11. Baldrige Framework and QAPI
AS2, AS9, AS10, AS11
AS4, AS5, AS9, AS10, E2
AS1, AS2, AS4, AS6, E1
AS9, AS10, AS11, AS12, E4, E5
AS3, AS7, AS8, E3

12. Deming restated
“The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.” --
Dr. Lucian Leape, Professor at Harvard School of Public Health

13. Need for a Just Culture
Long term care is heavily regulated by state and federal government
Immediate intervention of a disciplinary action needed as part of the corrective action
Error reporting by employees is not accurate for fear of reprisal
Managing not Leading
Scapegoats used frequently

14. Strong Leadership Needed

15. Meeting Improvement
Going through the “meeting motion” accomplishes nothing
Problem Statements
Root Cause Analysis—asking why, why, why, why…
Sharing action plans
Monitoring results—data driven
The goal changes from showing motion i.e. having an action plan, to making a measureable improvement
Holds your leadership accountable to have impact to a culture change

16. High Reliability Organization (HRO)
An organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity ……the hallmark of an HRO is not that is error free, but the errors do not disable it

17. HRO Characteristics Leaders at all levels know how to timeline events
Front line staff and get engaged in finding errors in the system
Culture that is highly aware of risks

18. HRO Focus
Look at system failures from a multiple cause of events approach; it is not just what is happening at the time of the event that leads to the failure
An accident, no matter how minor, is a failure in the system

19. QAPI—Think Outside the Box

20. How are you leading?

21. Questions? Lauren Hartlaub
Director of Quality Assurance and Risk Management
Tedd Snyder
Snyder Consulting & Associates

22. Resources

23. Centers for Medicare & Medicaid Services (CMS)
Section 6102 (c) of the Affordable Act provide the opportunity for CMS to mobilize some of the best practices in nursing home QAPI
Tools and resources
Advancing Excellence in American’s Nursing Homes
Agency for Healthcare Research and Quality
Training Materials
Lean Goddess Video Series
Donna’s Diary