Quality Assessment Performance Improvement Root Cause Analysis and

Quality Assessment & Performance Improvement, Root Cause Analysis and the Model for Improvement Melody Malone, PT, CPHQ TMF Health Quality Institute

Objectives The learner will be able to: § Describe quality assessment & performance improvement (QAPI) § Define three categories of human factor performance gaps § Explain root causes § Understand rapid cycle quality improvement methodology 2

About TMF Health Quality Institute focuses on improving lives by improving the quality of health care through contracts with federal, state and local governments, as well as private organizations. For more than 40 years, TMF has helped health care providers and practitioners in a variety of settings improve care for their patients. 3

About the QIO Program Leading rapid, large-scale change in health quality: § Goals are bolder. § The patient is at the center. § All improvers are welcome. § Everyone teaches and learns. § Greater value is fostered. 4

About the QIO Program Leading rapid, large-scale change in health quality: § Goals are bolder. § The patient is at the center. § All improvers are welcome. § Everyone teaches and learns. § Greater value is fostered. 5

Have You Ever Said “HUMMMM” 6

How come I CAN’T: § § § Get my calls returned on time? Why can’t I document in Ombuds. Manager? Stay within budget? Get my facilities where I want? Sustain improvements? 7

Q 1, Q 20 2, 0 Q 20 2 3, 0 Q 20 2 4, 0 Q 20 2 1, 0 Q 20 2 2, 0 Q 20 3 3, 0 Q 20 3 4, 0 Q 20 3 1, 0 Q 20 3 2, 0 Q 20 4 3, 0 Q 20 4 4, 0 Q 20 4 1, 0 Q 20 4 2, 0 Q 20 5 3, 0 Q 20 5 4, 0 Q 20 5 1, 0 Q 20 5 2, 0 Q 20 6 3, 0 Q 20 6 4, 0 Q 20 6 1, 0 Q 20 6 2, 0 Q 20 7 3, 0 Q 20 7 4, 0 Q 20 7 1, 0 Q 20 7 2, 0 Q 20 8 3, 0 Q 20 8 4, 0 Q 20 8 1, 0 Q 20 8 2, 0 Q 20 9 3, 0 Q 20 9 4, 0 Q 20 9 1, 0 Q 20 9 2, 1 Q 20 0 3, 1 Q 20 0 4, 1 20 0 10 Mean proportion of population How do I get here? ? 20. 0% 18. 0% 16. 0% 14. 0% 12. 0% 10. 0% 8. 0% 6. 0% 4. 0% 2. 0% 0. 0% 8

Through Quality Improvement 9

“Quality is not an act, it’s a habit. ” - Aristotle 10

Current State of Affairs “How do YOU do Quality Improvement Now? ” {in your office} 11

Current State of Affairs “We have our QAA meeting every month… isn’t that QI? ” {Nursing Home} 12

Comparison of QA and QI Quality Assurance (QA) Quality Improvement (QI) Focus: Catch “bad apples” or detect serious problems Goal: Meet minimal standards Improve processes—not fault finding Ongoing process improvement Who’s Involved: Usually 1 -2 individuals Teams Driven By: Regulation/accreditation Organizations Occurs: Monthly or quarterly Continuously 13

QA & A F 520 § A facility must maintain a quality assessment and assurance committee consisting of: • The director of nursing services • A physician designated by the facility • At least three other members of the facility’s staff § The quality assessment and assurance (QA & A) committee: • Meets at least quarterly to identify issues with respect to which QA & A activities are necessary • Develops and implements appropriate plans of action to correct identified quality deficiencies 14

QA & A F 520, cont. § The state or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section. § Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions. 15

Quality Assurance and Performance Improvement (QAPI) 16

QAPI Background § Mandated in the Affordable Care Act, enacted March 2010 § Legislation requires the Centers for Medicare & Medicaid Services (CMS) to establish QAPI program standards and provide technical assistance to nursing home providers. § CMS identified training needs for long-term care surveyors. § Demonstration projects are ongoing now and tools are coming. 17

5 Elements of QAPI • Element 1 – Design and scope § Element 2 – Governance and leadership § Element 3 – Feedback, data systems and monitoring § Element 4 – Performance improvement projects § Element 5 – Systematic analysis and systemic action 18

Element #1: Design and Scope § A QAPI program must be: • Ongoing and comprehensive • Dealing with the full range of services offered by the facility • Including ALL departments § It utilizes the best available evidence to define and measure goals. § A written QAPI plan § Address: • • Clinical care Quality of life Resident choice Care transitions § Aims for safety and high quality with all clinical interventions § Emphasizes autonomy and choice in daily life for residents 19

Element #2: Governance and Leadership The governing body and/or administration: § Develops and leads a QAPI program § Involves leadership § Uses input from facility staff, residents and their families and/or representatives § Assures the QAPI program is adequately resourced § Designates one or more persons to be accountable for QAPI § Develops leadership and facility-wide training on QAPI § Ensures staff time, equipment and technical training as needed for QAPI § Responsible for establishing policies to sustain the QAPI program despite changes in personnel and turnover 20

Element #2: Governance and Leadership, cont. Also responsible for: § Setting priorities for the QAPI program § Building on the principles identified in design and scope § Setting expectations around: • Safety • Quality • Rights • Choice • Respect • Balancing both a culture of safety and a culture of resident-centered rights and choice § The governing body ensures that while staff are held accountable, there exists an atmosphere in which staff are not punished for errors and do not fear retaliation for reporting quality concerns. 21

Element #3: Feedback, Data Systems and Monitoring § Use systems to monitor care and services, drawing data from multiple sources. § Feedback systems actively incorporate input from staff, residents, families and others as appropriate. § Use performance indicators to monitor a wide range of care processes and outcomes, and review findings against benchmarks and/or targets the facility has established for performance. § Use tracking, investigating and monitoring adverse events that must be investigated every time they occur, and action plans implemented to prevent recurrences. 22

Element #4: Performance Improvement Projects (PIPs) § Conduct PIPs to examine and improve care or services in areas identified as needing attention. § A PIP is: • A concentrated effort • On a particular problem in one area of the facility or facility-wide • Involves gathering information systematically to clarify issues or problems • Intervening for improvements • Selected in areas important and meaningful for the specific type and scope of services unique to each facility 23

Element #5: Systematic Analysis and Systemic Action § Use a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes and implications of a change (a. k. a. root cause analysis). § Use a thorough and highly organized/structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized/delivered. § Develop policies and procedures and demonstrate proficiency in the use of root cause analysis. § Systemic actions look comprehensively across all involved systems to prevent future events and promote sustained improvement. § This element includes a focus on continual learning and continuous improvement. 24

CMS QAPI Efforts § Nursing home quality improvement questionnaire § Development of QAPI tools and resources § Development of QAPI website § QAPI demonstration project: • Test tools/resources • Conduct learning collaboratives • Online resource center for demo participants 25

National Rollout Plans § Initial release of QAPI materials on CMS website (late summer, 2012) § Continued identification of resources and case examples § Engagement of state and national stakeholders § Encouragement of learning collaboratives with partner organizations § Development of regulation § Development of surveyor training materials and survey worksheet 26

LET’S WATCH A MOVIE! 27

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Human Errors in Medicine “… and the adverse events that may follow, are problems of psychology and engineering, not of medicine. ” - J. W. Senders, Ph. D, Medical Researcher 29

Human Error – The Old View The bad apple theory: § Complex systems would be fine if it weren’t for some unreliable people. § Human errors cause accidents. § Failures are surprises. 30

What’s wrong with the old view? § Focusing on individuals does not solve underlying problems. § Errors are not intrinsically bad. 31

Human Error § Human error is not the cause of accidents, it is a symptom of deeper trouble. § Human error is not random. § Human error is not the conclusion of an investigation, it is the beginning. 32

What is “Human Factors”? “Human Factors” is about how features of our tools, tasks and work environments continually influence what we do and how we do it. 33

In Other Words Human Factors is about how the design of things impacts how well we do any task. • Design of our workplace • Design of the tools we use • Design of processes (how we do our work) 34

What’s wrong with this picture? ? ? 35

Human Factors § How could this happen? • Distracted sign maker § What could happen as a result? • What were conditions and situation like when driving? • What are characteristics of the task? 36

Combating Human Error with Better Designs Where do we start? • Assume that people do reasonable things. • Look at why there is a performance gap. 37

3 Categories of Performance Gaps § The plan itself was inadequate to achieve desired outcome (planning error). § The plan is not executed properly (execution error). § There was a deliberate departure from “safe” practice (violation). 38

Planning Errors § Driving to favorite gas station—run out of gas § Giving antibiotics to a patient with a viral infection 39

When is it a planning error? § Don’t know what to do § Don’t know how to do it § Don’t know who is supposed to do it § “I couldn't do it” § “I used to do it differently” 40

Planning Errors § Table Talk… • What sort of planning errors have you experienced lately? 41

Planning Errors What may not work: 1. Punishment 2. Rewards 3. Reminders Why? They believe they are acting correctly or following the set process. 42

Planning Errors What may work: 1. Memory aids 2. Training or education 3. Creating/redesigning process 43

Execution Errors § Turning left instead of right! § Giving the wrong medicine when distracted § Forgetting to assess a patient’s pain due to interruptions 44

When is it an execution error? § Forgot § Distracted or interrupted § Steps look alike § “It slipped my mind” § Just “messed up” 45

Execution Errors § Table Talk… • What sort of execution errors have you experienced lately? 46

Execution Errors What may not work: 1. Punishment 2. Rewards 3. Training or education of skilled operators/experts Why? They intended to correctly complete the task. 47

Execution Errors What may work: 1. Prompts 2. Reminders 3. Memory aids 48

Violations § Act itself is deliberate § Negative consequences are not intended § Certain conditions more likely to produce violations 49

When is it a violation? § Don’t have to do it § Frustration § Cumbersome rules, policies § Perception of being above the rules § “Saving time if I do it my way” 50

Violations § Table Talk… • What sort of violations have you experienced lately? 51

Violations What may not work: 1. Training and education 2. Reminders 3. Prompts 4. Memory aids 5. Punishment Why? Violations are a product of consequences, and positive consequences are strongest. 52

Violations What may work: 1. Redesign work to eliminate frustrations. 2. Use policies and rules only when necessary. 3. Give positive feedback for desired behavior. 4. Simplify processes. 53

Possible Solutions in Summary § Planning errors • Memory aids • Training/education • Process changes § Execution errors § Violations • Redesign work • Use policies only when necessary • Positive feedback • Prompts • Reminders • Memory aids 54

Human Factors vs. Disciplinary Action § Human error (a. k. a. human factors): • Planning errors • Execution errors • Violation (intentional and/or recklessness) 55

Just Culture vs. Disciplinary Action § Just culture (safety thinking): • Promotes a questioning attitude • Resistant to complacency • Committed to excellence • Fosters both personal accountability and corporate self-regulation in safety matters • Atmosphere of trust 56

Goals of Quality Improvement § § § § Identify problem areas Identify sources of variation Simplification Eliminate duplication, rework, extra steps Improve fragmentation Remove waits, delays Eliminate errors 57

And Most Importantly, QI… Is a process to build a culture of safety and move beyond the culture of blame. Remember : Human Factors and a Just Culture! QI = No Blame 58

Quality Principles Systems Thinking § § § § Cyclical─not linear (cause/effect) System is dynamic in achieving goals Looks at a system in total, as sum of its parts, all working together Encourages communication and speaking up to break down silos Depends on feedback to maintain stability System at fault versus individual employee Promotes understanding of the patterns of behaviors that lead to outcomes, positive and negative Principles of QAPI § § § § Just culture Ongoing, continuous 5 elements that are interrelated Learning organization; sustaining improvements Culture where staff do not fear reporting quality concerns Feedback, data systems and monitoring An approach to QI where the culture is to make continuous improvement. “It’s just what we do. ” Feedback, data systems and 59 monitoring

Where do we begin? 60

Search for the Root Cause § The most fundamental reason a problem has occurred. When performance does not meet expectations 61

Root Cause Analysis § Inter-disciplinary § Involving experts from the frontline services § Continually digging deeper by asking why, why at each level of cause and effect 62

The Goal of a Root Cause Analysis is to Find Out: § What happened? § Why did it happen? § What to do to prevent it from happening again 63

Root Cause Analysis § Identifies needs for systems changes § Is a process that is as impartial as possible § As well as a tool for identifying prevention strategies § There are various tools to use. 64

5 WHYs Tool 65

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Brainstorming 67

Brainstorming Rules § Postpone and withhold your judgment of ideas. § Encourage wild and exaggerated ideas. § Quantity counts at this stage, not quality. § Build on the ideas put forward by others. § Every person and every idea has equal worth. 68

Brainstorming § Why can't we keep sufficient staff? 69

Silent Brainstorming 70

Silent Brainstorming § What do you want to change about the Ombudsman program? 71

Silent Brainstorming § What should not be changed about the Ombudsman program? 72

Fishbone Diagram Materials Staff Problem Statement Equipment Education 73

We Have the Root Cause Now what? 74

Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Act Plan Study Do 75

The PDSA Cycle for Learning and Improvement Act • What changes are to be made? • Ad. Apt? Ad. Opt? or Abandon? • Next cycle? Study • Complete the analysis of the data • Compare data to predictions • Summarize what was learned Plan • Objective • Questions and predictions (why) • Plan to carry out the cycle (who, what, where, when) Do • Carry out the plan • Document problems and unexpected observations • Begin analysis of the data 76

Model for Improvement What are we trying to accomplish? Decreasing falls How will we know that a change is an improvement? We are going to measure! Set a goal: 50% imp. Q 1 to Q 2 What change can we make that will result in improvement? Follow up daily on fall risk assessments from day before. 77

The PDSA Cycle for Learning and Improvement Act • What changes are to be made? • Ad. Apt? Ad. Opt? or Abandon? • Next cycle? Study • Complete the analysis of the data • Compare data to predictions • Summarize what was learned Plan • Verify one of prior day’s fall risk assessments • Validate 1 • Observe 1 • By unit manager • Track results Do • Carry out the plan • Document problems and unexpected observations • Begin analysis of the data 78

Repeated Use of the Cycle A T A D A S Hunches Theories Ideas D S P A P D A P S D Changes That Result in Improvement Spread Implementation of Change Wide-scale Tests of Change Follow-up Tests Very Small-scale Test 79

The PDSA Cycle for Learning and Improvement Act • What changes are to be made? • Ad. Apt? Ad. Opt? or Abandon? • Next cycle? Study • Complete the analysis of the data • Compare data to predictions • Summarize what was learned Plan • Verify prior day’s fall risk assessments Done, daily • Validate 10% of each • Observe 10% of each • By unit manager • Track results Do • Carry out the plan • Document problems and unexpected observations • Begin analysis of the data 80

Overall Goal: Implement the Model for Improvement A P S D D S P A A A P S D Concept A A P S D D S P A A P S D P A P S D Concept B Concept C A P S D Concept D A P S D D S P A A P S D Concept E Develop strategies for each component of the model. 81

GOAL – Improve Outcomes Concept D Concept A Concept C Concept B Change concepts, theories, ideas 82

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Start Small § What can you do by Tuesday? 84

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QI Resources: http: //Texas. QIO. tmf. org 87

Questions? 88

Contact Melody Malone, PT, CPHQ Quality Improvement Consultant TMF Health Quality Institute 214 -632 -2238 melodymalone@txqio. sdps. org http: //Texas. QIO. tmf. org This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U. S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10 SOW-TX-C 7 -12 -174 89