How to Direct and Produce a “BLOCKBUSTER” QAPI Meeting

1. How to Direct and Produce a “BLOCKBUSTER” QAPI Meeting A learning and action webinar for the South Dakota Nursing Home Quality Care Collaborative October 17, 2013 • Presented by: • Holly Beving, RN, hbeving@sdqio.sdps.org, 605-228-9594 • Lori Hintz, RN, lhintz@sdqio.sdps.org, 605 354-3187 • South Dakota Foundation for Medical Care This material was prepared by SDFMC, the Medicare Quality Improvement Organization for South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-SD-C7-13-410

2. The Plot . . . “aka” the objectives • Learn key strategies that will assist Quality Assurance Performance Improvement (QAPI) meetings to be more organized, more effective, and produce results. • Share meeting agenda template designed specifically for QAPI that incorporates an action and follow-up plan for EVERY meeting. • Learn when to form a PIP Team. Share PIP documentation tool. • Familiarize participants with the “National Nursing Home Quality Care Collaborative CHANGE Package” and “QAPI At A Glance” document. • Hear from three South Dakota DONs related to their QAPI best practices.

3. The Backdrop: F520 Regulation 483.75(o) Quality Assessment and Assurance • A facility must maintain a quality assessment and assurance committee consisting of: (i) the director of nursing services; (ii) a physician designated by the facility, and (iii) at least 3 other members of the facility’s staff. • . . . (i) Meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and (ii) develops and implements appropriate plans of actionsto correct identified quality deficiencies. • The Long Term Care Survey Manual, AHCA, May 2013 Edition

4. F520 Regulation continued • A state or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with requirements of this section. • Surveyors will ask for a record of dates of your QAPI meetings and list of attendee names and titles at each meeting. . .You do not have to give them your notes unless you choose to do so. • Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions. • The Long Term Care Survey Manual, AHCA, May 2013 Edition

5. F520 Guidance to Surveyors Section helpful • QA? QI? QAA? QAPI? • Technically have different meanings but are used interchangeably. QAA is what is used in F520 now . . . QAPI will probably be the term used in the sequel. • Root Cause Analysis mentioned frequently in the F520 Surveyor Guidance Section. Are you using this term in your building with all staff and departments? • Action Plan and Follow Up mentioned frequently

6. Also Helpful: The Investigative Protocol Under Guidance to Surveyors in F520 • Prior to the Survey Team visit they review: • CASPER Quality Measure Reports • 4 year history of the facilities’ deficiencies from past surveys, revisits, and complaint surveys • Look for repeat deficiencies • Survey Team will interview QAPI Committee Leader to determine the PROCESS: • How committee identifies current and ongoing issues • Methods used to develop action plans • How current action plans are being implemented • Survey Team will be looking that QAPI process is demonstrated facility wide.

7. Behind the ScenesGet your cast and crew selected • Designate a leader for the QAPI Committee • Need to BELIEVE in quality improvement • Need to be organized • Need to be given the time, resources, and equipment to do the “behind the scenes” work • Education, Long Term Care Survey Manual, CASPER QM reports, computer, email • Needs to be a good communicator with a hint of outspokenness . . . Can he/she lead the Root Cause Analysis (5 Why’s)? • Needs to drive accountability

8. Behind the ScenesGet your cast and crew selected • Director of Nursing • Medical Director • Administrator • Board Member(s) • Therapy • Maintenance • Laundry • Housekeeping • Social Services • Activities • Pharmacist • MDS Coordinator • Infection Control Coordinator Recommendation: Every department is represented at your QAPI Committee Meeting

9. QAPI Committee Roles • RESPECT - Each discipline brings a UNIQUE perspective • Each discipline is responsible for a focus area • Review the federal and state regulations that pertain to member’s focus area. Know what drives the data on the QM report. • Develops and modifies the QAPI plan • Reviews data measures • Sets benchmarks and goals • Prioritizes focus areas and PIPs • Target high volume, high risk, problem prone areas first • Not every focus area requires a PIP

10. Meeting Ground Rules • Meetings start and end on time (may consider having a timekeeper) • Use a consistent agenda/format • Set a regular time and place for meeting • Recommend MONTHLY QAPI meetings • If need be, post meeting reminders/send members reminders (email works great, create email data base so easy to send the group notices) • Avoid distractions and maintain active engagement • Create safe environment to brainstorm and voice concerns • Expectation that everyone is prepared for meeting

11. Meeting Ground Rules continued . . . Best Practice Idea! • All members report on their focus areas in the Agenda/Meeting Template PRIOR to QAPI meeting • Why? • Saves time! Increases efficiency! Promotes action! • Meeting time is reserved for real discussion of the facts, NOT to enter the facts. • Meeting minutes are essentially done with exception of QAPI leader taking notes of attendance, action plans, and follow-up. • How? • Put Agenda/Minutes Template on shared electronic drive – allows for easy access for members to complete. • QAPI Leader makes copies available for members at meeting.

12. Action Plans and Follow Up are the star attractions • Making action plans and following up on those action plans at EVERY meeting is key to producing results. • “It is not what the latest software or technology does. It’s what the user does.”

13. The Script . . . QAPI Agenda Meeting Template

14. The Script . . . QAPI Agenda Meeting Template Continued

15. Stunt Team aka “PIP Team” P P I • erformancemprovementroject • Charter PIP teams with a specific mission to look into a problem area. • Select those working closest to the challenge to explore the root cause and problem solve (i.e. direct caregivers, dietary, housekeeping, even family and residents in some cases). • PIP team always includes one member from the QAPI Committee. • PIP teams need to be given TIME to work on the issue. Give them a timeline and a budget. • Need a leader for the PIP team. • Need to report back to the QAPI Committee. • PIP teams must be considered VALUABLE and an important assignment.

16. Easy to Use Documentation Tool for PIPs

17. PIP Documentation Tool Continued

18. National Nursing Home Quality Care Collaborative “CHANGE Package” and “QAPI At A Glance” • “CHANGE Package” • Gives a menu of strategies, change concepts, and actionable items that will be helpful in finding solutions to challenge areas. • It is not the intent that nursing homes try to attempt every change concept at the same time. • Prioritize the areas where you feel change is needed. • Have document available at QAPI/ PIP meetings. Refer to the document when trying to problem solve and/or looking for ideas. • “QAPI At A Glance” • It is the “nuts and bolts” of QAPI. • Step by step guide to implementing QAPI, including the steps to write a written QAPI plan. • Excellent problem solving models outlined in this resource. • Have copies available. Both the “Change Package” and “QAPI At A Glance” can be found on the CMS, SDFMC websites (addresses on resource slide)

19. Metric / Benchmark Formula • FYI: A Way to Calculate Falls • Falls will be calculated by taking the total number of falls that have occurred for one month and dividing it by the total number of resident days for that same month. This figure will then be multiplied by 1000 to give you the average number of falls per 1000 resident days.

20. Best Performances go to . . . • Jenkins Living Center, Watertown, SD - Shawn Gilman, DON • Forming a PIP Squad • Platte Care Center Avera, Platte, SD - Traci Harrington, DON • QAPI and Falls • Firesteel Healthcare Center, Mitchell, SD - Sarah Comp, DON • Using the Connecticut RCA Event Tool

21. Credits “aka” resources • South Dakota Foundation for Medical Care: http://www.sdfmc.org/PatientSafety/SDNursingHomeQualityCareCollaborative/SDNHQCCResources/Index.cfm • CMS QAPI Webpage: http://go.cms.gov/Nhqapi • CMS QAPI AT A Glance document: http://cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/QAPIAtaGlance.pdf • Advancing Excellence in America’s Nursing Homes: http://www.nhqualitycampaign.org/ • Agency for Healthcare Research and Quality, STEPPS program: http://www.ahrq/gov/professionals/education/curriculum-tools/teamstepps/ltc/index.html • Department of Veterans Affairs, Root Cause Analysis: http://www/patientsafety.gov/CogAids/RCA/ • Getting Better All the Time: Working Together for Continuous Improvement: http://www.susanwehrymd.com/files/gettingbetterall-the-time.pdf • InterAct: www.interact2.net • Oklahoma Foundation for Medical Quality: National Nursing Home Quality Care Collaborative CHANGE Package: http://www.ofmq.com/nhtoolsandresources • Ohio KePro: Quality Improvement Workbook: https://www.ohiokepro.com/shopping/pdfs/QualityImprovementWorkbook.pdf • The Long Term Care Survey, AHCA, May 2013 Edition

22. Our Offer • Host Open Office Call • 9:00 am MT/ 10:00 am CT • Thursday, January 30, 2014 • * Purpose: Share how QI/QAPI meetings are going • What is working? What is not? • Contact Information: • Holly Beving: hbeving@sdqio.sdps.org 605-228-9594 • Lori Hintz: lhintz@sdqio.sdps.org 605-354-3187