QAPI in Action. Janet Snipes NHA

Transcription

1 QAPI in Action Janet Snipes NHA 1

2 Webinar Objectives Practical applications of CMS QAPI tools Common wins and challenges in developing QAPI programs How to use storyboards to communicate/ celebrate QAPI success Connect the Framework of QAPI & Baldrige QAPI Element Design and Scope Governance and Leadership Feedback, Data Systems and Monitoring Performance Improvement Projects Systematic Analysis and Systemic Action Baldrige Framework Organizational Profile Category 1 Leadership Category 2 Strategic Planning Category 3 Customer Focus Category 4 Measurement, Analysis & Knowledge Management Category 5 Workforce Focus Category 6 Operations Focus Category 7 Results 2

3 Tools and Resources CMS Process Tool Framework Provider-Enrollment-and- Certification/QAPI/downloads/P rocesstoolframework.pdf AHCA The Quality Initiative provement/qualityinitiative/pages/d efault.aspx National Quality award Program provement/quality_award/pages/def ault.aspx Quality Improvement provement/pages/default.aspx Common WINS! Purposeful Management vs. Management by Crisis CMS 5 star Rating Better Systems resulting in Better Outcomes Reduced Regulatory Burden Alarm Free, Restraint Free, Composite score Below 6, Antipsychotics 1.5% Resident, Family, Staff Satisfaction = Better Occupancy Quality Measures, when one trends up, put your time/ energy into PDSA Better Staff Retention/ Reduced Turnover Leaders have time to Lead! 3

4 QAPI Mission/Vision/Values Key requirements Establish Goals Establish benchmarks Review Data/ Comparative Data Results Drive Strategy Strategy Drives Results Common Challenges! AGENDA Infection Control Quality Measures Audits QIS Interviews/Observations Customer Satisfaction Deaths Survey Issues (real/potential) Staff Retention/Turnover Staff Competency Staff safety (Work Comp) Staff Satisfaction Resident Quality of Life Adverse Events (falls/med errors) Hospitalizations 4

5 Common Challenges! AGENDA Adverse Events Consultant Findings Medication Reconciliation Life Safety Current Clinical Indicators Pressure Ulcers Falls Weight Loss Antipsychotics Abuse/Occurrence reports Consistent Assignment Immunizations/Vaccinations QIS Observations (dining, sanitation, etc) Rounds (findings) Incident Report Trends Grievances Risk Reporting CMS Composite Score Other Challenges! Meetings QAPI vs. PIP Comparative Data Reporting: Monthly, Quarterly, Semi- Annually, Annually Staff Involvement/Engagement 5

6 QAPI Data Availability TrendTracker QIES/ Quality Measures Satisfaction Surveys Advancing Excellence Comparative Data (McKesson) Infection Control logs InterAct Rehospitalization Data Grievances Unexpected Deaths Incident Reports/Falls QIS Tools Examples of QAPI in Action LIVING AND BREATHING QAPI EVERY DAY! 6

7 Nursing/IDT Daily Meetings Interact QI Review of Hospitalization New Admit Charts/Diagnosis/Labs ordered/antipsychotics Telephone Orders / Antipsychotics/Stop Dates/ Diagnosis Adverse Events Findings from Rounds Departmental Meetings/Huddles/Performance Improvement Teams Performance Improvement Huddles Review Departmental Results/seek input 7

8 Operationalizing QAPI Mission/Vision/Values Performance Improvement Constant Reminders of PIP Graphs Huddles Neighborhood meetings Newsletters Walking Rounds Contests-Keep it Fun! 8

9 Graphs-Keep Staff Informed! Keep It Fresh! Rap Song Departmental Presentations/Celebrations at Staff Meetings 9

10 Celebrate! Hats off to Success! 10

11 Staff Comments about QAPI: I have worked in several different nursing homes and we went from one crisis to another, whether it was survey related, patient care related, missing documentation, increase in pressure ulcers, etc. we had to stop what we were doing and work on the crisis. At this facility, we have current data on each issue and we prioritize a systematic approach to correction, it is much more efficient to operate that way. I wish everyone could see the benefit. Staff Development Coordinator I really like to see where we have improved, that makes me feel good, but I also like to see what I need to be thinking about and working on for improvement. Dietary Staff Member QAPI takes the entire team to succeed! 11

12 Questions? Thank you! Good Luck! Have Fun! Janet Snipes, NHA 12