We're waiting for third quarter of to come out and populate the Five-Star reports now. The claims-based measures are only updated twice a year, and that's supposed to be done in April and October, at those two points in time. We didn't get the October updates yet to the claims-based data, so we're still waiting on that, and some folks with bated breath depending on where their quality measures fall.
As we're looking at value-based purchasing and looking at re-hospitalizations in that program, as well as the Five-Star program and the Quality Recording program, looking at that data that's claims-based is just as important as looking at the data that's clinically based on the MDS. DG: Right, right. I know we talked about using PBJ for staffing.
How will switching to MDS data as the source for patient census impact a facility's Five-Star rating? MM: We did have a few clients that had asked us to review their data when it first began to come out and they were looking at the census data related to the MDS's. We found that if folks are behind on completing discharge assessments, it could impact their census data.
We had some folks that didn't get discharge assessments in their look-back period when the patient was leaving the facility, so it overstated the number of residents that they have in the building, and therefore it diluted the staffing number because it made it look like you had more residents in the facility than you actually had beds for.
You've got to make sure you're keeping up on those discharge assessments because that will impact — and we found some facilities where the data didn't match, and they couldn't figure it out. The best comment that I would have or tip that I would have for providers out there is to pull their Missed Assessments report. That's going to tell you the last assessment that was in there for a resident.
If you see someone who's been gone out of your facility for quite some time, you may want to go into your system to look to make sure either you did a discharge assessment, or that it got accepted and it is on your validation report. You may have thought that it was in your batch to get submitted, and it may not have gotten accepted, therefore they're looking for that bookend to close out that person's story.
DG: Good tip, thank you. Maureen, as we all know the long-term care industry suffers from a really high turnover rate. CMS has mentioned several times that employee tenure and turnover are valuable measures of quality.
Why or why not, and how soon? MM: I'm not sure if they'll end up on the Five-Star rating, but I'm sure they will end up as some type of quality rating. They may go into the Nursing Home Compare site itself rather than just the Five-Star, but I know they were definitely interested in attrition rates. They could still get that information even though facilities don't have to specifically input that data.
They're able to back into that and able to figure that out. I think it will be something that will be reported once the data is reliable, but I'm not sure it will be the Five-Star report where it will end up.
DG: What's your advice to a facility that wants to predict its Five-Star rating? MM: I think that the hardest piece to predict is going to be your staffing piece. It's looking at the Strive Test to determine the amount of time per patient day and per RUG category, and also risk-adjust the patients based on the prior quarter that just closed out.
I think that's the most difficult part to predict when it comes to the Five-Star report. Now your survey, it is what it is. You can have a facility that does a phenomenal job, and on any given day a surveyor can come in and find something wrong.
You can have a facility that's sort of a little broken, trying to get back on their feet, and they can come in and not find any deficiencies, so that's a little bit harder to predict. When you're looking at your quality measures, that's probably the most common way to look at a Five-Star rating. That's probably using your CASPER reports to determine what that next quarter's going to be that's coming out on the Five-Star, and making sure that you're looking at your data real time.
You should be looking at your quality measures every month, or at least every quarter, and looking at the quarter that you're in to see do you have any trends. Are you having any issues with, let's say, a policy? Do you need to tweak that piece because you're not getting the quality of the documentation or the care process that you need to improve that outcome? DG: Yes, thank you.
I agree. I would say at SmartLinx that our mantra is real-time data. We're all about using real-time data as accurate measures of your quality of service and your staffing. I'm going to switch gears here. Can you tell me where we've been regulatory-wise and where do you think we're going in terms of QAPI? Basically, we've always had the Quality Assurance, the QAA tag for our surveys, and now that's a lot more detailed.
It makes sense when you think about it that we need to be proactive rather than reactive. When you're looking at a system that might not be performing to your satisfaction in a building and you go back and look at that system, you're looking at preventing something from happening. You don't react to something. Let's say it's falls with major injury. Someone had the fall with major injury, then we did something about it, but what did you do before someone had a negative outcome or an adverse event?
I think that's where we're looking more towards that QAPI piece is to prevent things, and identify trends, and looking at root causes, and that sort of a thing.
I think that's the difference of what we're looking at, is that it's facility wide and it's not just clinical problems, like you mentioned before. Staffing turnover, that could be one of your performance improvement projects. Maybe that is something that's affecting your patient satisfaction and they want to have consistent staff and folks and faces that they know every day, so it's not always just those pieces that come up on the Five-Star quality measure reports.
Look at your facility as a whole house, and find out what may be hindering your performance improvement. DG: Sounds good, thank you. QAPI has five basic elements: design and scope; government and site leadership; feedback data systems and monitoring; performance improvement projects or PIPs; and systematic analysis and systemic action.
That was a mouthful, wasn't it? What's one piece of advice you'd give to our listeners on each of these elements? MM: I think when you're looking at design and scope, make sure that you're designing a program that fits the pace and the size of your facility. If you have 23 things on a performance improvement wish list, you may want to start with 4 or 5 of those rather than 10 things at once.
I would just say when you're designing it and looking at the scope of what you're looking at, make it realistic for your building. For governance, leadership, feedback, and that piece of it, looking at assigning the right person to be in charge of the program. When you have your meetings, I think that's the time to look at that. When you're looking at feedback data systems and monitoring — so you've put something in place. You decided on which performance improvement projects you want to move forward with.
You put something in place, making sure that you're feeding back to the system and all those folks who are interested in how we're going to improve. It's not just a management thing. You have to get this down to the front-level staff because everyone needs to be excited about the improvements and have the same buy-in.
Then again, monitoring that to make sure it stays. Sort of like when you tell your kids to go clean their room. If you don't go back, that room's probably not going to be clean. Just like quality assurance, going back periodically to make sure you're still having that good outcome that you expected is going to be really important.
When it comes to Performance Improvement Projects, I think the biggest step there is making sure that you have an inventory list so that you know what projects you have going on and where you are with each one. I'm just starting this one. I'm in data collection with this one. I'm insuring with this one. This last one I think we're doing a great job on; we're just checking that twice a year rather than quarterly.
I think that having that organization is really going to help when it comes to the Performance Improvement Projects and looking outside of that clinical scope. Systematic analysis and action, my advice there would be to make sure that you've got the root cause of the problem, and making sure that you're going back far enough to address what the problem is and not just something that appears to be the problem. Many times you can go back and you don't really fix the problem, or it's fixed for a short period of time, but it's not fixed permanently.
Sometimes it's because we don't really have what the issue was. DG: All great advice, thank you. I have one more question. Can you give me an example of how you've helped a facility improve a specific process and how that impacted outcomes? MM: Absolutely. Like I was mentioning before, making sure you get to that root cause.
We had a group of folks that had issues with pressure ulcers. They end up doubling in one month and tripling in two months. For any facility, that's a significant change for them. We went into the facility, and we tried to look at what was happening. We looked at the care process. We looked at what their policy was for pressure ulcer identification.
We went through the whole gamut. It ended up that body audits were being done for the patients, turning and positioning schedules were assigned, care plans were updated, wounds were being identified. It came down to the turning and positioning was not being performed every two hours, but that wasn't the issue.
That wasn't the issue; it wasn't the root cause. No, the root cause: why are patients not being turned and positioned? The patients are not being turned and positioned because we don't have enough time to get to all of the patients that we have.
The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. Additionally, facilities will be expected to develop policies and procedures and demonstrate proficiency in the use of Root Cause Analysis. This element includes a focus on continual learning and continuous improvement. To begin the QAPI process in your building, you should begin with step one of the twelve step process from CMS, and work your way through to step twelve.
It may take anywhere from six to twelve months to get your program up and running. Remember, this is a process that requires a team approach to work through. Below is the basic framework you will need to build a successful QAPI process in your facility process. When writing your goal based on the SMART formula, the goal needs to be comprehensive, whilst still being succinct. You want to be able to easily articulate the goal you have written to your staff. Sharing the goal with the staff will promote a feeling of ownership and pride as you work through the QAPI process.
Download our free e-book or contact us. She is a passionate writer and a speaker at both state and national levels. Jennifer has been working in post-acute care for over 20 years. She is an avid proponent of education and providing those on the front lines of healthcare the tools they need to succeed. Follow us on social media:. Subscribe to our newsletter to receive the latest articles and updates aimed at helping you enhance operational, clinical and financial outcomes.
Site Search. 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 the full range of departments.
Element 3: Feedback, Data Systems, and Monitoring The facility puts systems in place to monitor care and services, drawing data from multiple sources. Element 4: Performance Improvement Projects A Performance Improvement Project PIP is a concentrated effort on a particular problem in one area of the facility or facility-wide; it involves gathering information systematically to clarify issues or problems and intervening for improvements.
Element 5: Systematic Analysis and Systematic Action The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. Identify Your Organization's Guiding Principles - This will unify the facility by tying the work being done to a purpose or philosophy.
Identify Your Gaps and Opportunities - Use this time to observe for any areas where processes are breaking down. Getting to the "Root" of the Problem - Determine all potential root cause s underlying the performance issue s. Take Systemic Action - Implement changes that will result in improvement of overall processes.
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