QAPI How To Do It Objectives •

3/26/2014
QAPI
How To Do It
1
Objectives
• List steps to take to become QAPI focused
• Explain how RCA and PDSA fit into QAPI
• Define system change
2
1
3/26/2014
Polling Question #1
• We believe we are doing QAPI in our
Nursing Home.
– Yes
– No
3
4
2
3/26/2014
QAPI at a Glance contents
•
•
•
•
•
•
Definition of QAPI
Sample scenarios
Five Elements of QAPI
Action Steps
QAPI Principles
Tools:
– QAPI Self-Assessment
– Guide for Developing Purpose, Guiding Principles, and
Scope for QAPI
– Guide for Developing a QAPI Plan
– Goal Setting Worksheet
– QAPI Definitions
5
6
3
3/26/2014
Change Package contents
• Seven Strategies for change with related action
items
–
–
–
–
–
–
Lead with a sense of purpose
Recruit and retain quality staff
Connect with residents in a celebration of their lives
Nourish teamwork and communication
Be a continuous learning organization
Provide exceptional compassionate clinical care that
treats the whole person
– Construct solid business practices that support your
purpose
7
Other Tools
•
•
•
•
•
•
•
•
•
•
•
QAPI News Brief – Volume 1
QAPI Leadership Rounding Tool
Examples of Performance Objectives for Job Descriptions and
Performance Reviews
Measure/Indicator Development Worksheet
Measure/Indicator Collection and Monitoring Plan
Instructions to Develop a Dashboard
Prioritization Worksheet for Performance Improvement Projects
Worksheet to Create a PIP Charter
PIP Launch Checklist
Plan-D-Study-Act Cycle Template
PIP Inventory
8
4
3/26/2014
Other Tools cont’d
•
•
•
•
•
•
•
•
•
•
Sustainability Decision Guide
Brainstorming, Affinity Grouping, and Multi-Voting Tool
Communications Plan Worksheet
Storyboard Guide for PIPs
Improvement Success Story Template
Guidance for Failure Mode and Effect Analysis
Guidance for Root Cause Analysis
Flowcharting
Five Whys
Fishbone Diagram
9
The Five Elements of QAPI
10
5
3/26/2014
CMS Video: Nursing Home QAPI –
What’s in it for you?
11
QAPI Process Tool Framework
12
6
3/26/2014
Element 1 Scope and Design
• Learn the basics of QAPI
– Review the QAPI five elements
– Understand how QAPI coordinates with QAA
– Assess QAPI in your organization
– Create a structure and plan to support QAPI
13
Polling Question #2
• Does your current QA committee contain all
the members just mentioned (ADM, DON,
MD, all department heads or their
representative)?
– Yes
– No
14
7
3/26/2014
Polling Question #3
• How often does your current QA committee
meet?
– A. weekly
– B. monthly
– C. quarterly
– D. other
15
QAPI SelfAssessment
Tool
16
8
3/26/2014
Guide for
Developing
Purpose,
Guiding
Principles, &
Scope for
QAPI
17
Steps
• 1. Locate or develop your organization’s
vision statement
• 2. Locate or develop your organization’s
mission statement
• 3. Develop a purpose statement for QAPI
• 4. Establish guiding principles
• 5. Define the scope of QAPI in your
organization
18
9
3/26/2014
Steps
• 1. Locate or develop your organization’s
vision statement
• 2. Locate or develop your organization’s
mission statement
• 3. Develop a purpose statement for QAPI
• 4. Establish guiding principles
• 5. Define the scope of QAPI in your
organization
19
Guide for
Developing a
QAPI Plan
20
10
3/26/2014
Guide for
Developing a
QAPI Plan
21
• Goal Setting
Worksheet
22
11
3/26/2014
Goal Setting Worksheet
• Describe the business problem to be solved.
– The incidence of facility acquired pressure
ulcers has increased gradually over the past
year.
23
Be Specific
• What do we want to accomplish?
– Stop the development of pressure ulcers of
residents.
• Who will be involved/affected?
– All staff, residents and families.
• Where will it take place?
– Start on south unit and spread house-wide.
24
12
3/26/2014
Be Measurable
• What is the measure you will use?
• What is the current data figure for that
measure?
• What do you want to increase/decrease
that number to?
25
Be Attainable
• Did you base the measure or figure you
want to attain on a particular best
practice/average score/benchmark?
• Is the goal measure set too low that it is not
challenging enough?
• Does the goal measure require a stretch
without being too unreasonable?
26
13
3/26/2014
Make it Relevant
• How will the goal address the business
problem stated at the beginning of the form
• Establish a reasonable target date
27
Element 2 Governance and Leadership
• Understand the QAPI business case
– See remainder of CMS video: Nursing Home QAPI – What’s
in it for you?
• Promote a fair and open culture where staff are
comfortable identifying quality problems and
opportunities
• Create a culture that embraces the principles of QAPI
• Promote engagement and commitment of staff,
residents and families in QAPI
• Involve residents and families
28
14
3/26/2014
• QAPI Leadership
Rounding Guide
29
• Examples of
Performance
Objectives for Job
Descriptions and
Performance
Reviews
30
15
3/26/2014
Element 3 Feedback, Data Systems
and Monitoring
• Use and make data meaningful
– Where is your data coming from?
– What is it telling you?
31
• Measure
/Indicator
Development
Worksheet
32
16
3/26/2014
• Measure
/Indicator
Collection and
Monitoring Plan
33
• Instructions to
Develop a
Dashboard
34
17
3/26/2014
Prioritization Worksheet for
Performance Improvement Projects
35
Element 4 Performance
Improvement Projects (PIPs)
• Implement performance improvement
projects
• Enhance QAPI communications
36
18
3/26/2014
• Worksheet to
Create a
Performance
Improvement
Project Charter
37
• Performance
Improvement
Project Launch
Checklist
38
19
3/26/2014
• PDSA Cycle
Template
39
• Performance
Improvement
Project
Inventory
40
20
3/26/2014
• Sustainability
Decision Guide
41
• Brainstorming,
Affinity
Grouping, and
Multi-Voting
Tool
42
21
3/26/2014
Communications Plan Worksheet
43
• Storyboard
Guide for
PIPs
44
22
3/26/2014
• Improvement
Success Story
Template
45
Element 5 Systematic Analysis and
Systemic Action
• Understand and focus on organizational
processes and systems
46
23
3/26/2014
• Guidance for
Performing
Failure Mode
and Effects
Analysis with
Performance
Improvement
Projects
47
• Guidance for
Performing
Root Cause
Analysis(RCA)
with
Performance
Improvement
Projects (PIPs)
48
24
3/26/2014
• How to use the
Fishbone Tool for
Root Cause
Analysis
49
Fishbone Diagram
50
25
3/26/2014
Fishbone Diagram
51
Fishbone Diagram for Falls
Goal: __Decrease the number of falls among residents in our facility to____ per month by ______________
Equipment
Staff
Environment
Adequate and
good lighting
No clutter in hallways
Walker in good repair
Staff aware of
resident’s fall adequate # of staff
risk status
No Alarms going off
Consistent Assignment
Staff adequately
trained in fall
High number of falls
prevention
in home resulting
No clutter in room
w/c in good repair
in poor quality of
life for the resident
Fall Risk Assessment
Completed on Admission Fall Huddle p a fall
Falls are Tracked
Identified Intrinsic Identified Extrinsic
Risk Factors*
Risk Factors+
Problem in Process
Referral to PT/OT
Falls are trended
Methods/ Processes
Resident Issues
52
26
3/26/2014
• Five Whys Tool
for Root Cause
Analysis
53
54
27
3/26/2014
55
• Flowchart
Guide
56
28
3/26/2014
Action Steps to QAPI
1. Leadership responsibility and accountability
2. Develop a deliberate approach to teamwork
3. Take your QAPI “pulse” with a SelfAssessment
4. Identify your organization’s guiding
principles
5. Develop your QAPI plan
6. Conduct a QAPI awareness campaign
57
Action Steps to QAPI cont’d
7. Develop a strategy for collecting and using
QAPI tools
8. Identify your gaps and opportunities
9. Prioritize quality opportunities and charter
PIPs
10. Plan, conduct and document PIPs
11. Getting to the “Root” of the problem
12. Take systemic action
58
29
3/26/2014
For More Information Contact
Darlene Smikahl, BSN, MSN, RN
Kansas Foundation for Medical Care, Inc.
2947 SW Wanamaker Drive
Topeka, Kansas 66614
[email protected] or 800-432-0770 ext 365
This material was prepared by the Kansas Foundation for Medical Care, Inc. (KFMC), the Medicare Quality Improvement Organization for Kansas, under
contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Servic es. The contents
presented do not necessarily reflect CMS policy. 10SOW-KS-NH_LAN_14_20
59
30