Introduction to Quality Assessment and Performance Improvement

Transcription

1 Introduction to and Performance Improvement Melanie P Merriman, PhD, MBA Touchstone Consulting touchst@ix.netcom.com 1 DOWNLOAD THE HANDOUTS Download a copy of the workshop handouts Click on the LINKS button Then click on the Handout link A PDF file will open save it, then print it Let s begin 2 Objectives Discuss why and how hospices use quality assessment and performance improvement Review the processes of quality assessment and performance improvement Understand your role in quality assessment and performance improvement 3 1

2 Performance Improvement Two different functions that go hand in hand. Sometimes referred to as QAPI. 4 Understanding QAPI The Blue-Ribbon Cookie Bake-Off Make some chocolate chip cookies Taste them with friends Figure out how to make them even better Bake some more Taste again Take home the prize! Performance Improvement Re- 5 Understanding QAPI Improving Hospice Performance Hire and train staff; Deliver care; Bill for services; Rent equipment; Manage finances Collect data on indicators of quality Identify areas that need improvement Systematically modify processes Collect data on quality and performance Show improvement! Performance Improvement Re- 6 2

3 Measuring and Improving Overall Collect data about» Clinical quality» Service quality» Patient and family outcomes results of your care» Non-clinical operations Monitor performance regularly Compare performance to your own and industry benchmarks Conduct Performance Improvement Projects when necessary 7 Data-driven Measurement Performance Improvement Process STEP 5 Track and measure success STEP 4 Action towards performance improvement STEP 1 Collect data STEP 2 Measure, analyze & track data STEP 3 Identify strengths & weaknesses Center for Medicare and Medicaid Services. Assurance/Performance Improvement (QAPI) Feedback Loop. 8 Where do quality data come from? Patient charts Incident reports Infection reports After hours call logs Satisfaction surveys Complaint logs Billing Records HR files Financial Reports Volunteer Records 9 3

4 Assess in All Areas Patient/Family outcomes» Comfort» Safety» Satisfaction Processes of Care» Staffing» Admissions» and Plan of Care Hospice Services» Pharmacy» DME» Volunteers Non-clinical operations» Human resources» Referral management» Finance» Billing 10 Measures: What is an indicator? A measured value used to monitor the operation or condition of a physical system (including a person) or an organizational system; a gauge of performance or outcome. 11 Indicators Meaningful measure things that matter to staff, patients or other stakeholders Measurable the data can be easily and accurately collected Manageable the hospice has some control over the factors affecting the indicator 12 4

5 Common hospice quality indicators % of patients admitted in pain who are more comfortable within 48 hr % families who report they were kept informed of the patient s condition How often patients have falls with and without injuries (incidence) Staff turnover Revenue and costs per patient per day 13 Actionable Reporting Example: Cholesterol Level Levels decreasing over time Goal < 200 Current level meets the goal 198 is a good score for this individual 14 Formal quality monitoring Pain Scores for One Patient % of Patients Uncomfortable on Admission, Comfortable in 48 hrs Patient Goal: 3 NHCPO Benchmark 82% 15 5

6 Conduct PIPs Performance Improvement Projects Identification of issues for PIPS» Management and staff suggestions» data monitoring» Survey deficiencies PIP teams mix of disciplines and roles I know there s a better way! PIP process:» Investigate the reasons for the current level of performance» Determine the best way to improve performance» Measure improvements and assure they are sustained 16 Who is involved in QAPI? Everybody! Idea Senior managers/directors» Selection of measures and PIPs» Review quality assessment data Administrative staff» Data entry» Run programmed analyses» Contribute ideas for PIPs and participate in PIP teams Managers and staff» Review quality assessment data relevant to their areas» Identify strengths and weaknesses» Contribute ideas for PIPs» Participate in PIP teams 17 6