QAPI Quality Assessment Performance Improvement Audrianne Stromski, RN, CNN
QAPI OBJECTIVES Describe an effective data driven quality assessment & performance improvement (QAPI) program List measures that facilities should review & work to improve through QAPI Discuss how to facilitate QAPI activities using the data collection process
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QAPI ??
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QAPI - Conditions of Coverage V626 QAPI Condition Statement
The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, quality assessment and performance improvement program with participation by the professional member of the interdisciplinary team (IDT) The program must reflect the complexity of the dialysis facility’s organization & services, and must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors 4
QAPI - Conditions of Coverage V627 Standard: Program scope
….an ongoing program that achieves: Measurable Reduction
improvement in health outcomes of medical errors
Data-Driven QAPI The
dialysis facility must measure, analyze, and track quality
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QAPI - Conditions of Coverage The program must include….. (V629) Adequacy (V630) Nutrition (V631) Bone Disease (V632) Anemia (V633) Vascular Access (V634) Medical Errors (V635) Reuse (V636) Patient Satisfaction (V637) Infection Control
Kt/V, URR Albumin, Body Weight PTH, Ca+, Phos Hgb, Ferritin ↑Fistula, ↓Catheter Rate ↓Frequency of specific errors ↓Adverse Outcomes ↑Survey Scores ↓Infections, ↑Vaccination Status 6
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QAPI - Conditions of Coverage Standard: Monitoring
performance improvement
The
dialysis facility must continuously monitor its performance; take actions that result in performance improvement, and track performance to ensure that improvements are sustained over time
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QAPI Program Tool Overview..
The important aspect of the QAPI program are appropriately monitoring and documenting: Data
collection/information areas for improvement Determining potential root causes/barriers Developing, implementing, evaluating, and revising plans that result in improvement in care. Prioritizing
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QAPI Program Tool
Section I Excel
Tutorial
Measures Assessment Tool
(MAT 2.2) & Evidence of Recognizing and Address (ERA) Interdisciplinary Clinical Care of the Individual Patient (laminate) ESRD Core Survey QAPI Review Worksheet Conditions for Coverage V Tag 625-640 Plan – Do – Study – Act Cycle QAPI Outline/Agenda Sample QAPI Interdisciplinary Team (IDT) meeting minute sign-in sheet. 9
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Title Page
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Table of Contents
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NRAA Disclaimer
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Excel Tutorial
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Data Entry Tab
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Texas Children Hospital Data Reviewed for Month of: March ANEMIA MANAGEMENT: Hgb 10-12g/dL (FDA recommends specified ceiling-Hgb of 11gm/dL in pts with ESRD) Data Comparison Goals Value
CMS
Network
Facility
10-12g/dL > 12g/dL < 10g/dL
0.0% 0.0% 0.0%
0.0% 0.0% 0.0%
0.0% 0.0% 0.0%
40% 30% 20% 10% 0%
Anemia Mean Overall
13.0
% Hgb < 10g/dL
12.0
Year: 2013 Go to Data Entry Tab
Go to Table of Contents
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10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%
% Hgb 10 - 12g/dL 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%
11.0 10.0
Anemia Tab
QAPI Meeting minutes for: April
100% 90%
80% % HD Anemia 70% 60% Overall 50%
% Hgb > 12g/dL
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
% Hgb < 12g/dL
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
9.0 8.0
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HD Hgb Mean
11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0
PD Hgb Mean
11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0
100% 90%
% PD Anemia80% 70% Overall 60% 50% 40% 30% 20% 10% 0%
HHD Hgb Mean 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 IDT to review, discuss, and develop action plan if applicable QAPI Meeting Minutes
% Hgb < 10g/dL
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10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%
% Hgb 10 - 12g/dL 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% % Hgb > 12g/dL
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
% Hgb < 12g/dL
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
100% 90%
80% % HHD Anemia 70% 60% Overall 50% 40% 30% 20% 10% 0%
% Hgb < 10g/dL
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10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%
% Hgb 10 - 12g/dL 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% % Hgb > 12g/dL
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
% Hgb < 12g/dL
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
Anemia Outlier report attached if applicable
PLAN - DO - STUDY - ACT CYCLE Outcomes: Are Improving Action Plan Needed? Yes ANEMIA MANAGEMENT: Anemia Overall
Are Declining No
If Yes,
Unchanged New Plan
Improvement Area? Yes No Plan Revision No Change in action at this time Go to Anemia-Iron Fishbone
Hgb 10-12g/dL
Problem Statement: Goal: Baseline Data: Root Cause(s)-Barriers Action
Responsible IDT Members
Start Date Check Point End Date
Status, Outcomes, and Evaluation Comments
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Bar Charts 100% 90%
% HD Anemia 80% 70% Overall 60%
50% 40% 30% 20% 10% 0%
% Hgb < 10g/dL
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10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0%
% Hgb 10 - 12g/dL 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% % Hgb > 12g/dL
5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0%
% Hgb < 12g/dL
5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 16
Anemia Mean Anemia Mean Overall
13.0 12.0 11.0 10.0 9.0 8.0
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HD Hgb Mean
11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0
PD Hgb Mean
11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0
HHD Hgb Mean 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 11.0 17
QAPI Outline/Agenda Example
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Interdisciplinary Team (IDT) Meeting QAPI IDT QAPI Program Meeting Minutes
Go to Table of Contents
Outstanding Items
Data Reviewed for Month of: March
Name of Facility
Date: Print Name
Title
Signature
Initials
Medical Director Unit Manager Nurse Manager Renal Dietitian Social Worker Biomedical Representative
Minutes Signature Date QAPI Meeting:: Time: 19
QAPI Program Readiness Section II
QAPI Readiness
Section II QAPI
Readiness Entry (Central Tab) Clinical Indicators Tracking Forms-infections, vaccinations, adverse occurrences and patient satisfaction/grievance Technical Reviews Data
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QAPI Program Readiness QAPI Program Readiness
Definition:
Main Focuses:
Standardized Tools:
The Facility must develop, implement, maintain, and evaluate an effective, data driven, quality assessment and performance improvement program with participation by the members of the interdisciplinary team.
Collect, review and act on indicator-related data shown to improve health outcomes (Current clinical practice data). Medical errors, mortality and morbidities - identification, prevention and reduction.
MAT (current version), CrownWeb, CMS Clinical Performance Measures (CPM) and Dialysis Facility Reports (DFR) to determine comparison or "average" values associated with clinical outcomes.
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Quality Assurance (QA)
Quality Assurance (Data Mining) Monitor
data/information Data Outcomes Prioritize area that need improvement (quality gaps) Trend
Have all of the patient data identified and trended, outlier interventions completed and documented, root causes identified and ready so the team can discuss the facility-wide improvements during the QAPI meeting. 23
Performance Improvement (PI)
Performance Improvement (Action Plans) Discuss
the identified root cause(s) of qualtiy gap(s) and possible barriers IDT develops, implements, evaluates the aggregate patient data and revises plan that result in improvement in facility wide care.
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Anemia Action Plan
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Tsat / Ferritin Action Plans
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Fishbone Diagrams
Cause & Effect Analysis
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Section III
Section III Cause
and effect analysis and effect diagrams (Fishbones) Anemia case study Facility-Wide anemia/iron action plan Example Blank Fish Bone diagram Cause
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Cause and Effect Diagram Go to Table of Contents
Cause and Effect Diagram (Fishbone) A cause and effect diagram, sometimes called a fishbone or root cause diagram, is one of the many tools used in the quality assessment and performance improvement (QAPI) process. QAPI tools are used to 1) identify gaps in quality, 2) analyze processes or factors, 3) problem solve and develop action plans, and/or, 4) evaluate the success of actions taken.
A quality gap can be defined as failure to meet established internal and/or community indicator-related clinical outcomes. Cause and effect (fishbone) diagrams are most commonly used by the interdisciplinary team (IDT) to isolate and evaluate the reasons for outcomes. The diagrams provide a consistent, organized, and scientific way for the team to make clear intervening decisions directed at the cause of an outcome, rather than reacting to often misdirected “gut reactions”, assumptions, past experience or hunches. Without identifying the specific reasons for an outcome, valuable time and resources will be wasted in developing inappropriate action plans that don’t target the right things.
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Cause and Effect Diagrams What they are? “Pictures” of the causes or reasons for something. Their purpose is to systematically guide the care team through the reasons for an outcome (can be either positive or negative). Used for individual patients or “rolled up” for unit-wide quality gap analysis.
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Anemia Fishbone Diagram Anemia and Iron Management: Success in Reaching Targets Anemia Action Plan Go to Table of Contents
Dialysis Related
Process or Methods
Critical thinking Control of blood Loss Monitoring P & Ps Adequacy of treatment Consistency w/follow up Appropriate heparinization State of the art protocols Managing both anemia & iron
CONSISTENTLY REACHING TARGETS Adherence to treatment regimen
Staff mixes, ratios and responsibilities
Knowledge/involvement
Physician presence and involvement
Control of morbidities
Experience and knowledge
Communication
Assessment w/follow through Use of the QAPI process Communication
Patients
Caregivers
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QUALITY IMPROVEMENT ACTION PLAN: UNIT-WIDE FACILITY NAME:
Jurassic Park
DATE STARTED:
Jan 1-2007
EXAMPLE
ANEMIA/IRON
Go to Table of Contents
Project Owner: TEAM MEMBERS First Level Members
DATE COMPLETED: PROBLEM STATEMENT:
Less than X% of patients reaching hemoglobin target of X%
GOAL:
Increase percent of patients within target range to at least X%
BASELINE DATA:
Monthly labs and dosing reports; Root causes of hyporesponse to ESA (see tool)
ROOT CAUSE(S):
Inadequate or inconsistent ESA dosing; Time lags in changing ESA doses after monthly labs; Outdated protocols Failure to resolve root causes of failure to respond to ESA therapy RESPONSIBLE TEAM MEMBER
ACTION PLAN Establish and consistently follow an anemia protocol
Anemia Manager
Designate staff nurses as anemia managers for their specify patients. Train. Audit 25% of charts for 3 months.
Staff RN Unit Manager RN Anemia Manager
Monitor anemia/iron labs and focus initially on patients with Staff RN sub xx hgb. Unit Manager RN Anemia Manager Use the xyz Labs generated anemia/iron trending report.
Staff RN Unit Manager RN Anemia Manager
START DATE
CHECK POINT
01-1-07
On Going
02-1-07
On Going
02-1-07
On Going
02-1-07
On Going
03-1-07
3-15-07
Train staff on principles of anemia/iron management Anemia Manager
END DATE
2-1-2007
COMMENTS (STATUS, OUTCOMES, EVALUATION, ETC. March 21 2007 update: New protocol in place as of February. Utilized for Feb and March ESA and iron dosing changes. xyz is taking lead on review of dosing changes with input by Dr. xyz. To date, gong well. Will monitor outcome improvement trends and report monthly. March 21: Out of 25 chart audits, 3 patients treated "off protocol". Reasons justified. RNs following protocol appropriately. Hyporesponse forms for individual patients being completed and care plans/action plans developed and implemented. Root causes being trended. March 21 update: Labs reviewed. 31% of patients have sub-xx hgb in March compared to 34% in February (3% improvement)
March 21 update: See attached report and CQI trending reports for February and March. March 21 update: All nurses, technicians, social workers and dietitians attended anemia/iron management 101 workshop. Anemia/iron management workshop 201 attended by all nurses. All staff nurses actively managing anemia/iron on their patients. Continue 25% of patients monthly audits for adherence to protocol.
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Regulatory Audit Tools: Part B How they work – What they do
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Data Collection Trending and analysis tools are included to assist in the quality assessment process and can be revised to facility specifications. Drop down list are provided on each tool , it improves the accuracy of the entries. Select a field and click on the drop down list arrow to select appropriate responses.
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Trends & Analysis Tools
Section IV Adverse
Occurrence Trends & Analysis
Hospitalizations/Discharge/Readmissions Access:
AVF/AVG/CVC/infections/analysis Trends/Mortality analysis Patient compliant/Grievance log CIPA/POC Immunization (Hep B, TB, Influenza, Pheumovax) 2746
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Tools-Audits Guidance Tab Adverse Occurrence Report (AOR) Trends GO TO Enter the number of Adverse Occurrences in the row that corresponds to the event for that month. Analyze the year to date numbers to identify trends (multiple occurrences of the same event, or with the same patient). The column Qtr is quarter-to-date; the column Total is year-to-date
Adverse Occurrence Analysis (AOR) Log
GO TO
Analyze event (s) to see if there was anything that contributed to the event occurring, if there were multiple events caused by the same contributing factor, and whether there is anything we can do to prevent further occurrences. Summarize the findings and document in the QAPI Meeting. Minutes. Completion of the analysis tool provides documentation of your review and follow up actions of each Adverse Occurrence.
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Tracking Trends Adverse Occurrence Trends for Hemodialysis Name of Facility Adverse Occurrence Events ACCESS-RELATED PROBLEMS Accidental cutting of catheter BFR Rate
