Embed Size (px)
Citation preview
Quality Assessment and Performance
Improvement: What’sNew in QAPI for 2015!
June 17, 2015
Michele Kala, MS, RN, Director of Accreditation and Certification
1
Objectives The Participant will be able to:1.Articulate HFAP surveyor expectations regarding demonstration of compliance for performance improvement during the survey process for frequently cited standards.2.Articulate the changes to the 2015 Acute Care Standards Manual regarding Chapter 12, Quality Assessment and Performance Improvement .
2
2015 Acute Care Manual Changes
Changes reflect the CMS changes to the Surveyor Operations Manual.
Content and standards intent has not changed, but standards have been combined.
HFAP has added interpretive guidelines.
3
2015 Acute Care Manual Changes
Chapter length has gone from 18 to 22 pages. Total number of standards has been reduced
from 34 to 19. (standards deletion and combining of standards)
Ten standards were deleted and one standard was added.
4
2015 Acute Care Manual Changes
12.00.07 Quality Assessment Performance Improvement: New standard—Allows surveyors the option of scoring the Condition of Participation out at a standard level rather than a condition level.
Crosswalk of standards
5
New Standards to Old Standards Crosswalk
2015 Acute Care Manual-Chapter 12—NEW
2014 V3 Acute Care Manual-Chapter 12—OLD
12.00.00 CoP citation QAPI 12.00.01 CoP citation QAPI
12.00.07 Standard citation QAPI Not in requirements
12.00.01 Data Collection and Analysis—Defines requirements of the quality plan. 12.00.03 Program Scope12.00.09 Program Accountability12.00.10 Program Data (1)12.00.12 Data Collection
12.00.02 Quality Improvement Program Activities. 12.00.10 Program Data (2)12.00.13 Program Activities12.00.15 Sustained Improvements
12.00.03 Patient Safety, Medical Errors and Adverse Events (Incorporates first two bulleted issues in standard 12.00.01 but is focused on IMPLEMENTATION of the quality plan)
12.00.03 Program Scope12.00.09 Program Accountability12.00.14 Medical Errors12.00.21 Governing Body Responsibilities (3)
12.00.04 Performance Improvement Projects. 12.00.16 Performance Improvement Projects12.00.17 Information Technology Systems12.00.18 Required Documentation 12.00.19 QIO Projects
12.00.05 Executive Responsibilities 12.00.21 Governing Body Responsibilities (1,2, & 5)
12.00.06 Adequate Resources 12.00.21 Governing Body Responsibilities (4)
12.01.01 Quality Management Position 12.00.02 Quality Management Position
12.01.02 Quality Committee/Function 12.00.05 Quality Committee/Function
12.01.03 Meetings & Documentation of Activities 12.00.06 Meetings & Documentation of Activities
12.01.04 Annual Quality Report 12.00.07 Annual Quality Report
12.01.05 Education Program 12.00.08 Education Program
12.00.06 HFAP Clinical Quality Measurement Program
12.00.20 HFAP Clinical Quality Measurement Program
New Standards to Old Standards Crosswalk, continued
12.01.07 Reporting to the Board of Trustees (expanded content) 12.01.08 Reporting to the Board of Trustees
12.02.01 Culture of Safety 12.00.22 Culture of Safety
12.02.02 Adverse Event Review Process 12.00.23 Adverse Event Review Process
12.02.03 Communication to the Patient of Adverse Events 12.01.10 Communication to the Patient of an Adverse Event
12.02.04 Support of Caregivers 12.01.11 Support of Caregivers
6
Old Standards to New Standards Crosswalk
2014 V3 Acute Care Manual-Chapter 12--OLD 2015 Acute Care Manual-Chapter 12--NEW
12.00.01 CoP citation QAPI 12.00.00 CoP citation QAPI
12.00.02 Quality Management Position 12.01.01 Quality Management Position
12.00.03 Program Scope 12.00.01 Data Collection and Analysis (required content in QA Plan)12.00.03 Patient Safety, Medical Errors and Adverse Events (program implementation requirements)
12.00.04 Leadership Accountability DELETED
12.00.05 Quality Committee Function 12.01.02 Quality Committee/Function
12.00.06 Meetings & Documentation of Activities 12.01.03 Meetings & Documentation of Activities
12.00.07 Annual Quality Report 12.01.04 Annual Quality Report
12.00.08 Education Program 12.01.05 Education Program
12.00.09 Program Accountability
12.00.01 Data Collection and Analysis—Defines requirements of the quality plan.12.00.03 Patient Safety, Medical Errors and Adverse Events (Incorporates first two bulleted issues in standard 12.00.01 but is focused on IMPLEMENTATION of the quality plan)
12.00.10 Program Data 12.00.01 Data Collection and Analysis—Defines requirements of the quality plan.(1)12.00.02 Quality Improvement Program Activities. (2)
12.00.11 Quality Principles DELETED
12.00.12 Data Collection 12.00.01 Data Collection and Analysis—Defines requirements of the quality plan.
12.00.13 Program Activities 12.00.02 Quality Improvement Program Activities.
7
Old Standards to New Standards Crosswalk, continued12.00.14 Medical Errors 12.00.03 Patient Safety, Medical Errors and Adverse Events (Incorporates first two
bulleted issues in standard 12.00.01 but is focused on IMPLEMENTATION of the quality plan)
12.00.15 Sustained Improvements 12.00.02 Quality Improvement Program Activities.
12.00.16 Performance Improvement Projects 12.00.04 Performance Improvement Projects
12.00.17 Information Technology Systems 12.00.04 Performance Improvement Projects
12.00.18 Required Documentation
12.00.04 Performance Improvement Projects
12.00.19 QIO Projects 12.00.04 Performance Improvement Projects
12.00.20 HFAP Clinical Quality Measurement Program 12.00.06 HFAP Clinical Quality Measurement Program
12.00.21 Governing Body Responsibilities 12.00.05 Executive Responsibilities (1-3)12.00.06 Adequate Resources (4)
12.00.22 Culture of Safety 12.02.01 Culture of Safety
12.00.23 Adverse Event Review Process 12.02.02 Adverse Event Review Process
12.01.01 Tracking Medical Errors DELETED
12.01.02 Monitoring System Accountability DELETED
12.01.03 Participation in Analysis of Medical Errors DELETED
12.01.04 Analysis of Medical Errors DELETED
12.01.05 Corrective Action DELETED
12.01.06 Medical Error Reporting DELETED
12.01.07 Reporting of QAPI Data DELETED
12.01.08 Reporting to the Board of Trustees 12.01.08 Reporting to the Board of Trustees (expanded content)
12.01.09 Statistical Analysis DELETED
12.01.10 Communication to the Patient of an Adverse Event 12.02.03 Communication to the Patient of Adverse Events
Old Standards to New Standards Crosswalk, continued12.01.11 Support of Caregivers 12.02.04 Support of Caregivers
8
Top Cited Deficiencies for 2014
• 12.00.07 Annual Quality Report:“There is an annual report based on the annual
plan which details all quality activities and their progress or resolution during the year. The report shall be submitted to the governing body for review and approval”
9
Top Cited Deficiencies for 2014
• Explanation The report must include the CEO’s review and
summary of leadership activities to support the program (deleted requirement in the 2015 publication).
The report must be provided annually.
The report must be presented to the governing body for review and input.
10
Top Cited Deficiencies for 2014
• Surveyor Process Review three years of annual reports for
required content
Review governance minutes for verification of review and discussion of the reports
11
Top Cited Deficiencies for 2014
• Frequently Cited Issues Reports not being provided annually
No CEO summary included in the report
No documentation in governance minutes of review and discussion of the annual report
12
Top Cited Deficiencies for 2014 • 12.00.12 Data Collection:“The frequency and detail of data collection
must be specified by the hospital’s governing body.” §482.21(b)(3)
• Explanation The governing body must approve the performance indicators and the frequency of reporting data each year.
13
Top Cited Deficiencies for 2014
• Surveyor Process Review the hospital quality plan for the
current year Review governance minutes to verify
the governing body has reviewed and approved the indicators and reporting frequency for the year.
14
Top Cited Deficiencies for 2014
• Frequently Cited Issues
Governance minutes do not reflect review and approval of the current years indicators and frequency of reporting.
15
Top Cited Deficiencies for 2014
• 12.00.21 Governing Body Responsibilities:“The hospital’s governing body, medical staff, and
administrative officials are responsible and accountable for ensuring the following:
Quality and patient safety program is defined, implemented and maintained.
QAPI plan addresses priorities … Clear Safety expectations are established Adequate resources are allocated Determination of the number of PI projects conducted
annually” §482.21(e)(1-5)16
Top Cited Deficiencies for 2014
• Explanation Governance, medical staff and senior leadership must
determine priorities regarding quality improvement efforts.
Governance must provide strong, clear, and visible attention to setting expectations for safety, allocating resources for supporting the PI process and reducing risk.
All leadership is accountable to implement an effective program which improves outcomes and reduces
medical errors.
17
Top Cited Deficiencies for 2014
• Surveyor Process Review of governance minutes to
determine involvement in performance improvement, improvement of patient outcomes and reduction of risk.
Review of processes to verify appropriate involvement and interventions by governance, medical staff and senior leadership.
18
Top Cited Deficiencies for 2014
• Frequently Cited Issues:Lack of apparent governance involvement in
the QAPI process as reflected in governance minutes.
Apparent lack of involvement and direction from the board, medical staff and/or senior leadership. This would be cited if unresolved quality issues or an ineffective quality plan were identified.
19
Top Cited Deficiencies for 2014
• 12.00.09 Program Accountability:“The hospital must measure, analyze, and track
quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service and operations.Ӥ482.21(a)(2)
20
Top Cited Deficiencies for 2014
• Explanation:The hospital must measure, analyze and track quality indicators that assess processes of care, hospital service and operations. This includes contract services.
21
Top Cited Deficiencies for 2014
• Surveyor Process Verify that data collection is appropriate to
the scope of the hospital (inclusive of all departments/areas). The surveyor will inquire
regarding quality initiatives in many/all departments.
Verify contracted services are included in the data collection process through review of
quality committee minutes and departmental reports.
22
Top Cited Deficiencies for 2014 • Frequently Cited Issues: Hospital departments (often outpatient
services, remote locations) not included in data collection and reporting of performance improvement.
Contracted services not included in data collection and reporting of performance improvement. (also cited in Chapter One, Administration of the Organizational Environment)
23
Patient Safety Initiatives, 2015
• Hospital Quality Assessment Performance Improvement Worksheet—finalized with minor changes to wording but with no changes regarding content.
• Now applicable for Acute Care Hospitals and Critical Access Hospitals.
• Final PSI worksheets can be accessed at www.hfap.org under Resources tab, in the Patient Safety folder
24
Screen Shot
25
Certificate of Attendance__________________________
Awarded 1.0 contact hours
Quality Assessment and Performance ImprovementA 60 minute audio-conference
June 17, 2015
_______________------- Michele Kala
Director of Accreditation and Certification
26
![QAPI DNS DSW final [Read-Only] - LeadingAge New York Synakowski_QAPI.pdf · Background • 2011: CMS QAPI Demonstration Project ... – The main document supporting QAPI in your organization](https://img.pdfslide.us/doc/110x75/601f6e170b75102b516eb6ce/qapi-dns-dsw-final-read-only-leadingage-new-synakowskiqapipdf-background.jpg)
