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Welcome to TMF conference call. Your host, Carla Smith, will now begin.
Good afternoon and welcome to the webinar -- QAPI What now?
I know that most of you have had contact with your TMF consultant. I am one of the consultants at TMF and I will be the moderator for today's webinar. The objectives for today are -- to be able to define quality measures, defined QAPI, verbalize understanding of the quality measure data and how it relates to QAPI, and understand how your ship and teams drive the QAPI process.
I want to introduce you to the safety team members -- first, Susan Purcell, the director of our team, Frank Barber, a consultant and one of the presenters were today's webinar, Cayce Brewster, our departmental assistant -- and we could not survive without her and all the extra things that she does for our team.
Then we have Tiffany Langham, I consulted in the Dallas area and Debi Majo, another consulted in the Austin area and Melody Malone will also present today.
We also have Minnie Malone, our project resource consultant. She keeps us on track and helps us prepare a lot of reports. Needless to say, many is valuable to our team. Then there is me -- Carla Smith.
Let's get started with the first session -- quality measure analysis and Quality Improvement.
Jot down your questions or feel free to use the chat feature and typing your questions anytime.
The first speaker will be Melody Malone.
Thanks, Carla. I want to welcome everyone to the webinar. I will discuss about QAPI -- What Now?
What is quality assurance it performance and improvement? As we start to open up to the idea of QAPI for quality assurance performance improvement, it is important to know that this is an initiative driven by CMS and will ultimately result in a major revision of the [indiscernible] 520 -- also known as quality assessment and assurance. We are not sure when the regulation will come out, but we know that it will. CMS has released that information.
The project you are in with us at TMF is based on helping you learn the concept of QAPI and to begin to integrate it into the facilities practices. The key concepts of QAPI are that data is used to drive decisions. It is an approach that is proactive and stays ahead of problems by creating a system for continuous monitoring that will sustain improvement. QAPI is comprehensive. It incorporates all departments and it encompasses all care and services.
QAPI is part of a culture of quality. We must constantly find ways to do things better. QAPI thrives in a just culture where all staff is willing to come forward to continuously identify opportunities for improvement and safety concerns.
The term "system" is used frequently. This refers to the interaction and interdependency of people with processes and the environment working together toward a common mission.
This system includes supporting components and all functions and activities of an organization, each element of the system influencing the other elements.
For example, staffing levels and equipment influence housestaff can carry out specific tasks. System thinking requires an understanding of the importance of each individual piece within a system. And the importance of how these pieces work or don't work together.
Each piece of a system influences the other pieces. In nursing homes, systems can be thought of as a combination of people, structures, supplies, and resources that come together to make the nursing home function.
By utilizing data, systems thinking, and teams as an approach to problem solving, the different parts or components of the system are viewed as belonging to a larger system. When a problem occurs, the entire system is ready to understand how all parts work together or not. Rather than just reacting to one of those parts in isolation.
Then we layer on person centered care and give the residents and staff a voice and a choice in how things are accomplished, we identify improvements that can be made. That will be sustained into the future.
Wouldn't it be great to sustain our improvement?
QAPI is more than a regulation or a healthcare reform requirement. It is a way of managing all polity operations. Since data is a driver, we will discuss the quality measures. Here is my disclaimer. I am not an MDS asks Bert. Always use the RAI manual. Always use the quality measure manual and be aware of the quality measure ID module and the five-star rating guide. I know it sounds like a lot, but good news -- I will show you where to find all of that. Three of the manuals are in one location at CMS but good news -- I will show you where to find all of that. Three of the manuals are in one location@CMS.gov. They are at the RAI manual page. If you scroll to the bottom into downloads, you will find three of the manuals -- the RAI manual or the MDS manual the quality measure ID module and the quality measure used to work user manual.
I have the web links at the end of the presentation if you downloaded the handouts they will be available. You can also see the web links on our homepage at the Texas QIO page 4 nursing homes under the QAPI resource button.
The other manual is the five-star quality rating system technical users guide. You can find this at CMS rating system technical users guide. You can find this@CMS.gov at the five-star rating page in the download section. Scroll down the page.
You really need all of these manuals and I like to keep them electronically because it makes them easy to search. I just keep them on my computer. You need all of them to understand the quality measures and you really want to understand them because they are used in a variety of ways. The quality measures were developed by both the national quality forum and CMS. Currently CMS uses 17 quality measures. This was just updated on Monday, so if you downloaded these handouts even as late as one hour ago, you may not have this current updated slide set. Quality measures were updated to include two new measures -- the Texas quality reporting system -- you may know it as they QRS site -- that is the Texas public site. They are going to be using the quality measures, but we do not know what they will be using it. When I last checked about a month ago they still did not have an answer.
Someday we will see an update from them.
The nursing home compare site -- you also may know it as Medicare.gov. They use 18 quality measures. The five-star polity raging system to actually come up with your quality measure five-star rating on the federal public website only uses 9 of those quality measures for their calculations.
Here are the nine quality measures -- this was as of the user guide July 2012. You can find it in that guide and you can't remember that it is on the CMS website.
-- You can remember this.
The survey process also uses the quality measure report. See how important they are? The facility report, as you will see in a few minutes, we'll give you an overall rating of how your building is doing compared to the state and national average. So, the surveyors are going to look to see if there are some high percent rankings that might indicate potential problem areas they would want to investigate. The resident level report can give them targeted residents that they may want to look at as well. This was released in guidance in appendix P in September 2012. You can find this on the CMS website as well.
Now, for those of you that actually use the key system to submit your MDS 's, this is how you get to your quality measure report. If you use another system, you may have to go through that system to get those reports. We actually have a how to access your quality measures document on our website in the QAPI button on the nursing home page. There are 4 reports that you can access. I encourage you to look at the characteristics report and the quality measure report for the facility and resident level report. There is a submission statistics report that you may choose. I personally do not use it that much, but you may want to.
Once you select the reports you want, you just have to put in your facility ID. I recommend that you select a six-month data time because otherwise at least one of the quality measures will not populate correctly if you ask for less than six months.
Plug-in the dates you want and hit submit. The reports will end up in your folders. There may be multiple folders, so you may have to hunt for it a little bit. Most only have two or three folders.
Then you will have your reports. The CASPER quality measure report today which is different from Sunday now has 17 quality measures. Three of them are short stay measures and the remaining are all long stay measures.
The two new measures are the ones that are the short stay residents who newly received antipsychotic medication and the residents who received antipsychotic medication long stay.
Let's take a quick look at the report. I will show you how to read the report. The first thing you want to make sure you do is double check your date range and ensure that you are looking at the same set of dates for every report. So, you are making sure that you are comparing -- I always call it by the ending time. In this case it would be the November report. You are always looking at the same set of reports. Otherwise, you could be comparing apples and oranges.
The way that this works -- whatever the problem is -- or in this case the characteristics of gender -- male and female, the numerator is the number of people that have that issue. In this case, there were 45 men and 71 women. I debate denominator or total sample for that item of 116.
You will see that the denominator changes depending upon the measure specification. You can find the measure specification for every measure in the quality measure user manual.
So you can see the numerator and denominator and if you divide the numerator by the denominator, you get the observed percent. Then you see the state average and the national average. In this case, the observed percent of 38.8 for males is slightly higher than the state average and a little bit higher than the national average. That is how you read these reports. I will not go through all of the items on the characteristics report. As you work with your quality consultant from TMF, they will be able to help you with these reports.
One thing I like to point out on this characteristics report is the issue of the number of residents on hospice. That is clearly a resident Joyce and family decision. -- Resident Joyce and family decision.
The resident must have a choice of life expectancy for less than six months. In this case, there are only format with that prognosis and there are 8 on hospice. I am sure that this facility was not emitting fraud. This may be a first indication of the quality opportunity with regard to and accuracy of MDS, ensuring that we always have accuracy as we answer the question. It could be a point and click error where we clicked wrong. Or it could have been a lack of understanding that they needed to go to the hospice document and find that answer. As you go through these, always challenge yourself. If you find a mistake, is it a point and click error or is it an understanding of how to answer the question? That would be another type of quality improvement opportunity. Or, is it a bedside quality improvement opportunity?
Now we will look at the facility quality measure report. Same thing -- always look at the date range. What is interesting in the quality measure report is now that the measures are delineated as short stay measures or long stay measures. A short stay include residents that have been in your building 100 days or less. A long stay measure means they have been in your building 101 days or more.
You will find all of the measure specifications in the quality measure user manual.
As we go across the table, the measure ID is going to change slightly when you pull your quality measure report. It will look slightly different since CMS did the update. I didn't have time to make a HIPAA compliant report to get it into this presentation. It won't change that much. It gives you where you can find the ID.
The numerator is the same thing. In this case there were 12 residents who short stay self-reported moderate to severe pain out of the denominator of that measure 421. Here is a really good opportunity to see how every denominator is different. It is driven by the measure specification. You have to understand the measure specification for each measure. Again, you see the facility person and the state average. Look at how much higher in short stay Payne this ability is -- 57.1 versus the state average. They are more than twice the state average. Look at the national average -- it is the same. But, look at the comparison group -- national percentile. This is something you have not seen yet. Read after that word -- percentile ranking -- where you rank in the country. We want to rank at 100%. We want to be really great, but in this case the quality measures are not really written in a positive way. So, 0 is good. We have a great indication of this. Look at the fourth item -- new pressure alters -- pressure ulcers -- 0 -- that's great -- we don't want any new ones. 0 is good. Keep this in mind. We look at this report and we see that the facility is that 98 percentile for short stay Payne and the 93rd percentile -- that means they are in the bottom 2% in the country.
That very well could be a quality improvement opportunity.
Then, on the CASPER report -- the resident level report -- this is where you can get the actual resident affirmation -- what resident triggered what item? Where you see the exes is where the resident triggered that quality measure.
The last column is a total quality measure count for each resident. If you find your highest quality measure counts, that would give you the opportunity to identify if the president needs some special quality improvement opportunity work.
In order to really analyze your report well, you need to use the quality measure manual to identify the measure specifications for the measures you have concerns about.
Then you need to go to the RAI or MDS manual and really understand why that resident triggered -- was it a point and click error? Was it an understanding of coding so the coding was inaccurate because the coding did not understand the question or maybe didn't understand ARD or the assessment reference date? Or is it a care at the bedside issue? Once you answer these questions and do the deep dive, then you can determine what is your quality improvement opportunity. That brings us to searching for the real root cause.
This is really the first step in your QAPI process -- trying to understand the fundamental reason why a problem exists. You're going to use your data -- your quality measure data and your internal reports that you may create to identify if you might have a problem. Then you need to do the deep dive of understanding how this problem happened because if someone has Payne -- has Payne that they are not asking for -- that would be a problem. How did the performance not meet the expectations? Once we do the root cause analysis, we can implement the model for improvement where we really go through establishing a test of change and come up with a plan and work the plan and study the results and decide how we are going to act on that test of change. Are we going to adapt a test of change or adopted into a larger test of change? Are we going to abandon that idea? To show this better, the worksheet for testing change is just a model for improvement pushed out onto a piece of paper. So, what are we trying to accomplish? You are in the project working to decrease antipsychotics, pressure ulcers, false, or UTI -- what are you trying to accomplish? How will you know that a changes and improvement? You will be working with your data. You will measure the data and said calls. What changes can we make their results in improvement? That is your test of change. Then you do your plan and do and study and act cycle.
You will have many resources available. Don't forget to use the resources and you can learn more about the model improvements in our improving healthcare brochure available in our resource center. I will now turn it back over to Carla and see what questions you may have.
Open up the lines for questions. Remember, you can use the chat feature and Tiger?.
Ladies and gentlemen, if you would like a to ask a question please press the number 1 key on your phone.
Melody must've done an excellent job if you have no questions. If you think of something, feel free to type it in and save it for the end.
For the final presentation -- creating effective teams to drive the QAPI process -- our speaker is Frank Barber.
Thank you very much and good afternoon. This afternoon I will talk about the importance of creating effective teams to help drive the QAPI process. At the end of the presentation there will be some questions. These are important aspects to think about as you form your teams and as you move forward.
Teamwork is a core component of QAPI. Remember at the beginning of the presentation -- the definition of QAPI -- it is related to creating teams. Teams drive the QAPI process. Teamwork and teams are a core component of QAPI and we should never take them for granted. The word teamwork has many different meanings. Many people work together without being a designated for formal team. One thing to remember is that you cannot implement QAPI by yourself.
Let's look at the definition of a team. It is a group of people working together toward one goal for each individual brings to the table their skills and coordinates those skills with others to produce a desirable outcome.
What are some characteristics of an effective team? Teams should have a their purpose. They should have defined goals. There should be commitment and accountability. And leadership support.
These characteristics lead to improved outcomes with a successful team.
You might ask yourself who should be on specific teams? Teams should be composed of interdisciplinary members. For antipsychotic medication, for example, would you have on your team? Feel free to use the chat box if you want to respond to these questions.
I will give you a second if you want to respond.
For starters, what about your nurses, physicians, pharmacy consultant and other disciplines and even remember to include family members and don't forget about the CNA's. They are the front line staff and they see changes in the resident's behavior that is important.
They all may bring a different perspective and understanding the issues or problems that should be considered for this team.
As I mentioned, QAPI lies on teamwork in several ways. When recruiting team members, keep in mind the following -- make sure that it includes content experts and those displaying leadership skills.
In addition, when recruiting for teams don't forget about the good leadership that is supportive of the team's efforts and stands behind the team's decisions. We need good and effective medication from top to bottom in the organization.
Recruitment of family members as I mentioned before, establishing team rules up front is very critical. We need to know where were going and what the deadlines are and why we are doing this and how things will be carried out.
Protocol 14 conflicts -- understanding that everyone has their own opinion and conflicts should be resolved by the team.
The queue I process includes PDS a -- these are terms that you will be familiar with over the next several months.
There is one of our first questions that I referred to in the beginning. There is a chance for you to start participating in use the chat box -- get familiar with that. Put your responses in the chat box as we go along. I will give a few seconds between questions. What are some ways to resolve conflict and establish teamwork?
We have one from Susan Purcell -- family and family members -- patient and family members have great perspective.
Also -- bring naysayers to the team. That way, hopefully you can get there by and and they can also be advocates for what the team is trying to accomplish.
So, as I mentioned before that will be conflicts in the team and how we handle this should be established up front and in teamwork is critical to let everyone speak and remember that all members are important. We can't lose the focus of the team. Next question --
What are some good examples of clear goals?
Boxing gloves -- that's a great response.
An environment where all members can contribute -- exactly.
Here are some good examples of clear goals. When we look at the specific projects we are dealing with, we want to come up with clear, concise goals. Reduce falls by 20% -- give it a date. Next quarter or next week or next month. What about zero restraints or no balls or reduction of falls or no facility wide pressure ulcers or reduction of antipsychotic medications by 15% or decreasing UTIs by 40%. These are all clear, concise goals.
Remember, SMART when you consider a idea -- this is a great technique to use when you are coming up with your goals -- they should be specific, measurable, attainable, relevant to the topic, and they should be timely.
The third question -- please continue to use the chat box -- everyone is doing great. What is the difference between team accountability and team commitment?
Commitment is where all members of the team need to understand what is needs to be accomplished. Without commitment, change is not likely to happen. Accountability is were all members of the team are charged with doing what they say they will do. Exactly -- we have some good responses.
The fourth question -- what is the importance of feedback in a team environment?
Feedback completes the cycle of communication. From staff as well as residents and their families. This is critical to monitor the effectiveness of the team. Feedback also helps generate new ideas.
One very important thing we need to do is establish a sense of urgency. In any business, deadlines are crucial. We all need to -- we don't want to wait or be left hanging. When someone says they are going to do something, they need to make it happen. Setting a deadline makes things happen quicker. Establishing deadlines for the team also helps increase the accountability of the team members.
Are you ready to get started on the QAPI? I want to conclude with this -- we need to start forming teams and know what projects we are working on -- reduction of falls or antipsychotic medications or reduction of facility wide pressure ulcers or UTIs. We should start to establish clear goals that are attainable. Remember to start on a small-scale. One resident or one unit. Start to establish the roles of the team as well. Start to collect the data and understand the data as Melody mentioned -- the quality measure report and the internal data as well as your external data sources.
Designate a leader to keep the team on track. Start utilizing the autocue I tools -- the PDS a and root cause analysis.
Any questions?
Thank you, Frank. We had a great discussion in the chat box. We got a request for [indiscernible] to explain the boxing gloves. Open up the line for questions. Feel free to use the chat feature.
Ladies and gentlemen, if you would like to ask a question, please press the number 1 key on your phone.
Why you think about your questions, the next slide tells you about TMF. Frank, can you advance it?
The next slide tells you about the QIO program. Surely somebody must have a question for Melody or Frank.
There are currently no questions in the queue.
If there are no questions, I want to thank you all for joining us for the webinar. Should you have future questions about the information today, please feel free to contact us at any time at the information on the slide. Also, don't forget to go to the Texas qio website and create an account. That way you will have access to all of the tools that Frank and Melody reference. Thank you again for your attendance. Have a wonderful afternoon.