Standard Mortality Ratio (SMR) Project: Developing QAPI Without Fear

1. Standard Mortality Ratio (SMR) Project: Developing QAPI Without Fear Svetlana (Lana) Kacherova, QI Director Lisle Mukai, QI Coordinator ESRD Network 18 November 12, 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 Concepts 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. SMR Project: Inclusion Criteria for Participating Facilities SMR rated “Worse than expected” (2008 DFR data) – 27 facilities IMPORTANT: State Surveyors review DFRs before visiting facilities SMR information is available on the Dialysis Facility Compare website at www.medicare.gov

10. SMR Project Goal: All participating facilities will develop to address identified issue(s) for high SMR and implement those processes by May 2008. Validation of implementation will be verified by supporting documentation and direct observation

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

12. 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

13. 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

14. 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

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

16. Quality Concepts • Customers • Processes • Variation • Measurement • Root Cause • Improvement

17. 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

18. Introducing the Quality Tools

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

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

21. 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

22. Flow Chart

23. 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)

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

25. 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

26. 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

27. 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.

28. 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

30. Check Sheet

31. Check Shet:Tracking Form

33. 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

34. Run Chart

35. 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

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

37. 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

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

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

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

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

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

43. Improvement in Wait Time (Team A)

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

45. Improvement in Wait Time (Team B)

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

47. Get more from the Data Segment or stratify - by day - by shift - by machine - by staff, surgeon, physician Use comparative data

48. Pareto Diagram A histogram charted in descending order of frequency Visually displays the contribution of each cause to the overall problem This part of problem analysis helps to focus action and resources on main causes

49. Identifying Major Issues based on Pareto Diagrams/Check sheets

50. Communication Communicate organizational quality definition Communicate customer/supplier needs Discuss problems (opportunities for improvement) Report team progress & project results Exchange information