Building the Capacity for QAPI Plans

Transcription

1 Building the Capacity for QAPI Plans Cultivating the Culture Publication MO NH December 2013 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, 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

2 Welcome!!!! Publication MO NH December 2013 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, 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

3 GoToWebinar The Questions Chat box

4 GoToWebinar Raise Hand Button

5 Please set your audio option

6 Show-Me Quality Games

7 Show-Me Quality Games 5 Simple Steps to Gold: 1. Select improvement project, a project team and send us a team photo. 2. Attend Show-Me Quality educational offerings. 3. Fill out QAPI Self Assessment Tool. 4. Complete the Using PDSA for QAPI worksheet. Because quality improvement projects are always a work in progress, submit a second Using PDSA for QAPI worksheet. 5. Submit a story of your home s success (or lessons learned) to Primaris.

8 Get Started Going for the Gold You ve already reached Copper Level by joining the collaborative. Your certificate is in the mail! Find the complete program guide and worksheets for submission at Contact your Program Manager with questions! Review webinars you missed via our website

9 Regional Affinity Groups your contact with suggestions Watch for announcements

10 Keeping You Up to date: Monthly newsletter Via QAPI-related tips Provider highlights: hear from colleagues about what works Updates on available tools, resources, and training to help you Upcoming events

11 Keeping You Up to date: on the Web All newsletters Calendar of events Register for all events Links to additional resources Archived webinars Show-Me Qua lity: QAPI In Action

12 Our Show Me Quality: QAPI in Action Consultant Team Pam Guyer BS, NHA Alexis Roam MSN, RN Judy Halley RN BC, BSN, LNHA Peggy Neale-Lewis BSN, RN, CPHQ Kent McGeeney LNHA, MPA, MSE

13 Today s Objectives: 1. Discuss the benefits of QAPI and the culture change that occurs. 2. Explore the CMS, Guide for Developing Purpose, Guiding Principles, and Scope for QAPI, to aid managers in developing and communicating the organization s vision and mission. 3. Describe how QAPI is integrated into all aspects of the organization.

14

15 Resources Show-Me Quality: QAPI In Action

16 Mission, Vision, and Purpose Locate or create your organization s: Mission statement Vision statement QAPI purpose statement Guiding principles

17

18 What is a Vision Statement? A vision statement is your center s desired future state. It describes where your organization is headed, what it intends to be, or how it wishes to be perceived in the future. Articulate what you are working toward. It is a longterm view and concentrates on the future. It can be emotive and is a source of inspiration. For example, a charity working with the poor might have a vision statement which reads "A World without Poverty. Your view of the world, not what you will do.

19 What is a Mission? A mission statement should reflect your center s overall function. The mission answers the question, What is your organization attempting to accomplish? A mission statement explains the company s reason for existence. The mission statement supports the vision and serves to communicate purpose and direction to employees, customers, vendors and other stakeholders. The mission can change to reflect a company s priorities and methods to accomplish its vision.

20 A Purpose Statement for QAPI How will QAPI support your home s overall vision and mission? For example, the purpose of QAPI in our organization is to take a proactive approach to continually improving the way we care for and engage with our residents, caregivers, and other partners so that we may realize our vision. To do this, all employees will participate in ongoing QAPI efforts which support our mission.

21 Polling Question Do you share your mission, vision, and values as people are applying to work in your home? Just starting On our way Almost there Doing great

22 Guiding Principles Values: Beliefs that are shared among the stakeholders of an organization. Values drive an organization s culture and priorities, and provide a framework in which decisions are made. The vision alone is not enough. Given your vision of the future, how, specifically, will your company work to achieve it? These guidelines or values should be written in a manner by which people, at all levels, can be held accountable.

23 Guiding Principles Guiding Principles describe the organization s beliefs and philosophy pertaining to quality assurance and performance improvement. The principles should guide what the organization does, and why and how it does it. Review the Five Elements in QAPI at a Glance on page 8 to ensure you capture all aspects of QAPI.

24 Guiding Principle Examples: In our organization, QAPI includes all employees, all departments, and all services provided. The outcome of QAPI in our organization is the quality of care and the quality of life of our residents. Our organization has a culture that encourages, rather than punishes, employees who identify errors or system breakdowns.

25 Polling Question Have you created guiding principles with staff and incorporated them in all job descriptions? Just started On our way Almost there Doing great

26 Let Vision, Mission, and Guiding Principles Drive Your Actions Change Concepts: Translate your organization s mission into action Inspire your passion Find meaning in the ideal Make images of the future Take pride in being unique

27 Developing the Why Specific, yet Broad enough that everyone can have ownership and engage. Inspires and activates engagement People buy in to the why, not the what or how.

28 Simon O. Sinek The Golden Circle

29 Don t Go at it Alone Have residents, staff, and family members assist in reaffirming your mission, vision, and establishing guiding principles. Establish your center's Guiding Principles incorporating QAPI in your home. Download CMS Guide to Develop Purpose, Guiding Principles, and Scope for QAPI tool for additional assistance in identifying your guiding principles.

30

31 Define the Scope of QAPI in Your Organization Outline the types of care and services you provide including quality of care, quality of life, resident choice, and care transitions, and include the care and services provided by all departments. Determine how each will: Use QAPI to assess, monitor, and improve on an ongoing basis Aim for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents (or resident s agents).

32 Polling Question Have you identified how all service lines and departments will be engaged and utilize QAPI to plan and do their work? Just starting On our way Almost there Doing great

33 Individualize to Your Home Describe how QAPI will utilize the best available evidence (e.g., data, national benchmarks, published best practices, clinical guidelines) to define and measure goals. Describe how QAPI is integrated into the responsibilities and accountabilities of top-level management and the Board of Directors (if applicable).

34 You Have Created the Preamble to Your QAPI Plan! Assemble the vision and mission statements, guiding principles, and scope of QAPI into a separate document. This will help you articulate the goals and objectives of your organization. Consider posting for all to see.

35 An Awareness Campaign with Inspiration! Back to The Why Inspire and inform everyone about QAPI ( staff, residents, family, consultants, ancillary services, etc.) and your organization s QAPI Plan Provide inspiration and training about QAPI to all Include QAPI training for new staff in their orientation

36 Your Values are a Verb: Try This! Stories make your vision come to life. Authentic behavior builds trust. Model your mission. Rounds catching people demonstrating your values. Highlight staff stories of positive examples. Keep talking about it! Share something about your mission, vision, and values at every staff, resident, and family meeting.

37

38

39 Resources Show-Me Quality: QAPI In Action

40 Actualize Your Guiding Principles As we leave you today, do one thing to bring life to your values in your home such as: Make rounds catching people demonstrating your values and share at staff meetings.

41 Next Time: Building Capacity for QAPI Plans The Guiding Team Roles and Responsibilities Difference of the Guiding Team and PIP Teams Pre-work for next webinar = Invite your team to attend

42 Next Webinar: Building the Capacity for QAPI Plans: The Guiding Team January 28, 2014 from 1-2 pm. Register at: Thank you for your time and sharing!