Late in 2012, the Centers for Medicare & Medicaid Services (CMS) released “QAPI at a Glance.” This 42-page guide previewed principles and tools needed to establish a Quality Assurance/Performance Improvement (QAPI) foundation in a nursing facility.
While the guidance is a comprehensive resource to create a solid QAPI program, there are simple steps the facility quality manager can utilize to systematically address problems and improve outcomes, an important QAPI goal when the guidance is finalized.

Source Available To Guide Quality Efforts

Many quality strategies provide proven methods to positively impact operations through continuous improvement.

The Baldrige Criteria for Health Care Excellence, Six Sigma, and Lean Healthcare are a few examples institutions have integrated into their business models.

Villa St. Vincent, a 2008 American Health Care Association Gold Award recipient, uses elements from multiple quality improvement approaches.

“The greatest challenges as a leader today are assuring regulations are met, expectations exceeded, financial health maintained, and doing all this and more each and every day,” says Judy Hulst, RN, administrator of Villa St. Vincent and a 34-year veteran of the facility, 28 of those as the director of nursing.
“It is crucial to address quality problems efficiently to not just survive, but thrive. Using simple steps for success is our mantra.”

Villa St. Vincent, a Benedictine Health System facility, has longstanding integrated quality management practices, including:
■ Leadership support with resource allocation;
■ Setting a goal—know where you are and where you want to be;
■ Base your decisions on data-collect information: Track, trend, and analyze;
■ Assure methods to listen to your customer and respond; and
■ Keep evaluating as you fix (in-process review).
Villa St. Vincent groups opportunities to improve into two categories: poor outcomes that need correction or work processes that need improving.
By following some simple steps, positive change and improved outcomes will likely result. Two  performance improvement projects (PIPs) will describe a formula easily replicated at any facility.

Outcomes Needing Improvement

Villa St. Vincent was typical in terms of the prevalence of off-label antipsychotic medication use in elders with dementia, at 21 percent in 2012. As new research came to light and CMS urged action to decrease these medications, a PIP was initiated.

1. A team was formed with wide interdisciplinary representation (IDT).

2. A Problem Scope Worksheet was completed with a goal to reduce the percentage of residents on antipsychotic medications without qualifying diagnosis to less than 9 percent by March 31, 2015.

3. Root cause analysis via Fishbone Chart determined core reasons for higher-than-desired prevalence of antipsychotic medications in residents with dementia, including:
■ Staff and medical providers were not aware of the new evidence/directive. “It is how we have always done it” was the attitude.
■ Systematic review of medications occurred quarterly vs. more frequently.
■ Gaps in ongoing training for “behavior” management.
■ Fewer pain management programs in clients with dementia.

4. An Action Plan based on root causes included the “owner” and timeline for completion.
■ Educate the IDT, medical providers, and families on the new guidance, including in-services, webinars, bathroom boards, mailings, and 1:1 training.
■ Communicate frequently to staff and family, and send letters to the medical providers; include graphs on progress.
■ IDT to review monthly all care plans, documentation, and reduction status.
■ Modify nurse assistant orientation to include a mentor with role playing to help learners understand “behaviors” are “communications” and how to therapeutically respond.
■ Review pain assessment processes; make comfort a high priority.

5. Monthly, the team reviews action. A group collaborative with Benedictine Health System sister facilities shared best practices. Halfway through the PIP, Villa St. Vincent met the target of 9 percent, with notable improvements also seen in anti-anxiety/hypnotics and overall behavior indicators. Further decreases are anticipated.

Work Processes Need Improvement

Villa St. Vincent surveys key customers annually. “Since we want to be an excellent facility, we seek and report the ‘excellent’ responses,” notes Nancy Moser, licensed practical nurse quality assistant.
“In 2010 our assisted living unit, The SUMMIT, revealed low scores in ‘Food Appeal’ so this became a priority PIP,” she says.

Identifying The Next Target

A Share the Survey meeting is held after each reporting cycle, led by Housing Manager Cindy Hulst, with tenants’ concerns outlined on a flip chart. “Don’t try to explain away the data, but drill down and look for core problems,” says Hulst.

Foods not consistently served piping hot, especially the cooked vegetables, pointed to a work process improvement opportunity. Initial data for “Food Appeal” showed only 23 percent scored “excellent.”

1. The IDT was formed.

2. The Project Scope Worksheet was completed, with the goal: “Improve satisfaction of food appeal to 35 percent answering excellent by the 2011 survey by improving food serving temperature.”

3. A flow chart mapped the start point when the food left the kitchen to the end service to the tenant. Gaps revealed a lack of solid flow and an inconsistent process.

4. The root cause analysis revealed:
■ Hot food served on cold ceramic plates;
■ Warmers turned on too late;
■ Plates being dished more quickly than they could be delivered; and
■ Staff turnover impacted by orientation gaps.

5. The Action Plan included:
■ Cook will turn on hot tables one hour prior to meal;
■ All ceramic plates will be heated via the steam table prior to the meal;
■ Temps tracked and documented through the meal;
■ Culinary services manager or second cook will assist with serving at all meals; and
■ Check-off sheets for orientating new culinary services staff developed.

6. Satisfaction in food appeal improved in 2011 to 28 percent scoring “excellent” and subsequently up to 47 percent in 2012. While the scores leveled off in 2013 to 41 percent, the “Recommendation Rate” rose to a high of 66 percent “excellent,” with a frequent comment being, “They take quality improvement seriously around here.”

“Villa St. Vincent uses different core concepts of many QI strategies” says Hulst.

“While we have a pretty large box of ‘quality tools,’ the same basic approach is very effective and gets results fast.
Jill Brown, RN
“It is easy to get wrapped up doing the work and not analyze the very work process occurring to make more efficient and accurate work flow. So, sometimes just stop, step back, and do a rapid improvement. Grab that diverse team, and let the PIP magic begin,” Hulst says.
Jill Brown, RN, C CN-E, is quality management coordinator at Villa St. Vincent, a Benedictine Health System organization, in Crookston, Minn.