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Hospices start their trip down the road of quality improvement
QAPI requirements go into effect as hospices figure out how to meet them
A group of 15 Indiana hospices has a two-year head start on all other hospices to meet the Quality Assessment and Performance Improvement (QAPI) requirements of the new Conditions of Participation (COP). The COPs, which were introduced in June 2008, require the collection and use of data to conduct studies designed to evaluate quality.
"We anticipated implementation of the COPs in 2007; so, in 2006, we developed a benchmarking project that would help our member agencies meet the requirements," says Todd Stallings, executive director of the Indiana Association for Home and Hospice Care (IAHHC) in Indianapolis. Because the implementation of the quality assessment requirement was delayed until February 2009, the participating hospices began 2009 with a lot more experience at collecting, analyzing, and using data, he says. "The problem with being proactive in this instance is that we went through a lot of effort, then nothing happened with the COPs," he laughs. "The good news is that the project is working well, and the participating hospices have learned a lot prior to implementation."
Each participating hospice enters data through an online system, then submits them to the vendor with whom IAHHC contracts, Outcome Concept Systems in Seattle. "The hospices receive a report that compares their results within their own peer group, as well as with national data," Stallings says. The four categories of information collected are quality outcomes, quality practices, patient volume and mix, and quality operations.
Participating hospices do pay an annual fee to the contractor, but IAHHC negotiated a reduced rate specifically for its members, says Stallings. "It was important to make the cost as reasonable as possible to encourage participation," he explains. "Hospices now realize that the fee is a good investment and is helpful."
Not only are participating hospices using the data to identify areas in which they are below the national or local peer group median, but IAHHC has used the results to develop educational programs for hospices, says Stallings. "When we began collecting data, we realized that our hospices had almost no nurses who were certified for hospice and palliative care," he says. "We began sponsoring certification exam programs twice a year, and we've seen the number steadily grow. In fact, one hospice sent the entire nursing staff to the program."
Some hospices starting from scratch
Most hospices don't have the history of quality improvement programs such as the one in Indiana, and the new QAPI requirements are a shock, says Lynda Laff, BSN, principal with Laff Associates, a home health and hospice consulting firm in Hilton Head, SC. "Everyone is capable of more sophisticated data collection and reporting, but it has not been a priority until now," she explains.
The reality is that the QAPI requirements are not onerous, says Laff. "They are standard performance improvement activities, but CMS [Centers for Medicare & Medicaid] does require that the studies and the program be ongoing, not just periodic," she says. "Most hospices have pieces in place; they just don't know where to start." Hospices that are affiliated with a home health agency, which already has been meeting this requirement, are 70% ready for QAPI, Laff says. "Hospices that are community-based and self-contained have more work to do," she adds.
The first step in developing a performance improvement program is to evaluate the data you are collecting, suggests Laff. "Look at your current weekly, monthly, or quarterly reports," she says. You should have information on days on service, length of stay, diagnosis, and age groups by length of stay, "then look at symptom management and adverse events that you want to monitor," Laff adds.
This point is where it becomes overwhelming for some hospices, says Laff. "Don't try to eat the elephant in one bite," she says. "Pick one symptom or event to monitor, then decide what information you need to collect." Falls will be a common first study for many hospices, because it is possible to collect the information, and reducing the number of falls is important to improvement of quality of life for patients, Laff points out.
Pain also is a key symptom to monitor for hospices, says Laff. Whichever symptom you select for your study, be sure your nurses are collecting information in the same manner, she warns. Develop a data collection tool that is very specific about how questions are asked, what is documented, and where the information should be kept in the chart, Laff suggests. Don't just ask if pain was controlled, she says; instead, ask about pain in 24- or 48-hour segments. "We don't just want to know about symptoms at the moment the nurse sees the patient; instead we want to know what happened before the visit," she says.
Although tracking your own trends and results is important, look for ways to compare yourself to other hospices, suggests Stallings. His benchmarking project is limited to his membership, but he recommends that hospice managers approach their associations about a similar project. Even if you can't find an overall QAPI benchmark project, look for symptom-related projects as well, Stallings suggests.
"In addition to the QAPI project for hospice, our association is participating in a pressure ulcer reduction project as part of a comprehensive program coordinated by the State Health Department," he says. Also, look for existing tools, studies, and research that can give you a reference point for your own data, Stallings recommends.
One of the hospices that Laff advises is Tidewater Hospice in Bluffton, SC. "We are a small hospice, but I have a home health background, so I am familiar with performance improvement," says Susan E. Saxon, RN, administrator and principal of the hospice. "We have been conducting patient care and clerical audits to identify adverse events such as falls or issues such as timeliness of documentation or physician orders," she says.
Even with a small staff, Saxon's agency is able to use multiple performance improvement teams to address issues such as falls or documentation. "You should use as many staff members as possible in the quality improvement process to improve understanding of the process and to make the program successful," she says.
With QAPI in place, Saxon has expanded her studies to address constipation, shortness of breath, and pain. "We have some information on these symptoms, but we've developed a tool to standardize the information that we capture and to give us data that we can use to identify areas of improvement," she explains. All three of these affect quality of life, and all three can be affected by staff members' actions, she adds.
Hospice managers shouldn't panic, Laff says. "Just read the COPs carefully, and pay close attention to QAPI," she adds. As you select outcomes to measure and studies to conduct, choose items that prove quality care, Laff suggests.
Why should hospice managers take QAPI seriously? Not only are they a COP that affects your reimbursement, but Laff believes this is a first step to further changes. "I foresee a standardization of information collected by all hospices, much like the OASIS [Outcome and Assessment Information Set] data collection tool that is required of all home health agencies," she says.