Clinical Indicator Goals Project: Developing QAPI Without Fear

1. Clinical Indicator Goals Project: Developing QAPI Without Fear Svetlana (Lana) Kacherova, QI Director Lisle Mukai, QI Coordinator ESRD Network 18 November 19, 2008

2. Special Acknowledgement forContent Contributions:Laura Adams, President and CEO Rhode Island Quality Institute & Quality Improvement Directors From other ESRD Networks!

3. Session Objectives Project Description Increase understanding of Quality Principles Use the Basic Quality Tools Apply PDSA cycle and project steps Learn something new Have some fun

4. V626 QAPI Condition Statement The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team... …The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS

5. Condition 494.110:Quality Assessment and Performance Improvement Project (QAPI) Interdisciplinary team (IDT) Must report problems to Medical Director and Quality Improvement committee Outcome- focused Process continuous & on-going Use community accepted standards as targets Include patient satisfaction, infection control, medical injuries & medication errors Plan/Do/Study/Act: Close the loop!

6. Monitoring Performance Improvement (V638) The facility must: Continuously monitor its performance Take actions that result in performance improvement Track to assure improvements are sustained over time

7. Interdisciplinary Team: Show Me The Progress:

8. Performance Measures: include but not limit to:

9. Clinical Indicator Goals Project: Inclusion Criteria for Participating Facilities Not meeting Network goals on at least 2 of 3 clinical indicators (N=63) - Anemia - Dialysis Adequacy - Albumin IMPORTANT: Anemia and Adequacy information is available on the Dialysis Facility Compare website at www.medicare.gov

10. Project Goal: All participating facilities will perform a Root-Cause Analysis (RCA) and develop QAPI to meet clinical indicator goals 65% of facilities (N- 40) will show improvement from baseline in at least 2 of 3 clinical indicators between October 2008 and March 2009 Goals are set per MRBs suggestion based on the historical clinical indicator monitoring processes

11. Reasons for Anemia Goals => 11.0 g/dl Network Goal – 85% patients with Hgb => 11.0 g/dl CPM study looks at the % of patients => 11.0 g/dl and Network goals are determined upon CPM results Hgb lower and upper limits discussion MRB suggested no more than 15% of patients with Hgb < 10.0 g/dl and no more 15% pts with Hgb > 13.0 g/dl

12. Important: If your facility anemia goals are different from the Network goal (upper and lower limits for Hgb or Hct) – provide the Network with your policy on Anemia goals Identify your goal on the Anemia Monitoring Run Chart when submitting data to the Network Same applies to other clinical indicator goals (for adequacy and nutrition)

16. What is QAPI and why do we need it: Quality Assessment and Performance Improvement Project/Program Previously known as a CQI (Continuous Quality Improvement)

17. Information that Duels the Growing Emphasis on Quality Two million documents will be lost by the IRS this year 18,322 pieces of mail will be mishandled in the next hour 20,000 incorrect drug prescriptions will be written in the next 12 months Data from the early 1990s

18. Quality in Healthcare Rather then just meeting fixed standards, a never ending search for ways to improve patient outcomes Focus on outcomes and the process that produce those outcomes Focus on systems of care not individual cases Improve the average and the outliers will improve too

19. Institute of Medicine Aims for Health Care: • Evidence-based • Patient centered • Outcome improvement driven • Systems/team oriented • Six aims of health care: • Safe • Effective • Patient centered • Timely • Efficient • Equitable

20. What is the cost of Poor Quality? No show rates? Lost charts? Lost labs? Train wreck visits? Lost revenue – improper billing? Staff turnover?

21. Basic Principles of Quality Improvement Focus on improving work processes A systems orientation to service delivery Services or products tailored to customers needs Staff involvement Emphasis on design and improvement of products/services A focus on continuously improving

22. Introducing the Quality Tools

23. Basic Quality Tools: Process Analysis Flow Chart Brainstorming Fishbone Diagram (Cause and Effect) Check Sheet Histogram or Pareto Diagram Run Chart Communication

24. Process Analysis:Basic Components or major Steps in a Process

25. Use Process Analysis to: Defines and evaluate the overall process Each box placed in order of occurrence, represents a key part of the process being examined The amount of time could be added as it could be important for improvement Once identified which part of the process needs improvement, the box could be further broken down into specific steps using a flow chart

26. Flow Chart

27. Use a Flow Chart to: Define specific steps in a process including choices and decision points If there is a decision to be made and no specific choices – this is a source of variation and a potential problem! Every process should have a clearly defined beginning and end (all team members must agree on steps)

28. Brainstorming Tool for gathering ideas, particularly about problem causes and solutions

29. Rules of Brainstorming Don’t criticize Be creative Go for quantity not quality Suspend judgment & evaluation Piggyback on others’ ideas Record all ideas Encourage others

30. Fishbone Diagram Also called Ishikawa Diagram in honor of the man who developed this tool Also called the Cause & Effect Diagram because it’s primary use is to assist in determining the root-cause of a problem Use this tool (bone by bone) to identify a major source and drill down to the level where action can be taken

31. Fishbone Diagram (cont). • Determine the problem and create a problem statement (effect). Write it at the right center of the chart • Brainstorm the major categories of causes of the problem. Write them as the main branches steaming from the center line • Brainstorm all possible causes of the problem. Ask “Why did this happen?” about each cause.

32. Fishbone Diagram – (cont). • Write sub-causes stemming from the category of causes • Collect data to confirm root-cause • If no further causes can be identified, then you found the root causes of the problem

34. Check Sheet

35. Check Sheet: Tracking Form

37. Check sheet Used when several possible problem causes are identified, but there is no information on the largest cause Designed to collect data on the number of times that those causes occur Collect data and evaluate action taken The results allow action to be focused in on main causes

38. Run Chart

39. Use Run Chart to: Follow performance (Y) over time (X) (“plotting the dots”) Allow you to visualize how the process is performing and helps you to identify trends (good or bad) Reveals the impact of improvement actions Add the goals to the chart to see progress toward achieving the goal

40. Using Run Charts to track AVF Rates in the Late Adopter Facilities

41. Using Run Charts as a Tracking Tool Where have you been? Where is the data going? Please “plot the dots” A word about “variation” - normal variation - special cause variation

42. Using Run Charts as an Evaluation Tool Compare performance before and after change Calculate % change between old and new level

43. The Danger of Comparing Two Data Points! Peritonitis Episodes/Year 5.9 % 1.1 % July 05 July 06 Average = 3.5%

44. Facility A:Peritonitis Episodes Per Year Peritonitis Episodes Per Year (%)

45. Facility B:Peritonitis Episodes Per Year Peritonitis Episodes Per Year (%)

46. Facility C:Peritonitis Episodes Per Year Peritonitis Episodes Per Year (%)

47. Improvement in Wait Time (Team A)

48. Improvement in Wait Time (Team A) Change Implemented

49. Improvement in Wait Time (Team B)

50. Improvement in Wait Time (Team B) Change Implemented