Clinical Indicator Goals Project: Developing QAPI Without Fear

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Clinical Indicator Goals Project Developing
QAPI Without Fear

• Svetlana (Lana) Kacherova, QI Director
• Lisle Mukai, QI Coordinator
• ESRD Network 18
• November 19, 2008

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Special Acknowledgement forContent
ContributionsLaura Adams, President and
CEO Rhode Island Quality Institute Quality
Improvement Directors From other ESRD Networks!
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Session Objectives

• Project Description
• Increase understanding of Quality Principles
• Use the Basic Quality Tools
• Apply PDSA cycle and project steps
• Learn something new
• Have some fun

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V626 QAPI Condition Statement

• The dialysis facility must develop, implement,
  maintain and evaluate an effective, data driven,
  quality assessment and performance improvement
  program with participation by the professional
  members of the interdisciplinary team...
• The dialysis facility must maintain and
  demonstrate evidence of its quality improvement
  and performance improvement program for review by
  CMS

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Condition 494.110Quality Assessment and
Performance Improvement Project (QAPI)

• Interdisciplinary team (IDT)
• Must report problems to Medical Director and
  Quality Improvement committee
• Outcome- focused
• Process continuous on-going
• Use community accepted standards as targets
• Include patient satisfaction, infection control,
  medical injuries medication errors
• Plan/Do/Study/Act Close the loop!

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Monitoring Performance Improvement

• (V638) The facility must
• Continuously monitor its performance
• Take actions that result in performance
  improvement
• Track to assure improvements are sustained over
  time

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Interdisciplinary Team

• Show Me The Progress

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Performance Measures include but not limit to
(V629) Adequacy Kt/V, URR
(V630) Nutrition Albumin, body weight
(V631) Bone disease PTH, Ca, Phos
(V632) Anemia Hgb, Ferritin
(V633)Vascular access ?Fistula, ?catheter rate
(V634) Medical errors ?Frequency of specific errors
V635) Reuse ?Adverse outcomes
(V636) Pt satisfaction ?Survey scores
(V637) Infection control ?Infections, ?vaccination status
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Clinical Indicator Goals Project Inclusion
Criteria for Participating Facilities

• Not meeting Network goals on at least 2 of 3
  clinical indicators (N63)
• - Anemia
• - Dialysis Adequacy
• - Albumin
• IMPORTANT
• Anemia and Adequacy information is available on
  the Dialysis Facility Compare website at
  www.medicare.gov

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Project Goal

• All participating facilities will perform a
  Root-Cause Analysis (RCA) and develop QAPI to
  meet clinical indicator goals
• 65 of facilities (N- 40) will show improvement
  from baseline in at least 2 of 3 clinical
  indicators between October 2008 and March 2009
• Goals are set per MRBs suggestion based on the
  historical clinical indicator monitoring processes

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Reasons for Anemia Goals gt 11.0 g/dl

• Network Goal 85 patients with Hgb gt 11.0 g/dl
• CPM study looks at the of patients gt 11.0
  g/dl and Network goals are determined upon CPM
  results
• Hgb lower and upper limits discussion
• MRB suggested no more than 15 of patients with
  Hgb lt 10.0 g/dl and no more 15 pts with Hgb gt
  13.0 g/dl

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Important

• If your facility anemia goals are different from
  the Network goal (upper and lower limits for Hgb
  or Hct) provide the Network with your policy on
  Anemia goals
• Identify your goal on the Anemia Monitoring Run
  Chart when submitting data to the Network
• Same applies to other clinical indicator goals
  (for adequacy and nutrition)

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What is QAPI and why do we need it

• Quality Assessment and Performance Improvement
  Project/Program
• Previously known as a CQI (Continuous Quality
  Improvement)

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Information that Duels the Growing Emphasis on
Quality

• Two million documents will be lost by the IRS
  this year
• 18,322 pieces of mail will be mishandled in the
  next hour
• 20,000 incorrect drug prescriptions will be
  written in the next 12 months
• Data from the early 1990s

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Quality in Healthcare

• Rather then just meeting fixed standards, a never
  ending search for ways to improve patient
  outcomes
• Focus on outcomes and the process that produce
  those outcomes
• Focus on systems of care not individual cases
• Improve the average and the outliers will improve
  too

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Institute of Medicine Aims for Health
Care

• Six aims of health care
• Safe
• Effective
• Patient centered
• Timely
• Efficient
• Equitable

1. Evidence-based
2. Patient centered
3. Outcome improvement driven
4. Systems/team oriented

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What is the cost of Poor Quality?

• No show rates?
• Lost charts?
• Lost labs?
• Train wreck visits?
• Lost revenue improper billing?
• Staff turnover?

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Basic Principles of Quality Improvement

• Focus on improving work processes
• A systems orientation to service delivery
• Services or products tailored to customers needs
• Staff involvement
• Emphasis on design and improvement of
  products/services
• A focus on continuously improving

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Introducing the Quality Tools
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Basic Quality Tools

• Process Analysis
• Flow Chart
• Brainstorming
• Fishbone Diagram (Cause and Effect)
• Check Sheet
• Histogram or Pareto Diagram
• Run Chart
• Communication

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Process AnalysisBasic Components or major Steps
in a Process
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Use Process Analysis to

• Defines and evaluate the overall process
• Each box placed in order of occurrence,
  represents a key part of the process being
  examined
• The amount of time could be added as it could be
  important for improvement
• Once identified which part of the process needs
  improvement, the box could be further broken down
  into specific steps using a flow chart

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Flow Chart
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Use a Flow Chart to

• Define specific steps in a process including
  choices and decision points
• If there is a decision to be made and no specific
  choices this is a source of variation and a
  potential problem!
• Every process should have a clearly defined
  beginning and end (all team members must agree on
  steps)

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Brainstorming

• Tool for gathering ideas, particularly about
  problem causes and solutions

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Rules of Brainstorming

• Dont criticize
• Be creative
• Go for quantity not quality
• Suspend judgment evaluation
• Piggyback on others ideas
• Record all ideas
• Encourage others

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Fishbone Diagram

• Also called Ishikawa Diagram in honor of the man
  who developed this tool
• Also called the Cause Effect Diagram because
  its primary use is to assist in determining the
  root-cause of a problem
• Use this tool (bone by bone) to identify a major
  source and drill down to the level where action
  can be taken

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Fishbone Diagram (cont).

• Determine the problem and create a problem
  statement (effect). Write it at the right center
  of the chart
• Brainstorm the major categories of causes of the
  problem. Write them as the main branches
  steaming from the center line
• Brainstorm all possible causes of the problem.
  Ask Why did this happen? about each cause.

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Fishbone Diagram (cont).

• Write sub-causes stemming from the category of
  causes
• Collect data to confirm root-cause
• If no further causes can be identified, then you
  found the root causes of the problem

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Check Sheet
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Check Sheet Tracking Form
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Check sheet

• Used when several possible problem causes are
  identified, but there is no information on the
  largest cause
• Designed to collect data on the number of times
  that those causes occur
• Collect data and evaluate action taken
• The results allow action to be focused in on main
  causes

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Run Chart
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Use Run Chart to

• Follow performance (Y) over time (X) (plotting
  the dots)
• Allow you to visualize how the process is
  performing and helps you to identify trends (good
  or bad)
• Reveals the impact of improvement actions
• Add the goals to the chart to see progress toward
  achieving the goal

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Using Run Charts to track AVF Rates in the Late
Adopter Facilities
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Using Run Charts as a Tracking Tool

• Where have you been?
• Where is the data going?
• Please plot the dots
• A word about variation
• - normal variation
• - special cause variation

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Using Run Charts as an Evaluation Tool

• Compare performance before and after change
• Calculate change between old and new level

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The Danger of Comparing Two Data Points!

Peritonitis Episodes/Year
5.9
1.1
July 05
July 06 Average 3.5
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Facility APeritonitis Episodes Per Year
Peritonitis Episodes Per Year ()
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Facility BPeritonitis Episodes Per Year
Peritonitis Episodes Per Year ()
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Facility CPeritonitis Episodes Per Year
Peritonitis Episodes Per Year ()
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Improvement in Wait Time (Team A)
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Improvement in Wait Time (Team A)
Change Implemented
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Improvement in Wait Time (Team B)
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Improvement in Wait Time (Team B)
Change Implemented
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Get more from the Data

• Segment or stratify
• - by day
• - by shift
• - by machine
• - by staff, surgeon, physician
• Use comparative data

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Pareto Diagram

• A histogram charted in descending order of
  frequency
• Visually displays the contribution of each cause
  to the overall problem
• This part of problem analysis helps to focus
  action and resources on main causes

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Identifying Major Issues based on Pareto
Diagrams/Check sheets
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Communication

• Communicate organizational quality definition
• Communicate customer/supplier needs
• Discuss problems (opportunities for improvement)
• Report team progress project results
• Exchange information

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Communication

• Critical in quality improvement but often ignored
  tool!
• For best results must be frequent and accurate
  communication among all involved
• Communication facilitates buy-in
• Let others know what improvement project is going
  on
• Gather input, report progress, celebrate results

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Listen to YourDATA

• What does the data say?

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Aims to Action Conducting QAPI
utilizing Rapid-Cycle Improvement
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What is Rapid Cycle Improvement?

• Variant of process improvement that
• relies on existing knowledge
• dramatically shortens discovery process
• works on rapid trial learn method
• relies heavily on action

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PDCA /PDSA Methodology
PLAN
ACT
DO
CHECK/STUDY
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Plan-Do-Study-Act

• Plan Identify Opportunity and plan for change
• Do Implement the Change on a small scale
• Study Use data to analyze for the change and
  determine whether it made a difference
• Act If the change was successful, implement the
  plan and continuously monitor results. If the
  change did not work start the process again.

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Root Cause Analysis

• Caution Avoid the quick fix
• Find and fix the root cause of the problem

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What is Root-Cause Analysis?

• Finding the basic cause
• Use brainstorming
• Use the fishbone diagram
• Collect data if you need to
• Get down to an actionable level
• Ask WHY? 3-5 times!

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

• Write a clear statement of aim--make the
  target for improvement unambiguous
• Include numeric goals
• Set stretch goals
• Focus on issues that are important to your
  organization - choose appropriate goals

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Developing Your Goal

• Improvement relies on intention to improve
• Senior leaders set align goal with
  strategic goals (involve Medical Director!)
• Agreement on goal is critical
• Include a specific time frame for accomplishing
  your goal

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Network Goals for Monitored Clinical Indicators
Clinical Indicators CMS Goal Network Goal Facility
Anemia pts with mean HGB gt 11.0 70 85
Adequacy Mean Kt/V gt 1.2 Mean URR gt 65 80 88
Nutrition (Albumin) Mean albumin gt 3.5/3.2 (BCG/BCP) 80 84
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Examples of Goals

• At least 88 of patients will have Albumin gt 3.5
  by May 2009.
• To increase the number of patients meeting the
  Network goal for anemia by 10 percentage points
  between baseline and January 2009 (from 75 to
  85)

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

• The key measures should clarify the goal and make
  it tangible
• Use outcome and process measures
• Integrate measurement into the daily routine
• Use qualitative as well as quantitative data
• Seek usefulness, not perfection

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Measures

• Outcome
• gt88 patients in the facility have Kt/V gt 1.2

• Process
• Identify patients with Kt/V lt 1.2
• Dialysis Prescription assessment
• Vascular access assessment
• Dietary assessment
• Communication of IDT members are essential!

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

• Blatantly steal Use the literature, the
  experience of others, hunches and theories (FFBI
  suggestions)
• Be strategic Set priorities based on the aim,
  known problems, and feasibility

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Objective of the TestChange or No Change?

• Probably Change
• Test
• Redesign
• Eliminate
• Reduce
• Deliver
• Implement

• Probably No Change
• Recruit
• Distribute
• Continue
• Examine
• Discuss
• Teach

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To Be Considered a Real Test

• Test was planned, including a plan for collecting
  data.
• Plan was attempted and data was collected.
• Time was set aside to analyze data and study the
  results.
• Action was taken, based on what was learned.

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Two Key Points

• Small scale ? small change
• Success (or failure) in one PDSA cycle ? success
  or failure of the project

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Clinical Indicator Goals ProjectNetwork
Responsibilities

• Project Leader (change agent)
• Supply the templates for RCA PDSA
• Supply facilities with tools and knowledge
• Periodic monitoring and feedback
• Conduct phone interviews to obtain
  facility-specific data
• Facility site visits for strugglers

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Facilities Responsibilities

• Return agreement letter (signed by MD)
• RCA PDSA due to the Network by December 12,
  2008
• Run Charts for October-December 2008 are due to
  the Network by January 9, 2009.
• Follow the project timelines

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• QUESTIONS?
• For questions please contact
• Svetlana (Lana) Kacherova, RN, MPH, CPHQ
• Quality Improvement Director
• ESRD Network 18
• 323-962-2020
• skacherova_at_nw18.esrd.net