QAPI - National Association of State Veterans Homes

Achieving a Culture of Excellence
 To demonstrate an understanding of how to use the
elements of QAPI within the performance
excellence framework.
 To verbalize how a SVH can mobilize an organization
to create and sustain a culture of excellence.
 To identify at least one method to involve team
members in creating a culture of learning
"Change would be easy if it weren't
for all of the people"
Balestracci and Barlow
Baldrige Quality Award
 All about results and improvement
 Using a framework
 A systematic approach
 Established by congress in 1987
 Designed to improve the competitiveness
of US businesses
 Identifies role model organization
 Internationally recognized and emulated.
Baldrige Background
 Studies done related to industries in the US who were
losing market share- such as steel and auto industries.
 Found a common set of values and process that
successful organizations used
 These process and values are now the framework for
performance excellence
Why Baldrige
 Study by Thompson Reuters found that hospitals
using the Baldrige criteria were 6X more likely to
be in the top 100 hospitals and outperformed nonBaldrige hospitals in:
Risk-adjusted mortality index
Risk-adjusted complications index
Patient safety index
CMS core measures score
Severity-adjusted average length of stay
 Adjusted operating profit margin
Baldrige categories
 Leadership: How do leaders create a sustainable organization?
 Strategic Planning: How do you develop strategy?
 Customer Focus: How do you listen to customers and
determine solutions upon feedback from the customer?
 Measurement, Analysis and Knowledge Management:
How do you select and use data to measure and improve
Baldrige categories
 Workforce: How do you assess capacity and capability to meet the
needs of the customer and accomplish the plan?
 Operations: How do you manage key work processes and systems to
create long term sustainable value?
 Results: What results are important to leadership and your
customers and how do you share with those that impact performance?
So what?
What’s the Goal?
Improvement of some components, processes, or
Complete system transformation to ensure success
every time?
“Tension for Change”
“To leave the comfort of the status quo, most
individuals need to believe that change is
truly imperative and there is a more
attractive alternative.”
Silversin, J. & Kornacki M.J, ,(2000) Leading Physicians Through Change
 Affordable Care Act
 A system to provide technical assistance to nursing
 Transformation of how we deliver quality
 Shift on delivering excellence proactively, not
 Approach where problems are caught before serious
“The Centers for Medicare & Medicaid Services (CMS) is
leading an initiative that could transform the way nursing
homes ensure quality. This initiative goes beyond the
current QAA provision, and aims to significantly expand the
intensity and scope of current activities in order to not
only correct quality deficiencies (quality assurance), but
also to put practices in place to monitor all nursing home
care and services to continuously improve performance.”
A framework of 5 elements:
1. Design and scope
2. Governance and leadership
3. Feedback and monitoring
4. PI projects
5. Analysis and systematic action
Feedback, Data
Performance Improvement
Systematic Analysis and Action
Quality of Care, Quality of Life, Resident Choice
QAPI: Design and Scope
 Plan should be comprehensive and include all the care
and services your facility provide
 Balancing safety and quality of care with resident
choice and autonomy
 Not just about nursing or the food in the kitchen—
involves every aspect of the care and services
QAPI: Governance and Leadership
 Expectation that the executive leadership of your
facility must be actively engaged and involved in
 It must be real visible involvement at all levels
QAPI: Feedback, Data Systems, and
 This element emphasizes the establishment
of systems for proactively identifying and
using data to measure performance and
identifying opportunities for improvement
QAPI: Performance Improvement
 Performance Improvement Projects (PIPs) to
improve care
 Builds on the other elements to ensure that the
opportunities for improvement are prioritized and
incorporated into PIPs
Systemic Analysis and Action
 Using a systematic formal process for analysis
 Example: root cause analysis
 Ensuring that actions taken address changes or
improvements to the system
 Continual improvement and learning
Design & Scope
Performance Improvement Projects
Systematic Analysis/
Systematic Action
Feedback, Data Systems
“Call the Question”
Are you proud of “your” performance?
How do your clinical scores compare to your competitors?
What did "we" do differently?
Does improving quality really matter in your organization?
How are quality initiatives prioritized within your organization?
Do you “know” how you do what you do to make success repeatable?
Developed from AHA Get w/ the Guidelines program (Houston, 2005)
Maine Veterans Homes Journey
Converging on Qapi
• Silver award applications
• Affordable Care Act mandate: QAPI
• Hardwire a culture of excellence
• Strategic Plan: Direction from the board
• Needed a framework
Leadership and Governance
• Developing the QAPI
• Educate board
• Obtain senior leadership
• Identified initial membership of
the Workgroup
• Board steers the QAPI
MVH QAPI Workgroup
 Representatives from all 6 homes and central office
 Standardized education to introduce QAPI
 Charter established and approved by Board
 Purpose – establish a fact based, data-driven system for improving
healthcare, safety, operational performance and competitiveness of
Maine Veterans’ Homes
 Goals:
 Development of an annual QAPI plan
 Development of a results dashboard
 Review of outcome results and identification of opportunities for
Purpose of the Committee
Primary Functions
The primary function of the Committee is to establish a fact based, data driven system for improving health care,
safety, operational performance, and competitiveness of Maine Veterans' Homes.
The Committee provides a stabilizing influence so organizational concepts and directions are established and
maintained with a visionary view. The Committee provides insight on long-term strategies in support of Quality
Assurance and Performance Improvement (QAPI).
Members of the Committee ensure the development, oversight, and publication of the annual QAPI Plan. The
Committee will establish a Results Dashboard that includes measurements of outcome results in Healthcare Process,
Customer Focus, Workforce Focus, Leadership & Governance, and Financial & Market. In practice these
responsibilities are carried out by performing the following functions:
Develop annual QAPI Plan and Results Dashboard to be formally accepted by the MVH Board Development
Identify all current QAPI-related initiatives throughout MVH;
Review outcome results to identify opportunities for improvement and strategy sharing;
Control project scope as emergent QAPI issues force changes to be considered, ensuring that scope aligns
with the agreed requirements of key stakeholder groups (Veterans, Families, and Staff);
Resolving project conflicts and disputes, reconciling differences of opinion and approach;
Role of a Committee member
It is intended that the Committee leverage the experiences, expertise, and insight of key individuals at each facility
committed to enhancing the QAPI process. Members will champion the development of a corporate culture of
transparency, employee involvement and development, and resident directed care to improve health care, safety,
operational performance, and competitiveness.
Committee members may not be directly responsible for conducting QAPI efforts, but they provide support and
guidance for those who do. Thus, individually, Committee members should:
Understand the strategic implications and outcomes of QAPI initiatives being pursued;
Appreciate the significance of QAPI for all stakeholders and represent their interests;
Be genuinely interested in the initiative and be an advocate for broad support for the outcomes being pursued
in the QAPI Plan and Results Dashboard;
Have a broad understanding of management issues and approaches being adopted.
In practice, this means Committee members:
Review the status of QAPI-related efforts within MVH;
Ensure the QAPI-related outputs in their respective fields meet the requirements of the Committee and
Help balance conflicting priorities and resources;
Provide guidance to the facility-level QAPI efforts;
Provide feedback on facility-level QAPI efforts to the Committee;
Consider ideas and issues raised;
Ensure adherence of QAPI activities to standards of best practice both within MVH and in any regulatory
manner; and
Foster positive communication outside of the Committee regarding the Committee’s progress and outcomes;
Design and Scope
 Reviewed organizational profiles
 Baldrige definition: What are your key organizational
characteristics? What is your organization's strategic situation?
 Products, vision, mission, workforce, assets, regulatory
requirements, organizational structure, customers/stakeholders,
 Self Assessment:
 CMS QAPI tools: QAPI at a Glance
 Organizationally and at each home
 QAPI Plan Development:
 Purpose Statement
 Development of guiding principles
Design and Scope
MVH QAPI Purpose Statement
The purpose of our Quality Assurance and
Performance Improvement (QAPI) Program is to
achieve and sustain a culture of excellence by using
a fact based, data driven decision making model
with a proactive approach to continually improving
the way we “Care for Those Who Served”.
QAPI Plan Goals
 QAPI Plan Goals:
 Utilize a dashboard to monitor key measures and
improve organizational performance
 Establish a framework for performance improvement
practices at MVH
 Promote a culture of safety for residents, families, and
 Enhance quality of life for our resident through culture
change activities
Design and Scope
MVH QAPI Guiding Principles
1. In our organization, QAPI includes all employees, all departments, and all services.
2. QAPI has a prominent role in our management and board functions.
3. Our organization uses QAPI to make informed decisions and guide our day to day
4. The outcome of QAPI in our organization is the quality of care and quality of life of
our residents within a framework of resident directed care and recognition that
“Veterans are Unique”.
5. QAPI focuses on systems and process. The emphasis is on identifying system gaps
rather than blaming individuals.
Design and Scope
MVH QAPI Guiding Principles
6. Our organization has a culture that supports “Honesty and Integrity”
by encouraging employees to identify errors and system breakdown.
7. Our decisions to improve will be guided by data, in conjunction with
individual care and choice, which includes to input and experience of
residents, families, caregivers, health care practitioners, and other
8. Our organization sets goals for performance and measures progress
towards those goals with a focus on “Leading the Way” within our
industry and sustaining a culture of “Excellence”.
9. Our organization supports performance improvement by encouraging
our employees to “Respect” and support each other as well as be
accountable for their own professional performance and practice.
10. MVH encourages “Team” collaboration, sharing of best practices, and
celebrating successes across the organization.
Development of Measures
 Measures were reviewed for
alignment with:
Industry goals and initiatives
MVH Strategic Plan
Customer Expectations
Core Values
Performance Excellence
Framework for Improving
Organizational Quality
 QAPI elements
Tool to determine measures
Type of measure:
Level of care applied to:
Goal of measure, link to strategic plan:
Customer Focus
Healthcare and Process
Leadership and Governance
Domiciliary, SNF, NF, other
Deliver highest quality of care to veterans
and their families.
Enhance quality of life through person
directed care.
Attract and retain the best employees.
Develop and maintain effective information
delivery systems.
Expand services to meet the evolving needs
for veterans care.
Environmental design/ Campus plan
Maintain the financial foundation to ensure
MVH care to veterans into the future.
What are we looking at to meet our goal (reflective of
the indicator). Examples decrease trash by 5% this
year, decrease falls by 3% this year, reduce the
number of falls.
Should be a ration or % if at all possible
Applied to:
Who or what does the indicator apply to? Example- a
specific employee group, an apartment or apartment
Frequency of measurement:
This may be daily, weekly, monthly, or more. May
also be a one time measurement-example an annual
satisfaction survey
Dashboard Measures
 Non-clinical Measures:
 Workforce – Total facility turnover; Nursing turnover; Days Away
Restricted Transferred Duties (DART)
 Operations – Days in Accounts Receivable; Occupancy
 Customer – Overall satisfaction; Recommends to others; Culture
 Clinical Measures:
 Healthcare – Hospital Readmissions; Serious Reportable Events;
Long-Stay, Short-Stay, & Res Care Antipsychotic Drug Use
Results Dashboard
 Visual representation of
organizational performance
 Displays clinical and nonclinical results called
 Displays MVH target
 Reflects trends in
organizational performance
Review of Measures
 Measures approved by board
and senior leaders
 QAPI Element: Actively
involved governing body
 Standardized training across
Person Responsible
Total Facility Turnover
4/20, 7/20, 10/20, 1/20
Nursing Turnover
4/20, 7/20, 10/20, 1/20
Hospital Readmissions
Alain with Rhona backup
Data entered by DNS by 15th
Culture Change
Every 6 months
Admistrators to Deb
Data due to Deb by 12/30, 6/30
1/20, 7/20
Days in AR
Jeremy with Karen backup
Overall Satisfaction
4/20, 7/20, 10/20, 1/20
Recommend to Others
Jeremy with Karen backup
Serious Reportable Events
Long Stay Antipsychotics
Jim with Rob backup
4/20, 7/20, 10/20, 1/20
Short Stay Antipsychotics
Jim with Rob backup
4/20, 7/20, 10/20, 1/20
Res Care Antipsychotics
Every 6 months
Jim with Rob backup
enter data by 15th
RCD to send QIQM report to Jim
Post to M-Drive by
5/20, 11/20
Systematic Analysis and action: Root
Cause Analysis
 Developed a root cause analysis tool
 Reviewed with VAMC liaison
 Educated clinical leaders
 Implemented
Root Cause analysis Tool
 What happened?
 Why did it happen?
Human Factors
Communication Factors
Equipment Factors
Information Factors
Environmental Factors
Root cause analysis tool
Root cause analysis tool
Cause and effect diagram tool
Performance Improvement projects
 One of our organization-wide
PIPs was regarding hospital
 We began this PIP by looking
at best practices and
researching tools to assist us
 Reviewed data using Trend
 Chose to use Interact tools
 Interfaced with local
Hospital Readmission PIP
Next Steps
Finalization of MVH QAPI Plan to
 Descriptions of:
 Scope
 Guidelines for Governance and
 Feedback, Data Systems, and Monitoring
 Guidelines for Performance
Improvement Project Teams
 Systematic Analysis and Systemic Action
 Communications
 Evaluation
Board review and Approval of Annual
Standardized training across the
Achieving a Culture of Excellence
One Home’s Journey
Maine Veterans’ Home, Scarborough
The past
 Reviewing QIQM reports
 Counting beans
Department Measures
 Each department measuring their own area
 Narrow focus
Functional Measures
 Transition to
functional measures
 Interdisciplinary
 Measures across
departments for
functional groups
Engaging and Building Relationship with Stakeholders
In the true sense
of resident directed
and person-centered
approach to all that we
do, we have developed
and/or revised seven
Engaging and Building Relationship stakeholders
 These committees are:
Employee Recognition
Public Relations & Marketing
Activities and Dining
 Staff, residents, and family members
agreed to populate them.
Where we are now
 Prior to QAPI we were adding pieces
but not building from the foundation
 Using the Baldrige criteria and the
elements of QAPI to hardwire a
culture of excellence
 Not only understand HOW but WHY we
have quality assurance and
performance improvement activities
Engaging and Building Relationship with Staff:
Cultivating Excellence & Improve Staff Satisfaction
 Not easy
 Persevere
Engaging and Building Relationship with Staff:
Cultivating Excellence & Improve Staff Satisfaction
 Hear the negatives
 Stay focused
 Don’t overwhelm
 Make it THE most important
 Let them do their work, if they do it
wrong at least they are doing it.
Engaging and Building Relationship with Staff:
Cultivating Excellence & Improve Staff Satisfaction
Celebrate the successes
Acknowledge the failures
 Thomas Edison said, “I did not fail, I
discovered thousands of things that did
not work”
Contact Information
Debra Fournier, Chief Operations Officer
Maine Veterans’ Homes
[email protected]
Kevin Warren, Deputy Commissioner
Texas State Veterans Homes & Cemeteries
[email protected]

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