Quality Assessment and Performance Improvement

Presented by:

Jodi Oglesby, RN, CNN

Nurse Manager

Dialysis Clinic, Inc. Warrensburg

History of QAPI

Quality Improvement Quality Assurance Continuous Quality Improvement Quality Assessment and Performance

Improvement

Do we get it yet?????

QAPI 2009

“It’s what you learn after you know it all that counts”

John Wooden, UCLA Basketball coach for 27 seasons, 10 national championships including 7 in a row from 1967-1973.

Objectives

Tracking and Trending Identifying Areas for Improvement Creation of a Quality Improvement Plan Defining Goals Measuring and Prioritizing “root” cause Developing Interventions Remeasurement – Testing Changes

When solving problems, dig at the roots instead of just hacking at the leaves.  ~

Anthony J. D'Angelo, The College Blue Book

Vtag 625 Condition: Quality Assessment and Performance Improvement (QAPI)

This Condition looks at: Facility data Requires facility-based assessment and

improvement of care This is different from the Plan of Care which is

patient-based improvement

Quality Indicators

Adequacy of Dialysis Nutritional Status Mineral Metabolism and Renal Bone Disease Anemia Management Vascular Access Medical Injuries and Medical Errors Identification Hemodialyzer Reuse Program (if the facility reuses

hemodialyzers) Patient Satisfaction and Grievances Infection Control As well as, Measures of Water and Dialysate Quality and

Safety, and Safe Machine Maintenance

Program Scope An “ongoing” program

Continuously looks at all indicators (overall vs. individual)

Trends outcomes (again, overall…) Develops an improvement plan when indicated.

Generally will require at least monthly review of indicators Prescribed patient indicators are typically evaluated

with laboratory results monthly Serves as a functional time frame for trending of data

within the facility

Goals/Benchmarks

Set Facility Specific Goals Data on current professionally-accepted clinical

practice standards must be used MAT CPM’s

Goals vs. Outcomes If facility performance is below average

Expected to take action toward improving those outcomes

Monitoring Data/Information

Facility must measure, analyze, and track quality indicators (or other aspects of performance that the facility adopts or develops) that reflect processes of care facility operations

Records of QAPI activities including minutes or another method of demonstrating this analysis and action must be available for review

Facility should compare their performance with community-based standards other facilities in their State their Network the U.S.

Measure, Analyze, and Track

Trending Data Collective patient data Review HD and PD separately

Priority Identify potential problems Prioritize areas for improvement Identify opportunities for improving care

(drop down box)

FrequencyAnnual

QuarterlyMonthly

Bi-annual

(drop down box)

Goal MetYes/No

(drop down box)

PriorityLowHigh

Urgent

(drop down box)

Action Plan RequiredYes/NoOngoing

JAN FEB MAR

Anemia (add Threshold/Goal)

Hgb < 10

Hgb > 11

Hgb > 13

Iron Sat: % pt's >25

Ferritin: % pt's 100 - 800

Discussion:

TRACKING TOOL

Add your facility determined goals and thresholds

You may choose to use a variety of tools and tracking methods for data review: Aggregate trend spreadsheets

You may choose to use a variety of

tools and tracking methods for data

review:Graphs

Identifying Problems Review collective patient data;

Look at trends Steady improvement or stable outcomes Abrupt or steady decline in outcomes

Identify any commonalities among patients who do not reach the minimum expected targets;

One vehicle accident may not indicate you are a bad driver…..

However…10 accidents a year may cause your insurance company to make some changes in your plan!

Quality Improvement Plan Plan that results in improvement in care

Developing Implementing Evaluating

Monitor the effectiveness of the plan Revising

Adjust portions of the plan that are not successful

What are we trying to accomplish? How will we know if a change is an improvement? What changes can we make that will result in

improvement?

Quality Improvement Plan

QIP (Quality Improvement Plan) should include the following:

• Identify Opportunity for Improvement • Set Specific goal for Improvement • Define and Measure Root Causes – PRIORITIZE!• Identify Interventions • Identify Person(s) responsible • Date Process began • Date/Frequency of Re-measurement • Outcomes-Measurement results

Develop Goal Work together – entire IDT Write clear statement identifying problem Use numerical “measurable” goal Set specific time range to meet goal Assure goal is obtainable within specified

time range Use smaller goals in step by step

fashion until ultimate goal is reached

Example: GOAL: Reduce number of catheter patients to <10% by December 2009

Or … Reduce number of catheter patients by 2% each month

Identify Root Cause For Example: If a data report shows that the facility’s

ranking for hemodialysis adequacy is below the expected average Facility must demonstrate QAPI review of global factors

that might affect adequacy Brainstorming with IDT Data/Spreadsheets to “measure” barriers

Identify Root Cause

Show “Root Cause Analysis” What %

Missed or shortened treatments; Use Less-efficient dialyzers; or Fail to achieve the ordered blood flow rates

Prioritize Which root cause is having the greatest impact on the

problem? Often the “assumed” root cause turns out to be different

when the barriers are actually measured! Avoid Scattergun Approach!

Develop Actions/Interventions

Focus on process What process can you change or create that will have a

positive impact? Make actions barrier-specific

How will changes impact the root cause? Choose one or two actions which will have the greatest

impact (Rapid cycle improvement) Review available best practices

Will they work in your facility? Discuss how you will monitor new processes

How will you know if changes are an improvement?

You can’t fatten a cow by weighing it.

-Middle Eastern Proverb

Doing the same things over and over will not result in change!

If interventions are not having positive effects Try a different approach Go back to root cause… has anything changed? Remember… look at process, not just outcomes

Changing A Process

Example: Facility determines inadequate BFR’s are highest priority

root cause for patients not achieving adequacy Facility reviews current process and determines new

process is needed

NEW PROCESS > Daily audit checksheet: Nurse rounds after initiation of each shift to assure BFR

and other prescription parameters are met Allows action to be taken immediately rather than waiting

for monthly lab review to reveal a problem

Evaluation:Measuring Changes Graph monthly data Review trends for improvement Discuss and document changes in monthly QAPI

meetings What’s working? What’s not working?

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Electronic Data Collection Some facilities may be able to pull

“electronic” reports for trending data

REMEMBER… Data reported is only as good as the

data entered in the electronic or hard copy collection tools. This takes participation and cooperation of all staff.