Chapter 22 Quality Assurance and Performance Improvement

education/curriculum-tools/teamstepps/ longtermcare/).

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CMS Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents

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This initiative is operating in seven states with over 145 nursing facilities to implement evidence-based interventions aimed at enhancing care, improving outcomes, and reducing costs. These interventions range from implementing indirect care models for best practices (eg, “train the trainer”) to deploying highly skilled clinicians to deliver direct bedside care. The initiative also includes some unique components such as telemedi- cine, oral care, and the use of consultant social workers and pharmacists. These interventions address specific issues within nursing homes, seek to enhance the quality of care delivered facility-wide, and are consistent with the goals of QAPI (http://innovation.cms.gov/initiatives/ rahnfr/).

● Department of Veterans Affairs (VA) ➤➤

The National Center for Patient Safety supports and leads the patient safety activities for all VA medical centers and has developed tools including RCA investigations (www. patientsafety.va.gov/).

● Model for Improvement ➤➤

The Institute for Healthcare Improvement uses the Model for Improvement as the framework to guide improvement work. This model, developed by Associates in Process Improve- ment, is a simple, yet powerful tool for accelerating improvement. Learn about the fundamentals of the Model for Improvement and testing changes on a small scale using Plan-Do-Study-Act (PDSA; www.ihi.org/ resources/Pages/HowtoImprove/default.aspx).

● Quality Improvement Organizations ➤➤

Each state is served by a quality improvement organization that offers resources and tools for nursing facilities. To find your QIO, go to the QualityNet website (www.qualitynet.org).

RESOURCES FOR IMPLEMENTING QUALITY ASSURANCE AND PERFOR- MANCE IMPROVEMENT

There are many resources (materials or websites) to support QAPI implementation. Use of any particular resource is not mandated by CMS for regulatory com- pliance, nor will their use ensure regulatory compli- ance. The CMS Guides to Quality from the CMS QAPI Resources Site can be accessed on the website (www.

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cms.gov/Medicare/Provider-Enrollment-and- Certification/QAPI/qapiresources.html). The following are resources included on the CMS

website: ●

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Getting Better All the Time: Working Together for Continuous Improvement

Implementing Change in Long-Term Care: A Practical Guide to Transformation

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National Nursing Home Quality Care Collaborative Change Package

● QAPI at a Glance Two scenarios of nutrition comparing a nutrition

area with QA and QAPI are demonstrated in QAPI at a Glance (see Box 22.4 on pages 335–336). Root cause analysis is a structured team process that assists in identifying underlying factors or causes of an event, such as an adverse event or near miss. Understanding the contributing factors or causes of a system failure can help develop actions that sustain corrections. RCA may identify the following:

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No process existed for identifying residents at risk for unintended weight loss with specific criteria such as significant and slow, insidious trending weight loss; poor oral intake; decline in ability to self-feed/need of restorative feeding skills or assistance; decline in ability to chew or swallow; expected outcome of diagnosis; or use of appetite suppressive medications.

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No process existed for addressing and document- ing facility staff efforts for residents at risk, such as a weekly weight variance meeting.

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No process existed to evaluate the facility’s effec- tiveness or performance measures of dietary systems in related areas, such as nursing and dietary communicating about weight decline and decline in food intakes; documenting food intake percentages; documenting supplement intakes as ordered; ensuring resident preferences were honored; or getting resident food committee feed- back from residents on palatability and preferred menu changes.

No process to ensure that the diets are liberalized (according to resident’s informed choice) for increased quality of life and acceptance of food before oral liquid supplements are ordered; con- sideration is given for “real foods first” with real food fortifications (every bite counts); and extra calories, fiber, and protein added to smoothies and drinks that are more acceptable, as empha- sized in the Dining Practice Standards (10).