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Thank You for Joining!
New England Nursing Home Quality Care Collaborative
(NE NHQCC)
Learning Series: QAPI: Process, Plan, Outcomes, Part II
Webinar Will Begin Shortly.
Call-In Number: (888) 895-6448 Access Code: 5196001
This material was prepared by the New England Quality Innovation Network-Quality Improvement Organization (QIN-QIO), the Medicare Quality Improvement Organization for
New England, 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. CMSQINC22017040976.
QAPI: Process, Plan, Outcomes, Part II
Sandy Fitzler, RN
Senior Program Coordinator, NE QIN-QIO
Florence Johnson RN, MSN, MHA
Consulting Manager, NE QIN-QIO
Katie Lasewicz, MBA, LNHA
Executive Director, Beechwood Post Acute & Transitional Care
Agenda
Impact of Final Rule on Training
Sharing: Milford Health & Rehabilitation Center QAPI Program
Sharing: Beechwood Post Acute & Transitional Care QAPI Program
Q&A
POLLING QUESTION
Since the first webinar have you made and revisions to your QAPI/PIP teams?…
a) 0
b) 1-2
c) 3-4
d) ≥5
Please elaborate in chat
4
3 Phase Requirement Implementation
• Effective date: 11/28/16 Phase 1:
Existing requirements with minor changes to survey
process.
• Effective date: 11/28/17 Phase 2:
All Phase 1 and those needing more development
time.
• Effective date: 11/28/19 Phase 3:
All Phase 1 and 2 and those requirements needing more
development time.
https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2016-10-27-LTC-Presentation.pdf
Phase 1 - Current Training Requirements on 11/28/16
• Resident Rights & Facility Responsibility
• Abuse/Neglect/Exploitation
Phase 2 – Training Requirements on 11/28/17
• QAPI & Infection Control
• Resident Rights
• Compliance & Ethics Programs
• Abuse & Neglect
• CNA In-Service Training
• Behavioral Health
Phase 3 – Training Requirements on 11/28/19
• Behavioral Health
• QAPI & Infection Control
• Compliance & Ethics Programs
• Communication
Some Available Resources for Dementia & Behavioral Health Training
• Habilitation Therapy Toolkit: New England
QIN-QIO: http://www.healthcarefornewengland.org/wp-
content/uploads/HabTherapyToolkit_090816.pdf
• National Partnership to Improve Dementia
Care: https://www.cms.gov/Medicare/Provider-Enrollment-
and-Certification/SurveyCertificationGenInfo/National-
Partnership-to-Improve-Dementia-Care-in-Nursing-
Homes.html
• OASIS: http://www.maseniorcarefoundation.org/OASIS.aspx
POLLING QUESTION
Did your team identify a project to focus on after the first webinar? Yes No If yes, please share in chat
11
MILFORD HEALTH & REHABILITATION CENTER
• 120 bed facility
• 32 bed short term rehab unit focus on joints and
CHF/pulmonary programs
• 5 star facility
• 5 star Quality Measures
• Yale preferred provider and partnership with Dr. Lahav
(joint bundles)
DEVELOPMENT OF QAPI PROGRAM DESIGN & SCOPE
“We touch people’s lives
• It is our mission to provide our residents and their families with superior care
delivered by staff dedicated to the principles of: Kindness, Compassion, Service,
and Excellence in an environment where the individuality, dignity and value of those
who are served, as well as those who serve, is nurtured and appreciated.
• We believe that life, at all stages, and with all of its challenges is a precious gift to
be shared and celebrated.
• It is our privilege to participate in the lives of our residents, their friends, and
families by offering them not only physical but emotional care, comfort, and
support.”
GOVERNANCE & LEADERSHIP
• Administrator and DON
accountable for overseeing
committee
• Provide annual education on
committee purpose and how
to participate in program as
well as focused education
with identified areas
• Awareness
• Story boards
• Posters
• Pamphlets
• Newsletters
• Staff meetings
FEEDBACK, DATA & MONITORING
• Casper reports
• Quality Indicators
• LTC trend tracker
• Pinnacle interviews
• Strive for 5 interviews
• Food questionnaires
• Interact trending
• Ambassador Program
PERFORMANCE IMPROVEMENT PROJECTS
• Monthly Quality Risk Council (QRC) Meetings where we look at
Key Performance Improvement areas set by company as well
as data gathered from multiple sources
• Performance Improvement Projects are selected based on
quality standards set by team and CMS guidelines
* less than 10% of residents experience mod-severe
pain
* FA PU <2%
Quality – Risk Council (QRC) Monthly Meeting
KPI Process
Owner
Status of
KPI
SMART Goals and Plan
(Leading Indicators)
Results
Fin
an
ce
Facility daily Medicare rate is at or above the
targeted facility adjusted daily rate
EBITDAR is at or above budget
Days in AR are ≤ 38 days or the facility is
achieving improvement at the rate of 25%
reduction in total days
Long stay residents are participating in a
formal rehabilitation program at a rate of
15% of average monthly census
Clin
ica
l
Quality measures trigger at a rate of ≤ 2 per
month
The facility fall rate is ≤ 6.5 falls per 1000
days
Facility acquired pressure ulcers occur at a
rate of < 2% of average monthly census
Less than 10% of residents experience
moderate to severe daily pain
Re-hospitalizations within first 30 days of
SNF stay occurs for ≤ 14% of residents
Star Rating is ≥ 4 (QM star rating is = 5)
SYSTEMATIC ANALYSIS AND APPROACH
• Use reasoning mapping to find root cause of issues
• Focus on “why”
• Drill down to priority reason why issue had occurred
• Formulate and implement a PIP
• Evaluate effectiveness of PIP
• Update PIP as indicated
• Review monthly at QRC
Possible Reasons Likely Reason Priority Reason:
KPI
30 Day Goal:
Likely Reason
Get there:
Ways to get there:
1.
2.
Likely Reason 3.
4.
____________________
____________________
____________________
____________________
PIP – PRESSURE ULCERS
• Goal <2% facility acquired pressure ulcers
• Where we started 3.0% average over a 3 month period
before implementation of plan
• 0.9% after implementation of plan and continued
monitoring of the plan
Possible Reasons Likely Reason Priority Reason:
KPI
30 Day Goal:
Likely Reason
Get there:
Ways to get there:
Likely Reason
Facility
acquired
pressure ulcers
occur at a rate
of <2% of
average
monthly census
Care guides may not
reflect the accuracy of
the resident’s current
condition
Identification of those
residents at risk
Preventive measures on
in place on all areas
Care guides may not reflect the
accuracy of the resident’s current
condition
Upon reading care guides, aides will
identify those resident at risk for
skin breakdown and their
preventive measures.
1. Lack of at risk
identification for those
residents at risk – ie:
assignments, TAR, unit
list, etc.
2. Care guides may not
reflect accuracy of the
resident’s current
condition
3. Preventive measure
not in place on all areas
ie: care guide, care plan,
orders, etc. (boots,
mattresses, cushion,
etc.)
4. Discrepancies in
orders – heel boots vs.
lifts vs. pillow etc.
5. Staff not able to
identify those at higher
risk for pressure
breakdown
6. Braden scales may
not accurately reflect
overall status/condition
of the patient
1. ICN will audit each resident and
compile a list of those resident at risk
for skin breakdown
2. Each resident at risk for skin
breakdown will have preventive
measures identified on care guide,
care plan, and TAR as indicated
3. Each unit will be supplied with a
list of residents who have a
alternating mattress, heel
lifts/boots/cushions etc. and list will
be updated monthly by ICN
4. ICN will audit for accurate orders
and preventive needs based on risk of
the resident
5. Monthly review at QRC and
finding/trends
Facility acquired pressure ulcers occur at a rate
of < 2% of average monthly census Wound RN
FA PU <2%
December rate :
3:0 %
Goal: Upon reading care guides, aides will
identify those resident at risk for skin
breakdown and their preventive measures.
ICN will audit each resident and compile a list of those resident at risk for skin breakdown
Each resident at risk for skin breakdown will have preventive measures identified on care guide, care plan, and TAR as indicated
Each unit will be supplied with a list of residents who have a alternating mattress, heel lifts/boots/cushions etc. and list will be updated monthly by ICN
ICN will audit for accurate orders and preventive needs based on risk of the resident
Monthly review at QRC and finding/trends
1/31-2017 – Wound nurse
completed audits. HR/Bill/Sally
complete audit on alt. air
surfaces. Working to get short
term residents off surfaces that
we own and move them to
rental. Brief attendant in and
did audit on each resident for
correct sizing of briefs. Wound
nurse continue to update list of
residents at risk for skin
breakdown with any new
interventions.
BARRIERS
• Team wanted to focus on how to fix issue not on the “why”
it was happening
• Picking just one reason to “why” the issue was occurring
(the hope is to implement a plan to improve one reason
will trickle down and fix the others)
• It takes FOCUS and TIME to improve!!
SUCCESS!!
• Rate dropped to 0.9%
• Staff able to better identify those at risk and preventive
measures to put into place
Beechwood Post Acute & Transitional Care & Long Term Care
Katie Lasewicz, MBA, LNHA
Executive Director
Beechwood Post Acute & Transitional Care & Long Term Care
• 60 Beds
• 30 Short term (2 dedicated hospice beds)
• 30 Long term
• Independently Owned
• Live & Breathe QAPI
QAPI Committee
• Our committee does double duty as our Medical Staff Meeting- meets on a quarterly basis – Physician
– APRN
– IDT Team
– Vendors
• In between quarters if a need arises it is initiated by the IDT team in morning report.
Last year‘s/Current PIPs
• Revisited Steamtable Dining “Steam Team” • Re-hospitalization Rate • Discharge Process • Employee Injury/ Body Mechanics- Team Name “Body Safety champs” • Elopement • Quality Measures • Satisfaction Survey • Pressure Ulcer • Alarm Reduction • Grievance Process • Mega Rule Changes
– Hearing Aide/Dentures – Care Plans – Etc…
Pressure Ulcer Reduction
• Identified on our Quality Measures that our Short Term & Long Term rates were increasing.
• Long Stay Residents with High Risk Pressure Ulcers: – Q1 2016 6.9% – Q2 2016 11.1% – Q3 2016 12.9%
• Short Stay – Q1 1.3% – Q2 1.3% – Q3 1.3%
• Goal set by SMART formula to reduce percentages below State Average & Improve Quality Measures
• Root Cause Analysis Initiated with IDT team
Root Cause Analysis
• Identified Multiple Areas to Improve: – Wound Care Products & Application – Equipment – Skin Care
• Implementation – Multi Step Process
• Evaluated Current Wound Care Protocol & Skin Protocol – Vendor Switch, new protocol
• Evaluated Current Equipment – Heel equipment – Mattresses
– Goal for Q4 to show reduction once all pieces were in place
Pressure Ulcer Reduction
• Q4 2016 Long Stay- 0% Short Stay 1%
• Q1 2017 Long Stay- 3.2%** Short Stay 0%
Alarm Reduction PIP
• Quality of Life Improvement
– Hope to improve quality of life and potentially reduce falls
• IDT Team initial team to discuss
• Goal set by SMART formula to reduce Alarms
Root Cause Analysis
– Nursing learning circles/meetings identified 3-5 residents at a time to remove alarms
• Alternative intervention education given
– Letter sent to Families
– Other Staff (dietary, housekeeping, maintenance, recreation, office) educated on alarm reduction
– Each month a review was done, and then next residents identified per the Nursing team
Alarm Reduction
• Initiated End of March
• End of August- 2 residents with Alarms left (2 per family were never to be removed)
• October- facility was completely Alarm Free
• Falls have decreased, including repeat customers!
Upcoming Events
• Webinar - QAPI: Process, Plan, Outcomes - Part II:
Thursday, April 20th at 11am
• Webinar - Antimicrobial Stewardship in LTC 6-part Series – Approach to the
Patient with Suspected UTI (Part 3)
Tuesday, April 25th at 11am
• Face to Face Event- Pain Conference with Carol Curtiss
June 21st in West Lebanon, NH
• Face to Face Event - Pain Conference with Carol Curtiss
June 20th in Portsmouth, NH·
• Affinity Group: Focus on Improving Incontinence
4 monthly 1-hour calls with guest speakers, sharing and action plans
Starting in May
39
Contact your Nursing Home
Quality Improvement State Lead
• Connecticut
Florence Johnson:
• Maine
Danielle Watford
• Massachusetts
Sarah Dereniuk:
• New Hampshire
Pamela Heckman:
• Rhode Island
Nelia Silva Odom:
• Vermont
Gail Harbour:
40
Win Complementary Entries to Our
Pain Conferences
To enter, like us on Facebook between April 6th and June 7th:
https://www.facebook.com/pages/The-New-England-QIN-QIO/1792031427682514
42
The New England QIN-QIO Nursing Home Quality
Care Collaborative will choose one winner for per
location.
Each winner will receive 2 entries to the event of their
choice.