your Quality Assurance and Performance Improvement (QAPI) - - PowerPoint PPT Presentation
ESRD Professional Training Series Incorporating Patients into your Quality Assurance and Performance Improvement (QAPI) Activities April 2019 1 IPRO End Stage Renal Disease (ESRD) Network Part 1: National Quality Strategy and the ESRD
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Part 1: National Quality Strategy and the ESRD Quality Incentive Program Part 2: Quality Assurance and Performance Improvement (QAPI) Part 3: Planning to Incorporate Patient SMEs into QAPI Part 4: Recruiting and Incorporating Patient SMEs Part 5: Tips and Suggestions
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applying the 3 AIMS and 6 levers
measures
heightened focus on patient and family centered care
an improves patient engagement and participation in care
participation into the QAPI and governing body of the facility
At the completion of this activity the learner will be able to:
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Centers for Medicare & Medicaid Services (CMS)
18 ESRD Networks
design programs to help reach regional and national improvement goals
ESRD National Coordinating Center
Subject Matter experts to support the goals and share information on a national level
Centers for Medicare & Medicaid Services 18 ESRD Networks ESRD National Coordinating Center
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ESRD Networks are critical to achieving CMS goals for healthcare transformation and improving the patients experience of care by:
CMS Goal:
the ESRD population including BSI, transplant, and home dialysis
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their health care
accessibility, and affordability
ESRD Networks are tasked by CMS to support the achievement of national quality improvement goals and statutory requirements by aligning Network activities with the following CMS goals.
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Improving health and health care quality can occur only if all sectors, individuals, family members, payers, providers, employers, and communities, make it their mission. Members of the health care community can align to the National Quality Strategy by doing the following:
the individual and the community.
health care quality.
functions, resources, and/or actions that may serve as means for achieving improved health and health care quality.
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delivery of care.
is engaged as partners in their care.
and coordination of care.
prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
wide use of best practices.
by developing and spreading new health care delivery models.
Better Care: Improve the
making health care more patient-centered, reliable, accessible, and safe. Healthy People/Healthy Communities: Improve health by supporting proven interventions to address behavioral, social and, environmental determinants of health in addition to delivering higher-quality care. Affordable Care: Improve the overall quality, by making health care more patient-centered, reliable, accessible, and safe.
Clinical AIMs
National Quality Strategy levers represents a core business function, resource, and/or action that stakeholders can use to align to the Strategy.
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facilities treating patients with ESRD.
certain performance standards as much as 2 percent.
consumers to compare the results
– Dialysis Facility Compare – Performance Scores posted in the facility
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14 total measures for evaluating each facility. Scores will be combined to establish the Total Performance Score (TPS).
7 clinical measures categorized into two subdomains, reflecting domains of quality measurement based on the NQS. (75% of TPS)
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% Sub-Domain Measure
42% Patient and Family Engagement / Care Coordination ICH CAHPS patient satisfaction SRR unplanned patient readmissions to the hospital setting on a risk-adjusted basis. 58% Clinical Care Vascular Access Type Access via AVF Vascular Access Type Access via Catheter KT/V Adequacy Evaluates the success of dialysis treatment in removing waste products from the patients blood STrR in-facility transfusions on a risk-adjusted basis Hypercalcemi measure of mineral metabolism
Safety Measure Domain
reporting measure.
by in-center hemodialysis outpatients.
for which facilities report dialysis-event data to NHSN.
Medicare claims, CROWNWeb, and other CMS and federal databases. For a facility to receive maximum points in this domain, it must report 12 full months of data and experience a minimal number of dialysis events.
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Reporting Measure
The reporting measures require facilities to submit:
Medicare claims
Report to NHSN.
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Tools that help us measure or quantify healthcare processes,
systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care.
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Simply put, this means that systems are put in place to ensure:
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QAPI is an ongoing program, not an isolated meeting
team or IDT) and be driven by the Medical Director
to improved medical outcomes and reduction of medical errors
performance evaluation both clinically and
adjustment to meet changing facility needs
improvement, goals, estimated time to attainment, and priority within the system
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QAPI should be used to address any area of the facility that is identified as not performing optimally. QAPI must be demonstrated in the following areas:
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Start with completing a root cause analysis. This analysis should include all the barriers preventing the facility from performing
Use the PDSA model to make improvements in the identified areas.
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Patient or Family Member Medical Director Nephrologist Social Worker Special Project Leads Dietician Registered Nurse
Including patients in the QAPI team can provide the missing link to influence your daily work to drive improvement Patients have unique skills and perspectives that other members of the team do not…. They are subject matter experts or SMEs, about the care your facility provides!
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Creating partnerships are mutually beneficial to the patients and the facility. Involving patients in your facility’s Quality Assurance & Performance Improvement (QAPI) and/or Governing Body meetings can be an effective means of engagement and partnership. By expanding the team you also expand:
care your facility provides
at the dialysis facility
your facility.
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Subject Matter Experts (SME)
empowerment
communication in the facility
members to provide feedback.
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their views are sought, valued, and considered in facility healthcare decision- making and process improvements.
councils and other venues to solicit feedback.
about their quality concerns.
communications to patients and families or displaying progress toward goals in public areas of the facility.
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Promote sharing information across the facility on Quality Improvement activities
Seek information and learn from one another about barriers to reach goals Spread and promote the utilization of best practices, tools, resources to
Sharing focus area goals with staff, patients, and family members
SPREADING SEEKING SHARING
Clinical Data
Patient Satisfaction / Grievance Data
NHSN and Reporting Data
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Consider using open ended questions to solicit feedback:
that was important and how do you suggest that we assist patients with that?
challenges to starting a new (fill in the blank)?
challenges to changing (fill in the blank)?
approach (fill in the blank)?
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Do
partners in decision making
perspective
Don’t
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Identify Patients and Family members who have demonstrated interest in partnering with you by providing constructive feedback and work well with staff and other patients. Ideal Patient SMEs are those who can:
Use the 2018 Kidney Chronicles Issue 2 to help explain to patients their role in QAPI
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Define upfront the IDT expectation for participation by the patient SME.
in the facility’s QAPI meetings during personal time either in-person or via teleconference.
longer able to serve but shall provide ample notice to facility staff.
candidate’s membership at any time.
and he/she will respect the privacy
being invited.
meetings and answer any questions the patient might have.
– To offer suggestions for improved patient involvement with ideas and strategies for improved care. – To share his or her experience with other patients, if they are comfortable doing so.
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time, and location. – Use the sample invitation letter
Family Meeting Notes tool to help patients organize key information before, during, and after the meeting.
questions, concerns or feedback that they want to share
notes on key topics discussed that the patient or family members wants to capture.
information that can be shared with other patients after the meeting to support the quality
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meeting.
the meeting.
– Would he/she be willing to participate in future QAPI/Governing Body meetings? – Would he/she recommend participating in these meetings to other patients? – Does he/she have any recommendations for how participation can be made a better experience?
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10-15 minutes of the meeting.
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– Remember, this might be new to your patient SME – if possible provide them with an orientation of standard graphs or charts used prior to the meeting.
– Include the patient attendance and participation in committee meeting minutes
– What would be the best way to (fill in the blank?) – Based on this report, what do you think are important next steps toward improving patient experience of care or outcomes? – From your perspective, what are some challenges or barriers to improving patient experience of care or outcomes?
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Performance Improvement Module review quiz.
begin incorporating patients into QAPI.
understand your focus areas and the importance of their role in quality improvement
– Use the Invitation to invite your patient facility representative to a QAPI meeting – Review the QAPI Patient and Family Meeting Notes document with your patient facility representative
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Celebrate each success you have in empowering patients to be involved in their healthcare and in quality improvement. Thank you for your hard work and commitment to helping patients!
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