1. University of Colorado Anschutz Medical Campus It's not so much that we're afraid of change or so in love with the old ways, but it's that place in between that we fear.... It's like being between trapezes. It's Linus when his blanket is in the dryer. There's nothing to hold on to. MARILYN FERGUSON

2. 2 Using QIS for Quality Improvement Sayuri Kelly, MS, OTR University of Colorado Anschutz Medical Campus Division of Health Care Policy and Research September 13, 2012 University of Colorado Anschutz Medical Campus

3. 3  Federal Oversight for QIS  QIS stand-alone complaints  Using QIS for Quality Improvement University of Colorado Anschutz Medical Campus Overview

4. 4  FOSS (Traditional)  Regional Office (RO) Surveyor joins the State Agency team  Comparative (Traditional)  Team of RO Surveyors complete a separate survey and compare results with the State Agency Federal Oversight University of Colorado Anschutz Medical Campus

5. 5  FOQIS  More structured, objective process  Targeted, data driven approach using the DAR  Parallel investigations in Stage 1 and 2  On-going dialogue and RO education and guidance  Implemented in October 2011 University of Colorado Anschutz Medical Campus Federal Oversight of the QIS

6. 6  QIS Comparative  Matched Stage 1 and Stage 2 samples  Implementing in October 2012 QIS Comparative University of Colorado Anschutz Medical Campus

7. 7  Stand-alone Complaint  Completed preliminary work – fact finding and research phase  Development work and software requirements begin September 2013 University of Colorado Anschutz Medical Campus Implementation of the Stand-alone Complaints

8. 8  Two options  Option 1: Use Stage 1 forms and investigate all concerns  Option 2: Follow the same process as the State Agency (using all QIS forms) University of Colorado Anschutz Medical Campus Using QIS for Quality Improvement

9. 9  Complete the following for every resident in the facility (or a subset of residents):  Resident Observation  Staff Interview  Record Review  Resident Interview, if appropriate  Family Interview, if appropriate University of Colorado Anschutz Medical Campus Option 1 – Review Every Resident

10. Option 2 Follow the QIS Process University of Colorado Anschutz Medical Campus 10

11. 11  Modify to account for resources and time  Use the same QIS principles  10 residents for each staff member  Complete in 10 - 12 hours  Conduct multiple observations of the resident  At various times of the day University of Colorado Anschutz Medical Campus Follow the QIS Process

12. 12  Interview techniques and protocol  Complete the interview at one sitting  Ask the question exactly as written  Ask lengthy questions in parts  Ask the questions in sequence for skip patterns  Ask probing open-ended questions for any identified concerns  Staff interview – licensed staff with frequent or direct resident contact  Staff interview – required documentation University of Colorado Anschutz Medical Campus Follow the QIS Process (cont.)

13. 13  Stage 1 sample = 40 residents  Resident Interview - all interviewable residents  Observation = all 40 residents  Staff Interview = all 40 residents  Record Review = all 40 residents  Family Interview = 3 family interviews (non- interviewable residents)  Automate the process University of Colorado Anschutz Medical Campus QIS Stage 1 Sample

14. 14 Stage 1 Example – DAR Data University of Colorado Anschutz Medical Campus 19.Care Area Citation Rate for Triggered Areas: % of Triggered CAs/Tasks that were CitedNationRegion 5 Indiana (N=6) Positioning38%51%80% IN QIS DAR Data: 1/28/2011 – 7/17/2012

15. University of Colorado Anschutz Medical Campus H: Leaning to the side without support to maintain an upright position Relevant finding: 8/22/11, 8/23/11 observed resident leaning in wheelchair to the right side. Peyton Manning 15

16. University of Colorado Anschutz Medical Campus I: Lack of needed head or torso support Relevant finding: Resident observed sitting in high- back w/c in activity room, asleep, since 1:30 P.M. Head/neck leaning over toward chest. 10/18/11 at 10:10 A.M. Asleep in activity room in high back wheelchair. Head and neck down towards chest. Andrew Luck 16

17. University of Colorado Anschutz Medical Campus H: Leaning to the side without support to maintain an upright position Relevant finding: Yesterday during activities, the resident was sleeping and leaning to the left. Observed today also leaning to the left. Propelling self back from the dining room. Tim Tebow 17

18. University of Colorado Anschutz Medical Campus F: Uncomfortable Geri- chair positioning, hyper- flexion of the neck, sliding down in the chair, no-support for the legs Relevant finding: sliding down in chair. Redirected to sit up, scoot self up times two in a ten minute period 1:20 to 1:30 p.m. on 09/19/11. John Elway 18

19. 19  Complete an in-depth investigation for every triggered care area (e.g., positioning)  Exception: Harm, SQC or IJ  In-depth investigation = root cause determination  Sample size = 3 residents/care area University of Colorado Anschutz Medical Campus Investigate All Triggered Areas

20. 20 University of Colorado Anschutz Medical Campus Care Area Investigation Key

21. University of Colorado Anschutz Medical Campus Use To determine whether the facility is providing services to:  Meet ADL and positioning needs for those residents unable to carry out these activities;  Prevent decline in positioning, ADLs or ROM; or  Maintain or improve positioning, ADLs or ROM abilities. Use 21

22. University of Colorado Anschutz Medical Campus Procedure If resident is still in facility:  Briefly review the assessment, care plan, and orders to identify facility interventions and to guide observations to be made.  Corroborate observations by interview and record review. Procedure 22

23. University of Colorado Anschutz Medical Campus For the resident who is unable to position him/herself independently (F309) determine whether:  Staff are properly positioning the resident in bed to maintain proper body alignment, with limbs and head supported in a manner to prevent complications related to decreased mobility; and  A resident who has been placed in a wheelchair or reclining chair is positioned in correct alignment to prevent leaning, with limbs and head supported, as needed, and seated in a chair of appropriate size. Notes: 1)Were any of the following observed? (Mark all that apply) H: Leaning to the side without support to maintain an upright position Relevant finding: 8/22/12, 8/23/12 observed resident leaning in wheelchair to the right side. Unable to Position Independently 23

24. University of Colorado Anschutz Medical Campus Resident/Representative Interview  Interview the resident, family or responsible party to the degree possible to identify:  Resident's/Representative's involvement in the development of the care plan, defining the approaches and goals, and if interventions reflect choices and preferences;  Resident's/Representative's awareness of the interventions in use and how to use devices or equipment;  Whether timely assistance is provided as needed for positioning, toileting, eating, bathing, hygiene, grooming, dressing and ambulating according to the care plan;  If the resident comprehends and applies information and instructions to help improve or maintain ADL performance (where cognition permits);  Presence of pain that affects ADL performance including the location, cause, if any and how it is managed; and  If interventions were refused, whether alternatives and/or other alternative approaches were offered. Resident/Representative Interview 24

25. University of Colorado Anschutz Medical Campus Staff Interviews Interview staff on various shifts to determine:  How much assistance is needed with ADLs (including oral hygiene), positioning or ROM;  Whether there are any rehabilitation and/or restorative care schedules and instructions to be followed;  The resident’s level of comfort related to positioning, contractures and ADL care;  Whether there is any resistance to care provided, and if so, when does the resistance occur (for example, during certain types of care, certain times of the day, certain staff, etc.);  How the nurse monitors for the implementation of the care plan;  If interventions were refused, whether alternatives and/or other alternative approaches were offered; and  If the resident is not on a restorative program, how the determination was made that the resident could not benefit from a program. Staff Interviews 25

26. University of Colorado Anschutz Medical Campus Assessment  Review the MDS, physician orders, therapy notes and other progress notes that may have information regarding the assessment of ADL functioning and ROM, assessment of positioning needs, and resident responsiveness to ADL/ROM services.  Based on observation of the resident, interviews with staff, and interviews with the resident/responsible party (as possible), determine whether the assessment information accurately and comprehensively reflects the status of the resident for the following items: ▪Identifies causal factors for any limitations in physical functioning that affect ADLs, positioning and ROM; ▪Identifies the risk and contributing factors for decline or lack of improvement in ADLs or ROM such as presence of an unstable condition, acute health problem, pain, change in cognition, a change in medications that may affect functional performance such as psychoactive or anticholinergic medications, behavioral symptoms, or visual problems; ▪Discusses causal and contributing factors of any resistance to care; ▪Identifies the strengths and abilities that can contribute to the improvement in ADL performance and/or improvement in range of motion; and ▪Identifies the presence and degree of contractures. Assessment 26

27. University of Colorado Anschutz Medical Campus Care Planning If the comprehensive assessment was not completed (CE#1 = No), mark CE#2 “NA, the comprehensive assessment was not completed”. If the care plan refers to a specific facility treatment protocol that contains details of the treatment regimen, the care plan should refer to that protocol and should clarify any deviations from, or revisions to, the protocol for this resident. The treatment protocol must be available to the caregivers and staff should be familiar with the protocol requirements.  Review the care plan to determine whether the plan is based upon the goals, needs, and strengths specific to the resident and reflects the comprehensive assessment. Care Planning 27

28. University of Colorado Anschutz Medical Campus Care Planning  Determine whether the plan, as applicable: ▪Provides restorative approaches that are specific enough to identify the steps that both the resident and the staff will take to improve and or maintain ADL functioning and range of motion; ▪Provides specific care interventions staff will provide for the resident who is unable to participate in ADLs or range of motion, including the provision of oral care, hygiene and maintenance of cleanliness throughout the day; ▪Identifies quantifiable, measurable objectives with timeframes to be able to assess whether the objectives have been met; ▪Identifies interventions with sufficient specificity to guide the provision of services and treatment; ▪Is based upon resident choices and preferences and interdisciplinary expertise; Care Planning (cont’d) 28

29. University of Colorado Anschutz Medical Campus Care Planning  Determine whether the plan, as applicable: (cont’d) ▪Promotes maintenance of dignity; ▪Defines interventions to prevent skin breakdown in areas where contractures are present; ▪Provides for premedication prior to the provision of ADLs, PROM/AROM as applicable; ▪Defines environmental approaches and devices needed to promote independence in ADLs and to maximize independent functioning; ▪Provides positioning interventions and monitoring; and ▪Provides for needed devices, appliances, and equipment.  If care plan concerns are noted, interview staff responsible for care planning as to the rationale for the current plan of care. Care Planning (cont’d) 29

30. University of Colorado Anschutz Medical Campus Care Plan Implementation by Qualified Persons Observe care and interview staff over several shifts and determine whether:  Care is being provided by qualified staff, and/or  The care plan is adequately and/or correctly implemented. Care Plan Implementation 30

31. University of Colorado Anschutz Medical Campus Care Plan Revision If the comprehensive assessment was not completed (CE#1 = No), OR, if the care plan was not developed (CE#2 = No), mark CE#4 “NA, the comprehensive assessment was not completed OR the care plan was not developed”. Determine whether the resident's condition and effectiveness of the care plan interventions have been monitored and care plan revisions were made based upon the following:  The outcome and/or effects of goals and interventions;  A decline or lack of improvement in ADL or ROM status;  Complications with skin breakdown in areas with contractures; Care Plan Revision 31

32. University of Colorado Anschutz Medical Campus Care Plan Revision  Failure to comply with the provision of care for ADLs, positioning and range of motion activities and alternative approaches developed;  Change in condition, ability to make decisions, cognition, medications, behavioral symptoms or visual problems;  Input by the resident and/or the responsible person;  An evaluation of the resident’s level of participation with and response to the care plan; and  If the resident refuses or is resistant to services, alternative means are identified to address ADL, positioning and ROM needs. Care Plan Revision (cont’d) 32

33. University of Colorado Anschutz Medical Campus Provision of Care and Services For the resident who either needs assistance, or is totally dependent in the ability to position self:  F309, Quality of Care — The facility is in compliance with F309 if staff have: ▪Recognized and assessed the need and type of assistance the resident needs for positioning; ▪Defined and implemented pertinent interventions consistent with the resident’s condition, goals, and consistent with recognized standards of practice in order to pro vide needed services; ▪Monitored and evaluated the resident’s response to interventions; and ▪Revised the approaches as appropriate. If not, there is lack of provision of needed services: cite F309. Provision of Care and Services 33

34. University of Colorado Anschutz Medical Campus Concerns with Independent but Associated Structure, Process, and/or Outcome Requirements During the investigation of care and services provided to meet the needs of the resident, the surveyor may have identified concerns with related structure, process and/or outcome requirements, such as the examples listed below. If an additional concern has been identified, the surveyor should initiate the appropriate care area or F tag and investigate the identified concern. Do not cite any related or associated requirements before first conducting an investigation to determine compliance.  F271, Admission Orders — Determine whether the facility received physician orders for provision of immediate care before conducting the comprehensive assessment and developing an interdisciplinary care plan.  F278, Accuracy of Assessments — Determine whether the assessment accurately reflects the resident's status. Independent but Associated Concerns 34

35. 35  Modify Option 2 as necessary  One tool for providers for on-going quality improvement University of Colorado Anschutz Medical Campus Conclusions

36. 36 Martha Powell Martha.Powell@ucdenver.edu (303) 724-2434 Sayuri Kelly Sayuri.Kelly@ucdenver.edu (303) 724-2490 For CMS QIS forms and Information: https://www.qtso.com/qisdownload.html University of Colorado Anschutz Medical Campus Questions?