6-1 Basic Hospice
Learning Objectives
• Define Quality Assessment & Performance Improvement (QAPI)
• State the goal of QAPI
• Describe the key components of a QAPI program
• Verbalize the survey expectations
6-2 Basic Hospice
CMS Roadmap for Quality
6-3
• Vision: The right care for the every person every time
• Aims: Make care safe, effective, efficient, patient-centered, timely, equitable
Basic Hospice
QA vs. QAPI
Quality Assurance Regulation - 1983
• More process/audit oriented
• Goal is to demonstrate compliance
• Focus is on doing the right things and doing them well
• Implicitly but not explicitly related to other regulations
QAPI Regulation - 2008
• More patient-focused and outcome oriented
• Goal is to monitor quality/performance, find opportunities for improvement, and improve
• Focus is on achieving desired outcomes
• Explicitly related to other regulations
6-4 Basic Hospice
Desired Outcomes in Hospice vs.
Other Health Care Setting
• Hospice
– Comfortable dying – Safe dying – Self-determined life
closure – Effective grieving
• Other health care settings
– Cure of illness – Improved functionality
(including ADLs)
6-5
The goal of the professional palliative care team is “… to enable the dying person to live until he dies, at his own maximum potential, performing to the limit of his physical activity and mental capacity, with control and independence wherever possible.”
---The Oxford Textbook of Palliative Medicine
Basic Hospice
QAPI Regulation
• Condition of Participation (CoP) – 42 CFR 418.58
• Standards – more detail on what hospices must do
– Program scope – Program data – Program activities
– Performance improvement activities – Executive responsibilities
Key Points (QAPI in a Nutshell)
6-7
• QAPI operates on two levels – Patient-level and hospice-level
• At both levels, hospices must – Collect data to assess quality
– Use the data to identify opportunities for improvement – Demonstrate performance improvement in one or more areas
• Data-driven decision-making
– In combination with clinical and managerial expertise and experience
• Achieving desired outcomes – Clinical care
– Hospice operations
Basic Hospice
The QAPI CoP says:
• The hospice must develop, implement and maintain an effective, ongoing, hospice-wide, data-driven QAPI program
• The hospice’s governing body must ensure that the program:
– Reflects the complexity of its organization and services;
– Involves all hospice services (including those services furnished under contract or arrangement);
– Focuses on indicators related to palliative outcomes; and – Takes actions to demonstrate improvement in hospice
performance
• The hospice must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS
6-8 Basic Hospice
The QAPI Standards
• Program Scope
– Measure, analyze and track indicators (including adverse events) to assess processes of care, hospice services and operations
– Show measurable improvement in indicators of palliative outcomes and hospice services
• Program Data
– Collect data (as approved by governing body)
• Timing and detail approved by governing body
– Use data
• Monitor effectiveness and safety of services and quality of care
• Identify opportunities and priorities for improvement
6-9 Basic Hospice
The QAPI Standards (cont.)
• Program Activities
– Focus on high risk, high volume, problem prone areas affecting palliative outcomes, patient safety and quality of care (consider incidence, prevalence, severity)
– Track adverse events; analyze causes and develop processes and training to prevent them
– Take action to improve where and when necessary, AND measure (assess) to ensure that improvement is sustained
6-10 Basic Hospice
The QAPI Standards (cont.)
• Performance Improvement Projects (PIP) – Number and scope must be based on needs, and
reflect scope, complexity and past performance of hospice
– Document what, why and how successful (measurable improvement)
• Executive Responsibilities – must ensure:
– QAPI program is defined, implemented and maintained – annual review
– Quality of care and patient safety priorities are identified and addressed effectively
– One or more individuals are designated to be responsible for operating the QAPI program
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Timeframe
• Data collection and internal reporting must begin by Dec 2, 2008
• Performance improvement projects must begin by Feb 2, 2009
• 60 days to collect quality assessment data before beginning improvement projects
Think About QAPI As…
A combination of two different but related processes:
Quality Assessment (QA) Performance Improvement (PI)
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QAPI Functions
6-14 Basic Hospice
QAPI Operates on Two Levels
• Patient-level:
Individual patients outcomes or events
• Hospice level: Overall hospice performance
–Clinical (all patients) –Non-clinical
operations
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Patient-level QAPI Hospice-level
QAPI
Basic Hospice
Patient-Level QAPI
• Collect data on what happened for an individual patient
– Assessment/ Reassessment (§418.54) – Care plan (§418.56)
– Clinical notes
• Use the data to improve quality of care and outcomes for that patient (§418.56)
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Patient-Level The Cycle of Care
6-17 Basic Hospice
EXAMPLE:
Use of patient-level data
Symptom Management
Admit Day 3 First Last Patient Goal: 3
• Collect symptom severity data on each assessment
• Collect patient goal
• Monitor severity over time and relative to the goal
• Adjust interventions to reach goal and/or assist patient in refining the goal
Symptom 3/2/08 3/3/08 3/6/08 Anxiety Moderate Mild Mild
Dyspnea Mild None Mild
Hospice-Level QAPI
• Clinically focused
– Aggregate (patient-level) data – Collect satisfaction data
• Non-clinically focused – Administrative data
– Marketing - referral source contact – Outreach to community – Profitability
– Fundraising
• Use the data to improve clinical operations and non-clinical operations
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HOSPICE
Basic Hospice
Hospice-Level QAPI (cont.)
6-20 Basic Hospice
Hospice-Level QAPI (cont.)
• §418.58 (a) Program Scope
– The hospice must measure, analyze, and track quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services and operations.
• §418.54 (e) Patient outcome measures
– Assessment must Include data elements to be used for outcome measurement
– Data must be used in the aggregate for the hospice’s QAPI program
6-21 Basic Hospice
Aggregated Patient Data
Percentage of patients uncomfortable on admission who were more comfortable within 2 days
(Labels indicate # patients included)
28 30
1Q2007 2Q2007 3Q2007 4Q2007
% of patients uncomfortable on admission
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National Average 82%
Basic Hospice
Administrative Data - HR
85.6 79.5
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
%Reviews
“Hospice by the numbers”
• Quality assessment (QA) requires quantitative information
– Numbers OR
– Uniform variables (e.g. Yes/No; increased/decreased) that you can count
• Good patient care and PI require qualitative information
– Narrative data – usually “non-uniform”
– Provides detail behind quantitative information
• Hospices should be using a mix of data sources and types
Keys To Compliance
– Patient and family outcomes – Non-clinical operations
• Monitoring of quality/performance indicators at regular intervals (intervals may vary for different measures)
• Use of industry benchmarks and/or internal targets (and patient-identified goals at the patient-level)
• Implementation of performance improvement projects
• One or more individuals who have responsibility for operating the QAPI program
• Board involvement
• Evidence of improvement and achieving desired outcomes
Basic Hospice
Visualize – QAPI Hospice
• See – Quality information/data
– Data elements on patient assessment/care plan forms – PI data posted on bulletin boards or in reports
• Hear about– Culture of quality
– Quality assessment is a core activity across the organization
– Positive questioning, not finger pointing – Reliance on data for decision-making – Performance improvement, not criticism or
punishment, is the organizational response to errors and problems
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Visualize – QAPI Hospice (cont.)
• Read –Plans and reports – QAPI plan
– PIP reports
– Governing body meeting agendas/minutes
• Observe – Everybody participates
– 418.62 – All licensed professionals must participate – 418.76 (g) – Hospice aides must report changes in
patient needs as they relate to quality assessment and the plan of care
– Preamble – involve all employees, paid and volunteer, including contracted staff
6-27 Basic Hospice
Possible QAPI Participation
• Governing Body/senior managers/directors
– Appoints QAPI manager/team – Selection of measures and PIPs – Review quality assessment data
• Managers and staff
– Review quality assessment data relevant to their areas – Identify strengths and
weaknesses
– Contribute ideas for PIPs – Participate in PIP teams
• Administrative staff – Perform data entry – Run programmed
analyses
– Contribute ideas for PIPs – Participate in PIP teams
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Quality Idea
Basic Hospice
Case Study - Unwanted Hospitalization
• Data elements on comprehensive assessment
– Preference for hospitalization
• Interventions on the plan of care
• Reassessment review and update plan of care
– Update preferences – Note any
unwanted/unexpected hospitalizations
• Aggregate data for all closed charts quarterly
• Track percentage who did not want and did not get hospitalization
6-29 Basic Hospice
Q & A
Assessing the QAPI Program
• Questions for those who have responsibility for the QAPI program, and other managers and staff
• Observational evidence
• Documentary evidence
6-31 Basic Hospice
Overarching Question
Is the hospice using quality assessment and performance improvement to achieve desired palliative outcomes for patients/families and operational outcomes for the agency?
6-32 Basic Hospice
Regulatory Requirements
• Condition of Participation (CoP) – 42 CFR 418.58
• Standards – Program scope – Program data – Program activities
– Performance improvement activities – Executive responsibilities
6-33 Basic Hospice
The QAPI CoP
• The hospice must develop, implement and maintain an effective, ongoing, hospice-wide, data-driven QAPI program
• The hospice’s governing body must ensure that the program:
– Reflects the complexity of its organization and services;
– Involves all hospice services (including those services furnished under contract or arrangement);
– Focuses on indicators related to palliative outcomes; and – Takes actions to demonstrate improvement in hospice
performance
• The hospice must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS
6-34 Basic Hospice
Evidence of QAPI Compliance
(From the CMS Preamble to CoPs)
• QAPI plan and identified individual(s) responsible
• Meeting minutes – development and operation
• Quality indicators – Which ones; why; and how
assure consistent data collection
– Use of measures in patient – How data are aggregated care
and analyzed reports and patient charts)
• Evidence that QAPI is prevalent throughout operations
– Actual experience of patients and employees
6-35 Basic Hospice
Standard (a): Program Scope
1) The program must at least be capable of showing measurable improvement in indicators related to improved palliative outcomes and hospice services
2) The hospice must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations
Program Scope: What Might you Ask?
• Is the QAPI program hospice-wide, including patient outcomes, processes of care, hospice services and operations?
• What measures/indicators have been selected and why?
• How are adverse events and other indicators tracked over time and relative to benchmarks or targets?
• Is there evidence of improved patient care and/or operational outcomes?
6-37 Basic Hospice
Program Scope: Possible Evidence
• QAPI Plan with descriptions of indicators and processes for tracking
• Reports or storyboards of performance improvement activities
• Minutes of QAPI meetings
• Adverse events policy/procedure
6-38 Basic Hospice
Standard (b): Program Data
1) The program must use quality indicator data, including patient care, and other relevant data, in the design of its program
2) The hospice must use the data to do the following:
i. Monitor the effectiveness and safety of services and quality of care
ii. Identify opportunities and priorities for improvement
3) The frequency and detail of the data collection must be approved by the hospice’s governing body
6-39 Basic Hospice
Program Data: What Might you Ask?
• What kinds of patient care and other program data are included in the hospice’s QAPI program?
• What systems are in place to collect, aggregate and monitor data for quality assessment?
• How does the hospice use the data to track outcomes of patient care and operational efficiency and effectiveness?
• Has the governing body approved what data is to be collected?
6-40 Basic Hospice
Program Data: Possible Evidence
• QAPI Plan with information on the sources and types of data used in the QAPI program
• Policies, procedures or reports showing the collection and aggregation of data for quality assessment
• Governing body minutes documenting
discussions and/or decisions related to QAPI data
6-41 Basic Hospice
Standard (c): Program Activities
1) The hospice’s performance improvement activities must:
i. Focus on high risk, high volume, or problem-prone areas ii. Consider incidence, prevalence and severity of problems in those
areas
iii. Affect palliative outcomes, patient safety, and quality of care 2) Performance improvement activities must track adverse
patient events, analyze their causes and implement preventive actions and mechanisms that include feedback and learning throughout the hospice
3) The hospice must take actions aimed at performance improvement. After implementing these actions, the hospice must measure its success and track performance to ensure that improvements are sustained
Program Activities: What Might you Ask?
• In deciding what outcomes/indicators to track, does the hospice consider how many patients/families are affected and how severe the impact is?
• Does the hospice have adequate policies/ procedures for tracking, responding to and preventing adverse events?
(e.g., Are staff aware of what constitutes an adverse event and their responsibilities for reporting and preventing?)
• What improvements have been made through the QAPI program?
• How does the hospice assure that outcome and/or performance improvements are sustained?
6-43 Basic Hospice
Program Activities: Possible Evidence
• Data sources for information on adverse events (e.g., incident reports, complaint logs)
• Education records showing training on reporting and preventing adverse events
• PIP reports and/or QAPI meeting notes that document improvement in quality indicators that is sustained over time
6-44 Basic Hospice
Standard (d):
Performance Improvement Projects
Beginning February 2, 2009, hospices must develop, implement and evaluate performance improvement projects
1) The number and scope of distinct performance improvement projects conducted annually, based on the needs of the hospice’s population and internal organizational needs, must reflect the scope, complexity, and past performance of the hospice’s services and operations
2) The hospice must document what performance improvement projects are being conducted, the reasons for conducting these projects, and the measureable progress achieved on these projects
6-45 Basic Hospice
Performance Improvement Projects:
What Might you Ask?
• How does the hospice decide how many PIPs to do and what issues to address through PIPs?
• Does the hospice conduct a reasonable number of PIPs annually given its size, the needs of the hospice population and the past performance?
• Does the hospice maintain adequate documentation of PIPs?
• Do the PIPs show that adequate progress was made and sustained?
6-46 Basic Hospice
Performance Improvement Projects:
Possible Evidence
• QAPI committee and/or board minutes documenting discussions about choosing issues for PIPs
• PIP reports, or a PIP log, that document the focus of each PIP, the reason(s) for conducting it and data (or other results) showing progress was made and sustained
6-47 Basic Hospice
Standard (e): Executive Responsibilities
The hospice’s governing body is responsible for ensuring the following.
1) That an ongoing program for quality improvement and patient safety is defined, implemented and maintained and is evaluated annually
2) That the hospice-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness
3) That one or more individual(s) who are responsible for operating the quality assessment and performance improvement program are designated
Executive Responsibilities:
What Might you Ask?
• How is the governing body involved in the development and ongoing evaluation of the QAPI program?
• Has the hospice’s governing body designated responsibility for operation of the QAPI program to one or more individuals?
• Has the governing body assured that adequate resources are available to operate an effective QAPI program?
6-49 Basic Hospice
Executive Responsibilities:
Possible Evidence
• A governing body resolution regarding QAPI
• Governing body meeting agendas showing discussions and decisions regarding the QAPI program, such as:
– Appointment of one more individuals to run the program
– Approval of data collection
– Reviews of program effectiveness; specifically whether progress/improvements are being made and sustained
QAPI Exercise 6-1
• Each table will receive an assigned letter
• Find the question on the exercise handout assigned to your table’s letter
• Take 10 min to discuss with your tablemates appropriate responses/evidence for each item – note key points that should be covered; if you finish early, look at the other questions
• Report out to all participants – 1 minute per table
6-52 Basic Hospice
QAPI Case Study
Unwanted Hospitalization
At Hospice QE, the comprehensive assessment includes a question about whether the patient and family wish to avoid hospitalization if the patient’s condition worsens. The answer is recorded on the assessment form and on the cover sheet for the patient’s medical record in a specific shaded box provided for this information.
If hospitalization is to be avoided, there are specific interventions added to the plan of care, such as (1) a sticker on the phones at the patient’s home directing everyone to call the hospice’s 24 hour
number rather than 911 if the patient’s condition worsens, (2) a note in the patient’s electronic and paper record for on-call staff that
indicates the preference to avoid hospitalization, and (3) other procedures to assure that calls from this patient and family receive priority response from a team member.
At each reassessment, the patient and family preference regarding hospitalization is reviewed and updated. The information is also updated on the face sheet, and any unwanted and/or unexpected hospitalizations since the last review are also noted on the care plan and on the cover sheet (in the area provided for this information);
then the team determines whether any interventions need to be changed.
During the monthly review of all
discharged patient charts, the medical records reviewer adds the information on unwanted hospitalization for each individual patient to the Excel
spreadsheet created for aggregating the data.
Quarterly, the QAPI manager runs a preprogrammed report from the Excel spreadsheet that tallies the number of patients who had data on this indicator, the number who at any time wanted to avoid
hospitalization, and the number of those wanting to avoid
hospitalization, but were still hospitalized. The percentage [i.e., those who wanted to avoid AND who were not hospitalized divided by the number who wanted to avoid X 100] is tracked for every month and reported quarterly as shown in the graph. If the percentage
drops below 95 percent more than once in a quarter, the hospice will conduct a performance improvement study to understand why
patients are receiving unwanted hospitalization and to determine whether and how the hospice can improve.
Quality Assessment and
Performance Improvement (QAPI) Exercise 6-1
A. How do quality assessment and performance improvement work together?
B. What is the key goal/purpose for the hospice’s QAPI program?
C. How might a hospice show that the QAPI program hospice-wide, including patient outcomes, processes of care, hospice services and operations?
D. Name three documents that you might review to learn about operation of the QAPI program.
E. What should be included in the QAPI Plan? (Name at least three items/topics.)
F. How would a hospice demonstrate improved patient care and/or operational outcomes?
G. What kinds of patient care and other program data might be included in the hospice’s QAPI program?
H. Where would you expect to find data elements used to track operational outcomes? (Name at least three data sources.) I. Briefly describe how QAPI plays out at the level of an individual
patient.
J. What do we mean by “hospice-level” QAPI?
K. What should the hospice consider when deciding what outcomes/indicators to track?
L. List two items you might look for on governing body meeting agendas showing discussions and decisions regarding the QAPI program.
M. How will you know if the hospice has an effective QAPI program?
N. Name two possible data sources for information on adverse events.
O. When interviewing interdisciplinary team members about their role in QAPI, what are two questions you might ask?
P. When interviewing senior managers about their role in QAPI, what are two questions you might ask?
Q. How should the hospice decide how many performance
Q. How should the hospice decide how many performance