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CALVERT HOSPICE: QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT(QAPI) PROJECT 1 Operational Benefits to Quality Improvement CALVERT HOSPICE: QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT(QAPI) PROJECT 1 Operational Benefits to Quality Improvement Benchmarking

Team Members 2 v Jean Fleming, RN, BSN, CHCE Calvert Hospice Executive Director v Team Members 2 v Jean Fleming, RN, BSN, CHCE Calvert Hospice Executive Director v Sarah E. Simmons RN, BSN, CHCE Calvert Hospice Director/Clinical Quality Management v Karen Carloni, LSM v Mary Beth Cook, LSM v Jim Gotsch, LSM v Eusebio Quinones “Q”, LSM

Calvert Hospice ~Mission Statement 3 “The mission of Calvert Hospice, a not-for-profit community-based organization, Calvert Hospice ~Mission Statement 3 “The mission of Calvert Hospice, a not-for-profit community-based organization, is to provide comprehensive, interdisciplinary services focused on medical care and psychosocial, emotional, and spiritual support to residents of Calvert County who are dying; to promote and support the provision of palliative care to those in need; to provide emotional, psychosocial, and spiritual support to those in Calvert County grieving the loss of a loved one; and, to provide educational services to the entire community about the processes that accompany death and loss. Calvert Hospice promotes quality of life , respect, and dignity for the individual, and recognition of the significance of loss throughout life. ”

Calvert Hospice ~Who They Are 4 Located in Prince Fredrick Maryland Calvert Hospice began Calvert Hospice ~Who They Are 4 Located in Prince Fredrick Maryland Calvert Hospice began serving patients with serious, life-limiting illnesses in Calvert County in 1984. Calvert Hospice cares for those in Calvert County who are living with a serious, life-limiting illness. They provide expert medical care, which includes pain and symptom management that is personalized for each patient. The hospice team also provides emotional and spiritual support to patients and affected family members Calvert Hospice focuses on caring, compassion, dignity, and our patients’ quality of life. They support patients in their final months, weeks, and days amid familiar surroundings, pain-free and surrounded by their loved ones and friends At Calvert Hospice, they understand that the need for support does not end with a patient’s death. After a patient passes, they provide bereavement support for the family and loved ones left behind

Calvert Hospice ~Support Services 5 Burnett-Calvert House: opened in 2010, a 6 bed residential Calvert Hospice ~Support Services 5 Burnett-Calvert House: opened in 2010, a 6 bed residential home designed for Calvert County residents in hospice care who require more skilled care than those at home can provide Shoppe For Hospice - boutique Support Groups o o o Drop-In Grief Support Group Substance Abuse Loss Grief Support Group Suicide Loss Grief Support Group Children’s Programs o Bridges o Camp Phoenix o CONNECT: A Grief Support Group for Teens Education Seminars Grief Resources & Support Programs o Grief Counseling o Lending Library

Hospice Volunteers: 6 • Defined Hours to Qualify for Medicare: o • Volunteers must Hospice Volunteers: 6 • Defined Hours to Qualify for Medicare: o • Volunteers must complete: o o • Medicare requires “Volunteers to provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum equals 5% of the total patient care hours of all paid hospice employees and contract staff. ” Without volunteers, hospice would be unable to meet Medicare standards. 11 hour classroom training program 11 hours of online training (RELIAS) for Clinical Volunteers (patient/family contact) and for 7. 5 for Administrative Volunteers (shoppe/office) Volunteer Opportunities: o o o o Office Volunteers Family Service Volunteers Bereavement Volunteers Event Volunteers Burnett Calvert Hospice House Volunteers Shoppe for Hospice Volunteers Board of Directors

Project Objectives: 7 • Define and document QAPI Process and target goals for: Pain Project Objectives: 7 • Define and document QAPI Process and target goals for: Pain Management within 48 hours o Falls with Injury o Completion of Post-Admission Surveys within 3 -7 days o Hospice Visits when Death is Imminent (2 visits within last 7 days) Organize staff to implement the process Select the process improvement Measure results through outcomes and benchmarks Recognize the benchmarking results and successes o • •

Quality Assurance Performance Improvement (QAPI) 8 Why QAPI? o Increase focus on QAPI including Quality Assurance Performance Improvement (QAPI) 8 Why QAPI? o Increase focus on QAPI including Outcomes • • • o Health Reform National Quality Forum Endorsed Measures Public Reported Measures Pay for Performance Institute of Medicine’s Six Aim Increased focus related to new hospice COPs • • • Importance of data driven quality management Utilizing rapid response and QAPI loop Importance of 360 -degree operational review

Plan of Action: 9 Utilize Phased Implementation Plan Identify QAPI data and reports to Plan of Action: 9 Utilize Phased Implementation Plan Identify QAPI data and reports to focus organizational plan Implementation and education of the Quality Program i. e. Quality Partners Initiative Promote Innovations Build a sustainable QAPI program to impact the operational performance Strive to improve operational models and performance i. e. leverage benchmarking opportunities Celebrate success Implement appreciative inquiry Communicate and Display the success

Initial QAPI Challenges 10 New QAPI COP and other regulations Implementation of numerous new Initial QAPI Challenges 10 New QAPI COP and other regulations Implementation of numerous new regulations Educating and engaging the hospice team Extremely limited personnel resources QAPI Indicator selection and measurement What should be collected and why QAPI Tools and data collection Selection and implementation of tools and data collection Data Overload Collecting a large amount of data Don’t know what to do with the data Outcome and benchmark selection

Outcome: 11 The following slides illustrate the Work Flows and Trend Results created for Outcome: 11 The following slides illustrate the Work Flows and Trend Results created for the reporting on “Falls With Injury” and “Pain Management within 48 hours”. Similar Work Flows were created for the other 2 processes.

Work Flow Work Flow

Specific Benefits to Calvert Hospice: 13 Streamline Process Tracking/Measurement Developed baseline process maps to Specific Benefits to Calvert Hospice: 13 Streamline Process Tracking/Measurement Developed baseline process maps to capture/measure “as is” conditions Target process areas and track as ‘open actions” until final resolution/compliance Automatically Trigger Process Review/PDSA Cycle Developed Process Management Control Model with thresholds for selected Performance Improvement Project (PIP) areas that would “trigger” an in-depth root cause analysis using the PDSA (Plan-Do-Study-Act)/QAPI methodology Create the ability to utilize Quality Benchmarks to improve clinical and operational performance Model incorporated a method of visually linking benchmarks to daily process work flow activities at the user input level by using Control Trend Charts (accreditor dictated requirement in adherence to local and state ACA Regulations)

Trend Results: Individual Measures Input: Falls Data Input Sheet 14 Trend Results: Individual Measures Input: Falls Data Input Sheet 14

Trend Results: Individual Measures Output: Falls Data Control Trend Chart 15 Trend Results: Individual Measures Output: Falls Data Control Trend Chart 15

Trend Results: Input: Pain Data Measure Sheet 16 Trend Results: Input: Pain Data Measure Sheet 16

Trend Results: Individual Measures Output: Pain Management Control Trend Chart 17 Trend Results: Individual Measures Output: Pain Management Control Trend Chart 17

Trend Results: Individual Measures Output: Pain Management 4 Year Control Trend Chart 18 Trend Results: Individual Measures Output: Pain Management 4 Year Control Trend Chart 18

Questions? 19 21 Questions? 19 21