qapi what medicare really wants? presented to: region 7 presented on: february 13, 2015 presented...

QAPIWhat Medicare Really Wants?

Presented to: Region 7 Presented on: February 13, 2015Presented by: Gwen McNatt

Getting to Yes-Where: CMS Quality Strategy

Overview of CMS Approach

CMS Requirements + Survey Findings

• Program Design + Management• ABO Verification• Multi-Disciplinary Planning• Patient + Living Donor Care• Informed Consent• Patient Selection• Data Submission to OPTN• Quality Assessment + Performance Improvement

(QAPI)

• Risk-Adjusted Outcomes (Graft + Patient Survival) • Deficiency is Cited if:

1. SMR: Observed/Expected Failures > 1.5 (One-Year Post-Tx)2. P < .05 (one-sided value, same as OPTN)3. Observed minus Expected > 3

Five Medicare QAPI Themes

5

Key QAPI Themes1. Design and Scope

1. Design + Scope(a) Effective (b) On-Going(c) Data-driven(d) Hospital-wide(e) Reflects Complexity

of Hospital + Services

(f) Focus on Outcomes +

Prevention of Medical Errors

Regulation: Key QAPI Themes1. Design + Scope

2. Organizational Awareness - Feedback Systems, Quality Indicators, Culture of Safety

(a) Adverse Events

1. Identified Systematically,

2. Tracked,

3. Investigated

4. Analyzed

5. Used

(b) Quality Indicators 6. Problem Prone Areas

7. High Risk Areas

8. Tracked

9. Used for Quality Improvement

2.

Organizational Awareness:

(a) Adverse Events(b) Quality

Indicators

High Reliability Organizations

Weick, K.E + Sutcliffe, K.M; 2007

Managing the Unexpected, 2d Ed.

San Francisco; Jossey-Bass

2. Awareness - Feedback + QI Systems

Adverse Events

1. Identified! (e.g., internal incident reporting systems)

2. Tracked,

3. Investigated

4. Analyzed5. Used to Improve Systems – Prevent Recurrence …“to

effect changes in the transplant center’s policies and practices to prevent repeat incidents” (42 CFR 482.96(b)(2))

Systematic Analysis for Systemic Improvement

Case Examples: Challenges Evident in Many Programs

•Root Cause Analysis (RCA) Expertise: • Expertise• Low Quest Quotient, • Low Level of Systems Thinking• Culture of Blame • Silos, professional autonomy

•Informatics Expertise: Lack of expertise in using available sources of data, such as the SRTR data set.

•Informational Infrastructure: Info systems, measures, data input, staffing, tracking…

•Beliefs, Attitudes• We don’t need this…• QI is just an added burden imposed on us.

Case Example: The Case of the Non-Compliant Patient

5x Why or 5x How

1. How did he Die?• Succumbed to Aspergillus

Were technical issues (surgical or non-surgical) a factor in this event?

If yes, describe. Recommendation:

Were donor selection issues a factor in this event? If yes, describe. Recommendation:

Were recipient selection issues a factor in this event If yes, describe. Recommendation:

Management: Was post-transplant management a factor in this event?


Management: Was medication dosing or protocols a factor in this event?


Management: Was coagulopathy a factor in this event? If yes, describe. Recommendation:

Management: Were policies, protocol, or guidelines a factor in this event?


Recipient factors: Was non-compliance or missed care a factor in this event?


Were human resources an issue in this event? If yes, describe. Recommendation:

Was communication a factor in this event? If yes, describe. Recommendation:

Was a lack or misinterpretation of information a factor in this event?


Was lack or inadequate training a factor in this event? If yes, describe. Recommendation:

Was availability or use of equipment a factor in this event? If yes, describe. Recommendation:

Was the physical environment a factor in the event? If yes, describe. Recommendation:

Contributing Factors

Develop a Improvement Master Plan

Case Example - The Case of the Non-Compliant Patient

5x Why or 5x How


2. How ?• Hung out at a Construction Site • Failed to Follow Instructions to

Avoid Construction Sites, Gardening


5x Why or 5x How




3. How Could he Fail to Follow Instructions?• Instructions were Clear!

Case Example # 3 - The Case of the Non-Compliant Patient

5x Why or 5x How





4. How were the Instructions Given• Clearly Written with Warnings in his

Instruction Materials


5x Why or 5x How





4. How were the Instructions Given• Clearly Written with Warnings in his Instruction

Materials

5. How is it that Written Instructions are Always Adequate?

Mastering SRTR Data as a QI Tool

• Valuable Quality Improvement Tool• Risk-Adjusted Outcomes Data

• Subgroup Analyses• Team Performance

• SRTR Methodology: http://www.srtr.org/csr/current/programs-report.aspx

• CUSUM Tool – Added

July 2013

SRTR Tools (continued)

SRTR Worksheets:https://securesrtr.transplant.hrsa.gov

https://securesrtr.transplant.hrsa.gov/

Existing SRTR Quality Improvement ToolKidney program – 1-year post-transplant graft survival for deceased donors

All SRTR risk factors in this row

This row auto re-

calculatesSub-

group? (Y/N)

QAPI Theme: Performance Improvement Projects

1. Design + Scope

2. Feedback, QI Systems, Awareness

(a) Adverse Events 1. Reported, 2. Tracked, 3. Investigated 4. Analyzed

(b) Quality Indicators 5. Problem Prone Areas6. High Risk Areas 7. Tracked8. Used for Quality

Improvement

3. Performance Improvement Processes

4. Systemic Improvement5. Governing Body +

Leadership

3. Performance

Improvement Projects and

Processes

(a) Not Specified by CMS(b) Tailored + Determined

by Transplant Program(c) Used to Improve

Systems(d) Data-driven(e) Effective (at least

sometimes!)

QAPI Theme: Governing Body + Leadership

1. Design + Scope2. Feedback, QI Systems,

Awareness

(a) Adverse Events 1. Reported, 2. Tracked, 3. Investigated 4. Analyzed

(b) Quality Indicators 5. Problem Prone Areas6. High Risk Areas 7. Tracked8. Used for Quality

Improvement

3. Performance Improvement Processes

4. Systemic Improvement

5. Governing Body + Leadership

5. Governing Body

and Leadership (482.21 + 482.96)

QAPI is:(a) Resourced(b) Used to Improve

Systems(c) On-going(d) Data-driven(e) Hospital-Wide(f) Effective

Special Responsibility

to:(g) Set Expectations(h) Ensure

Staffing/Personnel

Concerns

• How is this in the regs?• What are triggers for FQAPI?• Where are published Igs? • Cost issues

Questions?

qapi what medicare really wants? presented to: region 7 presented on: february 13, 2015 presented...

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