Building QI Skills for QAPI

1. Building QI Skills for QAPI CCME Nursing Home Team August 15, 16, 20, 22, 2013 www.ccmemedicare.org

2. Objectives • Outline QAPI framework. • Describe root cause analysis (RCA). • List three RCA tools. • Apply RCA to clinical situations.

3. The final regulations are not even here! What is QAPI anyway? Wouldn’t you think CMS would stop with the acronym thing! This is way too complicated! I don’t have time for this! I don’t have the financial resources to make this happen.

4. QAPI Truths QAPI is not new. QAPI is expanded quality improvement (QI). QAPI framework uses basic QI skills and tools. QAPI is based on strong leadership and teamwork. QAPI is driven by data. QAPI involves all staff.

5. QAPI Truths Good QI = QAPI • QAPI is not a program. • QAPI is changing to a culture of continuous quality improvement (CQI). • QAPI is already in other settings with federal funding such as hospitals, hospice, home health, transplant providers, dialysis units, and ambulatory clinics.

6. QAPI Truths If you spend your time helping staff build strong QI skills and embed CQI into your culture, you will have no trouble meeting QAPI regulations when they are finalized.

7. Old Model • QI based on regulatory requirements • Low active physician/nurse practitioner engagement • Less frontline involvement • Few early catches • Focus on most serious events • Reaction to spikes and events What does the NEW model look like?

8. New Model Building a QAPI Foundation • Systematic • Comprehensive • Data-driven • Proactive • Real-time problem-solving • Teamwork

9. QAPI A process to continuously identify opportunities for improvement and address gaps in systems through planned interventions to improve the overall quality of care and services

10. QAPI At a Glance http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-05.pdf CCME Process Improvement Handbook www.ccmemedicare.org

11. Polling Question 1 In your opinion, what will be the most difficult aspect of QAPI? QAPI steering committee QAPI self-assessment Selecting target area(s) for PIP Forming PIP teams Facility-wide QAPI plan QAPI staff training Other

12. “Just trying harder is the worst quality improvement plan of all.” —Deming

13. Donabedian Model, 1966 Method for Evaluating Quality • Facility structures • Building, staffing, and financing • Processes for providing care • Methods for providing care and services • Outcomes of that care • Resident outcome measures

14. Basic Quality Improvement Skills • What happened? • Why it happened? • What to do to prevent it from happening again? Systematic structured comprehensive process

15. What happened? Process Map • All steps in current process • In sequence • Outlined in visual diagram • Need input from those who work in the process When complete, analyze it to pinpoint areas for improvement.

16. Process Map for New NA Hire

17. Exercise • At your table, work in teams of 3‒4. • Complete a process map using the template provided. • Fill in steps of immediate post-fall response by frontline staff, development of interventions, and communication to frontline staff. • Use either your facility or someone else’s facility at the table. • One process map per team.

18. Basic Quality Improvement Skills • What happened? • Why it happened? • What to do to prevent it from happening again?

19. Why it happened? Root Cause Analysis (RCA) • Backbone of quality improvement • RCA Tools • 5 Whys • Brainstorming • Fishbone diagram

20. Polling Question 2 What is the most common tool your staff uses for RCA? • 5 Whys • Brainstorming • Fishbone diagram • Other

21. RCA Principles Principles Focus on system, not individual.Each human error must have a preceding cause. Get to root of the problem.Take time now and save time later. Be comprehensive.Get it right the first time, and get all necessary input.

22. RCA Tools Consider All Factors • Human – fatigue, illness, stress, judgment, distraction • Communication – timely, barriers, accuracy, complete • Staffing – schedules, staff/resident ratios, teamwork • Training – content and frequency, staff competency • Supervision – medical, management, and supervisory • Equipment – function, safety, individualized

23. RCA Tools 5 Whys • Easy way to analyze problem • Gets to root cause • No data needed. • Peel away layers. • Determine relationship between different root causes of problem.

24. RCA Tools 5 Whys • Write down specific problem. • Ask Why the problem happens, and write answer down below problem. • Ask Why again, and write that answer down. • Keep asking Why until root cause is identified. • Keep asking until no new answer is given. • This may take 5 Whys or more.

25. RCA Tools Different levels of 5 Whys • Ask 5 Whys on the unit as you discuss a facility-acquired pressure ulcer with frontline staff • Ask 5 Whys during an interdisciplinary team meeting when you discuss a rise in the number of UTIs • Ask 5 Whys as the DON is talking with the nurse supervisors about a spike in CNA turnover

26. 5 Whys Exercise Mr. B fell 15 minutes ago. Why?He got up by himself around 2:00 a.m. He was found on floor by CNA who heard him cry out. Why?Forgets he’s unsafe and does not call for assistance. Is anxious. Why?Moderate Alzheimer's disease. Normal pattern is up 1‒2 times per night with anxiety. Why?Is inactive during day, naps 1-2 hours. Becomes anxious at night and calls out for wife. Why?Refuses to go to activities and is immobile in wheelchair 4‒6 hours a day.

27. RCA Tools Brainstorming Provide inspiration for your team. Stimulate your team’s thinking. Encourage wild ideas. Remind everyone of rules. Provide prompts. Build on ideas of others. Go for quantity. Range of time needed: 5‒30 minutes.

28. RCA Tools Brainstorming • Conference room, at bedside, on unit • Be visual – post-it notes or markers on a whiteboard • Rules • No judgment • All ideas are welcome. • Stay focused. • One conversation at a time • Stay visual.

29. RCA Tools Brainstorming • May need to sort ideas • May need to vote • Identify some ideas that team wants to develop. • Identify worthy goals. • Some are short-term and some are long-term

30. Brainstorming Exercise Mr. B fell 15 minutes ago. He got up by himself around 2:00 a.m. He was found on floor by a CNA who heard him cry out. Immobility + naps + refuses to go to activities + sits in w/c 4-6 hours per day = Awake at night Brainstorm ideas about why he is immobile, does not attend activities, and naps 1‒2 hours per day. As you brainstorm, be aware of opportunities for improvement.

31. RCA Tools Fishbone Diagram • Visual guide and record for root cause process • Helps identify, sort, display, and analyze possible causes • Skeleton of a fish is used • Head is problem • Larger bones are general categories • Smaller bones are causes under each category

32. RCA Tools Fishbone Diagram • Problem stated in box on right (outcome) • Large categories in boxes at end of larger bones • Staff factors (structure) • Care methods (process) • Environmental factors (structure) • Equipment factors (structure)

33. Root Cause Analysis using the Fishbone Diagram: Increase in Falls Facility-wide

34. At no time does robust quality improvement take place with you, alone in your office.

35. Basic Quality Improvement Skills • What happened? • Why it happened? • What to do to prevent it from happening again?

36. Resources for New Strategies Best practices Clinical guidelines Input from frontline workers Input from all staff responsible for process Corporate guidelines Experts in the field National and state resources CCME website, webinars, and learning sessions

37. Methods of Developing New Strategies Process map helps pinpoint areas to change and leads staff in the development of new strategies. Root cause analysis tools help pinpoint areas and potential new interventions. Brainstorm new ideas and interventions in a group. Coordinate team huddles and debriefs.

38. Thank You for Making a Difference! This material was prepared by The Carolinas Center for Medical Excellence (CCME), the Medicare Quality Improvement Organization for North and South Carolina, 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-BI-C7-13-97