3/10/2015
National Nursing Home
Quality Care Collaborative:
QAPI in Action
Brenda Groves, LPN and Johnathan Reeves, BA
Kansas Foundation for Medical Care, Inc.
March 2015
Objectives
 Understand the purpose of the National
Nursing Home Quality Care Collaborative
 Learn how to utilize resident and their families
to improve the quality of care provided.
 Learn how to use QAPI tools to assess areas of
improvement
 Utilize the CASPER report to focus on specific
quality measures for improvement
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3/10/2015
QIN-QIO Map
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National Nursing Home Quality
Care Collaborative (NNHQCC)
 Seeks to…
• Ensure every nursing home resident receives the
highest quality care
• Instill quality and performance improvement
practices
• Eliminate healthcare-acquired conditions
• Improve resident satisfaction
• 50% of homes will achieve Quality Measure
Composite Score of 6.00 or better (lower) by July
31, 2019
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NNHQCC Quality Composite Measure Score
Includes These QMs
The composite score is comprised of 13 NQF-endorsed, long-stay quality
measures:
1. Percent of residents who self-report moderate to severe pain
2. Percent of high-risk residents with pressure ulcer
3. Percent of residents physically restrained
4. Percent of residents with one or more falls with major injury
5. Percent of residents who received antipsychotic medications
6. Percent of residents who have depressive symptoms
7. Percent of residents with a UTI
8. Percent of residents with catheter inserted or left in bladder
9. Percent of low-risk residents with loss of bowels or bladder
10. Percent of residents who lose too much weight
11. Percent of residents whose need for help with ADL has increased
12. Percent of residents assessed and appropriately given flu vaccine*
13. Percent of residents assessed and appropriately given Pneumococcal
vaccine*
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Composite Comparison
Where We Are vs. Where We Want to Be
Kansas Composite Score Distribution
Comparison
140
Count of Nursing Homes
120
KS Composite Comparison
Current
Goal
Mean
10.12
6.58
Median
9.80
6.37
Mode
7.69
5.00
Standard Deviation
2.93
1.90
Minimum
1.65
1.07
Maximum
20.11
13.07
100
80
60
40
20
0
2.05
4.1
6.15
8.2
10.25
12.3
14.35
16.4
18.45
20.5
Composite Score
Current KS Composite
5 Year Goal Composite
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Great Plains Quality Care
Collaborative Milestones
-Join the NNHQCC, Attend a Pre-Work Webinar, Complete Pre-Work, Know your QM Composite Score
-Reached the Copper Milestone, Chosen QI Project, Begun first PDSA Cycle, Identified possible success story,
Attended two educational offerings, Know your current QM Composite Score
-Reached the Bronze Milestone, Attended a total of five educational offerings, Shared a success story,
completed the first PDSA worksheet, Know your current QM Composite Score
-Reached the Silver Milestone, Attended a total of eight educational offerings, Completed a second QAPI
Self-Assessment, Shared a second success story, completed the second PDSA worksheet, Know your current
QM Composite Score
-Reached the Gold Milestone, Attended a total of 12 educational offerings, Attained a QM Composite Score
of 6.0 or better, Shared a third success story, completed the second PDSA worksheet, Know your current
QM Composite Score
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3/10/2015
Polling Question
What do you plan to get out of the NNHQCC?
A) Increase our resident satisfaction by incorporating
resident centered principles.
B) Lower our individual quality measure percentages.
C) Reduce our inappropriate antipsychotic use rate.
D) Improve our QAPI implementation and practices.
E) Access to best practices for clinical and staffing
support.
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Resident and Family Self-Assessment
 Resident and Family Engagement emerging
priority
 Designed to give feedback on current
engagement activities
 Utilizes representatives from all aspects of
home
• Administration, direct care, resident or resident
family member
 Taken three times throughout collaborative
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Resident and Family Self-Assessment
 Once completed your
home will be given level
of 1, 2, or 3
• 1= Low Level
• 2= Medium Level
• 3= High Level
 Given personalized
toolkit of suggested
interventions and
activities to increase
level
 Goal is to move your
home up one level by
end of collaborative
 KFMC Engagement
Team will work with you
to increase Engagement
Score to next higher
level
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Be Proactive, Not Reactive
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QAPI Process Tool Framework
 Your one stop shop for everything QAPI…
 Provided by CMS
 Includes Tools for the Entire QAPI Process
 http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/QAPI/Downloads/ProcessToolFramework.pdf
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QAPI at a Glance
 Comprehensive QAPI
Implementation Guide
 QAPI Tools
• QAPI Self-Assessment
Tool
• Guide for Developing
QAPI Plan
• Goal Setting Worksheet
http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/QAPI/downloads/QAPIAtaGlance.pdf
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PDSA Cycle Template
 Three page template that
walks through each step of
the cycle with examples and
question prompts.
 A Key Component of the IHI
Model for Success and
QAPI.
 Continuous PDSA cycles are
necessary to create
effective long term change.
 Included in the Great Plains
Quality Care Collaborative
Milestones packet.
http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/QAPI/downloads/PDSACycledebedits.pdf
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Process Improvement Tools
 Root Cause
Analysis
• The Five Why’s
• Fishbone
Analysis
 SBAR Analysis
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Root Cause Analysis (RCA)

RCA is a structured facilitated team
process to identify root causes of an event
that resulted in an undesired outcome
and develop corrective actions.

The RCA process provides you with a way
to identify breakdowns in processes and
systems that contributed to the event and
how to prevent future events.

The purpose of an RCA is to find out what
happened, why it happened, and
determine what changes need to be
made.

It can be an early step in a PIP, helping to
identify what needs to be changed to
improve performance.
http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/QAPI/downloads/GuidanceforRCA.pdf
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The 5 Why’s
 Develops the problem statement.
 Asks why the problem happened and
records the team response.
 If the answer provided is a contributing
factor to the problem, the team keeps
asking “Why?” until there is agreement
from the team that the root cause has been
identified.
 It often takes three to five whys, but it can
take more than five! So keep going until the
team agrees the root cause has been
identified.
http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/QAPI/downloads/FiveWhys.pdf
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Fishbone Analysis
 Agree on the problem statement (or effect).
 Agree on the major categories of causes of
the problem (written as branches from the
main arrow).
 Brainstorm all the possible causes of the
problem. Ask “Why does this happen?”
 Again asks “Why does this happen?” about
each cause. Write sub-causes branching off
the cause branches.
 Continues to ask “Why?” and generate
deeper levels of causes and continue
organizing them under related causes or
categories.
http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/QAPI/downloads/FishboneRevised.pdf
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ituation
 Using the SBAR method creates a staff of
critical thinkers and empowers individuals
to determine solutions on their own.
ackground
 Widely used throughout the healthcare
community.
ssess
ecomendation
 Using SBAR forms for situational needs
will help to organize and process needed
responses for almost every situation.
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Improvement Success Story
 Documenting success stories is useful for a
number of reasons:
• it provides a historical record of efforts undertaken by
your organization that produced positive results;
• it promotes taking the time to celebrate achievements;
• it assists in pinpointing important messages to
communicate to stakeholders; and
• it can relay important lessons for others wishing to
emulate your success and establish your organization
as a model leader.
http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/QAPI/downloads/ImproveSuccessStorydebedits.pdf
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Polling Question
What extent has your nursing home utilized data driven
evaluation measures to implement and document effective
change?
A) We do not used data driven process to drive change.
B) We would like to use data driven change processes but need
more education on how to implement an effective system.
C) We have tried to implement data driven change methods but
the process has not been consistently applied throughout the
nursing home.
D) We have succeeded at implementing data driven change
processes.
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Utilizing the CASPER report
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CASPER Quality Measures (17)
1.
2.
3.
4.
5.
6.
7.
8.
Self-reported
moderate/severe pain (S)
Self-reported
moderate/severe pain (L)
High-risk pressure ulcers (L)
New/worsened pressure
ulcers (S)
Physical restraints (L)
Falls (L)
Falls with major injury (L)
Antipsychotic Medication (S)
9. Antipsychotic Medication (L)
10. Antianxiety/hypnotic med (L)
11. Behavior symptoms affecting
others (L)
12. Depressive symptoms (L)
13. Urinary tract infection (L)
14. Catheter inserted and left in
bladder (L)
15. Lose control of bowels or
bladder (L)
16. Excessive weight loss (L)
17. Need for increased ADL help (L)
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Short Stay vs. Long Stay Measures
 Cumulative days in facility (CDIF) includes discharges and
re-admits, but only days actually in the facility count
(hospitalized days or days at home are not included)
 Short stay = CDIF < 100 days
 Long stay = CDIF > 101 days
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Select the QM Reports, Facility ID and Date
Range – Submit
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CASPER QM Report Page
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The Facility Level Report – Quality
Measure Analysis
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Resident Level
Quality Measure Report
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Polling Question
How often does your team utilize the resident level
quality measure report to guide your quality
improvement plans/activities?
A) Never
B) Less than quarterly
C) Quarterly
D) More than quarterly
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Basic QM Calculation
Numerator
(those with the problem)
Divided by
Denominator
(all who could have the
problem)
Times 100 gives the
percentage
EXAMPLE:
Using Pain – Short Stay QM:
12/21 = 0.571 X 100 = 57.1%
12 residents experienced pain out
of 21 possible which says that
57.1% of residents have
experienced pain.
This is reflected in the Facility
Observed Percent Column of the
CASPER Report
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Composite Measure Score Calculation Excluding the
Immunization Measures for Monitoring Purposes
 Step 1: Run your facility CASPER QM reports for 6
month time period.
 Step 2: Sum the numerators for measures indicated.
Example: numerator =76
 Step 3: Sum the denominators for measures
indicated. Example: denominator =918
 Step 4: Divide the composite numerator by the
composite denominator. Example: 76/918 = 0.08
 Step 5: Multiply by 100. Example: 0.08 x100 = 8.0
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3/10/2015
Nursing Home Composite Calculator
 Aim was to help NH plug in the CASPER QMs that are
specific to the QM Composite Measure Score to
calculate composite score and then apply scenarios to
what their composite score might look like if they
changed certain numerators.
 It is an Excel file.
 There are some blocked cells that can’t be manipulated
and will only allow user to input data to certain fields
(you can’t mess it up).
 Download and save to your computer desktop or
specific file for easy access.
 http://greatplainsqin.org/initiatives/hac-nh/
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Nursing Home Composite Calculator
In Action
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3/10/2015
Polling Question
If Great Plains QIN/KFMC utilized social media
(Facebook, Twitter, or YouTube) platforms to
communicate with front line staff would you encourage
the utilization of the information?
A)Yes
B) No
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Homework
Copper
□Signed Participation agreement for collaborative
□Formed a facility project team
□Completed Pre-Work Assessments/Attend Pre-Work webinar
□Completed an Educational Needs Assessment
□Know your Quality Measures Composite Score
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3/10/2015
Collaborative Kick-Off
April 23, 2015
2:00-4:00 p.m. CST
QAPI In Action
Reginald Hislop, III, Ph.D.
President and Chief Executive Officer
Larksfield Place Retirement Communities, Inc.
Conquering The “It can’t be done” Attitude
Sheila Brown
Administrator
Lone Tree Retirement Center
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Contact Information
Brenda Groves, LPN
[email protected]
Johnathan Reeves, BA
[email protected]
2947 SW Wanamaker Drive
Topeka, Kansas 66614
P: 785-273-2552 or 800-432-0770
F: 785-273-5130
This material was prepared by the Great Plains Quality Innovation Network, the Medicare Quality Improvement Organization for Kansas, Nebraska, North Dakota
and South Dakota, 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. 11SOW-GQIN-KS-C2-25/0315
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