Carole Dykhouse, BSN, RN-BC, CPHQ, Director of Education, Align

On July 13, 2015 the most comprehensive change to nursing home regulations in 25 years was proposed by the Centers for Medicare & Medicaid Services.  The proposal addresses two major revisions: discharge planning and the overall quality and safety of nursing homes. In anticipation of the release of the new regulations, it is critical that organizations carefully evaluate existing practices and make improvements as needed. But where and how should you start? Because QAPI is threaded throughout all of the proposed changes, all current practices should be reviewed and possibly revised to assure QAPI philosophy is embedded. The following guidelines serve as a model for integrating QAPI principles into transition planning improvement within your own organization.

To begin with, let’s define QAPI. QAPI is defined by CMS as “an initiative that goes beyond the current Quality Assessment and Assurance 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 continuously.” Five important and interconnected elements are:       

  • Element 1:  Design and scope encompasses all systems of care and management practices, including clinical care, quality of life and resident choice. Defined goals and measurements need to focus on safety and clinical interventions emphasizing autonomy and residents choice in their daily life.  
  • Element 2: Governance and leadership requires establishment of a QAPI culture of safety, quality, rights, choices and respect by balancing safety with resident-centered practices, with input from facility staff, residents, and family representatives, and adequate resources to conduct meaningful QAPI efforts.
  • Element 3: Feedback, data systems and monitoring entails putting systems in place to monitor care and services, drawing data from multiple sources.
  • Element 4: Performance improvement projects (PIPs) involves a concentrated effort on a problematic area in a systematic process.
  • Element 5: Systematic analysis and systemic action comprises a systematic approach to determine in-depth analysis to continually understand and improve.  

So what steps can a provider take to ensure that you are addressing the requirements in the new CMS rules, integrating QAPI principles, and improving upon your current practices related to transition planning? The focus of our discussion today will be on Elements 3, 4, and 5. Start by asking yourself: “What are we trying to accomplish?”, “How will we know that a change is an improvement?” and “What changes can we make to result in improvement?” If these questions sound familiar, it is because they are the driving questions in the PDSA Cycle, a proven tool used for process improvement.  The PDSA cycle is your roadmap.

P (PLAN):  During the planning phase you should define the change you intend to make. Be clear on what you predict will happen as a result of the change. When planning an improvement project related to transition planning there are several key factors to consider. Ask yourself:

  • Are patients actively involved in transition planning and decision making early on and throughout the stay?
  • Do we clearly understand patient expectations?
  • Are we providing timely and relevant patient education?
  • Do we solicit feedback from the patient and family during the stay?
  • Do patients confirm that they are ready to self-manage after discharge?
  • Do we provide comprehensive, clear post-transition instructions?
  • Do we follow up with the patient after discharge to provide ongoing support?
  • Is the transition planning process interdisciplinary?

These factors form the foundation for post-transition success and represent a systematic framework for process improvement evaluation and implementation. As you ponder and answer these questions the improvement opportunities will begin to emerge. Your objective is to incorporate them into your plan and to determine how you will measure success. You can tackle one, a combination, or all of these factors at a time depending upon what works best for your team. However, it will be important to ultimately evaluate improvement opportunities on all key factors.  During the Plan phase you will:

  • Identify the project team
  • Identify the scope of the project. It is recommended that you test out your plan on a small scale. Once you have an opportunity to measure the results you can determine if wide-scale implementation is appropriate.
  • Determine a timeline for evaluation of all key factors.
  • Assign specific roles and responsibilities.
  • Evaluate existing facility practices related to the key factors noted above.
  • Identify the changes you want to make, the results you expect to see, and the method for evaluating those results.
  • Determine the length of the change project. For example, you will evaluate the impact of the changes for 90 days.
  • Develop data gathering tools. These don’t have to be complicated but it is critical that you gather the information necessary to evaluate whether you achieved the desired changes you were looking for.
  • Establish “Smart Goals” to measure the predicted change throughout the process. For example, A transition planning conference will be conducted within 72 hours of admission for all short stay patients.
  • Develop the implementation and evaluation plan.

D (DO): Implement the plan.

  • Instruct all involved staff on the changes being evaluated and their role in driving those changes.
  • Collect data using the data collection tools you have developed.
  • Solicit feedback from staff along the way. Capture that feedback.
  • Solicit feedback from patients and families along the way. Capture that feedback.
  • Continue the plan for the entire length of the project timeline. If you don’t have enough information at the end of that time, consider extending. At the completion of the project you will study the results.

S (Study): Study and Understand the data collected.

Once you have completed the ‘DO’ phase you can study the results of your efforts. Remember, you predicted early on what changes you expected to see. Now is the time to evaluate whether those desired changes actually occurred. What did you learn from this process? A review of the data you collected will tell you.

A (ACT): It is now time to determine what changes should be made.

  • Did your predictions come true?
  • Should you adopt these changes on a wider scale because the results were favorable?
  • Should you abandon the change because it didn’t produce the results you were looking for?
  • Should you repeat the cycle? A decision to repeat the cycle would be appropriate if you saw some change but not as much as you had expected. However, during the process you identified other improvement opportunities that could be built into the plan.

If you adopt the changes it will be important to continue to evaluate the ongoing impact over time. If you abandon the change because it didn’t produce the desired results, don’t quit now! It would be wise to go back to the drawing board and consider again what you can do to improve upon your transition planning process. The outcomes to your patients will continue to become more and more important in the emerging healthcare marketplace.

QAPI is intended to be an ongoing process that is continually looking for ways quality and safety can be improved. Using QAPI principles in evaluating transition planning processes supports your ability to meet the requirements in the new CMS proposal, but more importantly, promotes the likelihood of safe and sustainable transitions for your patients. By evaluating all of the key factors that impact transition success, identifying opportunities for improvement, and planning for and implementing those improvements your facility is better positioned to be on the ‘A’ list of providers in the new healthcare marketplace.

Carole Dykhouse, BSN, RN-BC, CPHQ is the director of education at Align.