The QAPI feature that will be the focus of this article is something with which many providers struggle—effectively using data. The QAPI feature reads: Using data to not only identify quality problems, but to also identify other opportunities for improvement and then set priorities for action.

Relationship To Bronze Criteria

Recognizing that the effective use of data can be a difficult concept for many organizations, the Bronze criteria focus on the basics to help providers build a foundation of important facts. The Bronze criteria ask that Bronze applicants simply list their key sources of comparative and competitive data that are available from within and from outside the health care industry, as well as list any limitations that affect their ability to obtain or use these data. Listing data sources and limitations requires providers to consider the availability and use of data in the organization.

Applicants at the Bronze level are also required to report one health care-focused outcome that was improved through their established performance improvement system.

Other important facts that should be reported in the Bronze application reflect the foundation of the applicant’s business, which sets the context for examiners as they evaluate the maturity of processes required at the Silver and Gold levels.

For example, the Bronze criteria ask applicants to do the following:

■ Define your main health care services;
■ Define your core competencies (the abilities and skills that are critical to your organization’s success);
■ Describe your workforce, including different employee groups and volunteers;
■ List the applicable health and safety regulations and accreditation, certification, or registration requirements with which your organization must comply;
■ List your key patient, resident, family, and other customer groups and define the key requirements and expectations of each group;
■ Identify your key strategic challenges and advantages (factors that may hinder or help your organization achieve success); and
■ List your techniques for fact-based evaluation and improvement of key processes.

The data and information listed above directly support the QAPI feature of this article, namely to use data to not only identify quality problems, but to also identify other opportunities for improvement and then set priorities for action.

Relationship To Silver Criteria

At the Silver award level, applicants are asked to discuss how they measure, analyze, and then improve organizational performance. They must describe how they review organizational performance by using data and information at all levels and in all parts of the organization and how they use comparative and customer data to support decision making. This includes both the effective use and analysis of data.
The Performance Excellence Criteria, like the QAPI framework, assert that measurement and analysis of performance are required for good decision making at all levels of an organization.

Organizations must determine which measures relate to the organizational outcomes and strategies they have defined as important. This includes health care outcomes, but also could encompass business outcomes such as administrative and process performance, competitive or collaborative comparisons, customer satisfaction, and governance and compliance results. Outcome measures should also tie directly to the accomplishment of the organization’s strategic objectives.

Senior leaders must be able to extract larger meaning out of the data and information for their analyses to be truly useful. This may include determining trends, projections, and cause-and-effect relationships that might not otherwise be evident. In high-performing organizations, data support evaluation, decision making, improvement, and innovation.

Also, when reviewing the maturity of an organization’s systems and processes, examiners for both the Silver and Gold applications base their analyses, in part, on the factual background information reported in the Bronze application, such as basic health care services, core competencies, employee groups, applicable health and safety regulations, and accreditation requirements.

They also look at key patient or resident groups and their key requirements and key elements of the center’s performance improvement system.

Relationship To Gold Criteria

Gold recipients must demonstrate all of the principles and requirements laid out for Silver recipients, and more. In Gold recipient organizations, organizational decision making, continuous improvement, and innovation are supported by the use of data and information. Fact-based analyses support effective decision making, which enables the organization to improve continually.

Gold recipients support their patient-focused culture through the effective use of voice-of-the-customer and market data and information. Patients, families, and residents benefit when the organization has a deep understanding of their needs and requirements and sets priorities based on what is most important to them. Senior leaders use data to track both daily operations and overall organizational performance in addition to developing and monitoring specific strategic objectives and action plans. Effective use of performance measures and analysis of findings helps the organization set and achieve high-performance improvement goals and also identify opportunities for innovation.

Nursing Center Results

Maryruth Butler, executive directorof Kindred Nursing and Rehabilitation - Mountain Valley, Idaho, shares the following story on behalf of the center’s journey to achieve the Gold National Quality Award in 2011.
Kindred, Mountain Valley, quickly realized that going through the three-level process toward the Gold award was educationally rewarding, Butler says.

“The senior leadership team continues to recognize issues before becoming problems, effectively determines the root cause when problems arise, and applies the appropriate process improvement steps for long-term solutions.”

Staff learned their most essential lessons when responding to the Baldrige criteria and reviewing the examiner feedback on the effectiveness of their use of data in driving desired quality outcomes, Butler says.

One area that has been an industry focus is reducing hospital readmissions. Butler says that as Kindred, Mountain Valley, developed its strategic objective to reduce hospital readmissions by 8 percent in 2013-14, staff identified the sources of data to be monitored, how often they needed to be monitored, what benchmark data to use, and the format to communicate their progress.
Barbara Baylis, RN MSN, vice president of clinical services at Sava Senior Care Consulting, is a nurse executive accomplished in clinical and quality improvement systems. She serves as an AHCA/NCAL Quality Award Examiner as well as a member of the Quality Award Board of Overseers. Mark Blazey, PhD, is a leading expert in the application of the Baldrige criteria for performance excellence. Blazey is currently serving as a member of the AHCA/NCAL Quality Award Panel of Judges and is a member of the Quality Award Board of Overseers.