F15 Unit 6 Quality Care.Quality Management in Therapy records

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Quality Improvement and Quality Management in Therapy:

Quality Improvement and Quality Management in Therapy Quality: “I know when I don’t see it”


Objectives: The student will have the ability to: Understand the various aspects of quality in the delivery of patient therapy services. Describe the role of accrediting bodies and facilitating patient safety and care Identify the various public and private quality management efforts Demonstrate the ability to design ongoing processes for quality improvement. Understand the process of implementing program changes as needed to ensure quality of services and to direct administrative changes.


1. Null, G et al. ERRORS: Account for as many as 98,000 to 420,000 deaths per year in the U.S How many errors occur each year in PT and OT???? Condition Deaths Author Adverse Drug Reaction 106,000 Lazarou , Suh . Medical Error 98,000 IOM Drug Error 322,000 Leape

Quality Defined: “It Depends on Who is Asking and Who is Answering”:

Quality Defined: “ It Depends on Who is Asking and Who is Answering ” Patient happy with quality of OT and PT: “ therapists were sincere, cared, helped a lot. ” Insurance Providers consider therapy as having significant quality if therapies are cost effective Researchers consider interventions as having high quality if therapies are evidenced based Therapists characterize interventions as being of high quality if functional outcomes achieved

What Do Patients Really Want From Health Care? What Do They Really Want From You?:

What Do Patients Really Want From Health Care? What Do They Really Want From You? Main Priorities Responsiveness from You! Timeliness Kindness Hope Continuity of Care! (building relationships) No OOPEs Best Quality Therapy Lower Priorities Efficiency Aggregate Statistics (Its all about ME!) Equity Profit based decisions Billed Costs (vs. real cost) Detsky 2011 JAMA

Quality in Health Care: Measure of excellence or state of being free from defects, deficiencies, and significant variations. http://www.businessdictionary.com “The degree to which health services for individuals and populations increase the likelihood of achieving desired health outcomes and are consistent with current professional knowledge.” Institute of Medicine 2008 :

Quality in Health Care: Measure of excellence or state of being free from defects, deficiencies, and significant variations. http://www.businessdictionary.com “ The degree to which health services for individuals and populations increase the likelihood of achieving desired health outcomes and are consistent with current professional knowledge . ” Institute of Medicine 2008


Quality of Therapy Services What Happens to the Patient, (their perspective) The Care Delivered by the Therapy Staff The Organization ’ s Management and Coordination Abilities The External Environment Where Policies and Regulations Come From Quality Therapy Services: Its Not Just About Your Clinical Skills


The Fundamental Triad Of Interdependent Variables In The Delivery Of Therapy Services Would You Accept Lower Quality Health Care If Offered at a Lower Cost? Should a Clinic Lower Costs by Denying Services? Quality Driven by Government, Payers, Patients, & The Organization

The Governmental Quality Agenda:

The Governmental Quality Agenda 2001: Committee on the Quality of Health Care in America--- Crossing the Quality Chasm: A New Health System for the 21 st Century Highlighted the deficiencies in health care quality in the USA, analyzed the contributory factors, and proposed 13 recommendations for improvements Urged all parties (policymakers, purchasers, regulators, health professionals, and consumers) to commit to a national statement of purpose for the health care system as a whole and to a shared agenda to pursue 6 dimensions of quality .

How SHOULD We Define Quality Therapy Care???:


Quality Therapy Services:

Quality Therapy Services Safe: avoiding injuries to patients from the care that is intended to help them Effective: providing care that is based on scientific knowledge Patient-centered : providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. Timely : reducing waits and sometimes harmful delays for both those who receive and those who give care. Efficient : avoiding waste, including waste of equipment, supplies, ideas, and energy. Equitable : providing care that does not vary in quality because of gender, ethnicity, geographic location and socioeconomic status https://www.youtube.com/watch?v=5vOxunpnIsQ

3 Main Quality Defects in Health Care (including Therapy):

3 Main Quality Defects in Health Care (including Therapy) Underuse Failure to employ scientifically sound practices Overuse Failure to eliminate interventions when they are not indicated. Misuse Failure to appropriately execute proper clinical care processes.


QUALITY: AVOIDING ERRORS Millions of people suffer every year from mistakes in health care. Why do those mistakes happen — and how can we prevent them?

Terminology You Should be Familiar With:

Terminology You Should be Familiar With Quality Assurance : comparison of your practices to existing standards Identifies deviations from the norm Helps to establish new standards and criteria Defines optimal and achievable levels of competence and quality Problem: Can you really assure quality or are you just assuring minimal competence? BUT The focus of QA has been to demonstrate that a service (therapy) fulfills or meets a set of requirements or criteria.

Terminology You Should be Familiar With:

Terminology You Should be Familiar With Quality Control : the systematic use of methods to ensure that services (therapy) conform to the desired standard. Primary emphasis is placed on monitoring the processes and/or outcomes .

What is QI?:

What is QI? Quality Improvement is a formal approach to the analysis of performance and systematic efforts to improve it. There are numerous models used. Some commonly discussed include: FADE PDSA Six Sigma (DMAIC) CQI: Continuous Quality Improvement TQM: Total Quality Management

Terminology You Should be Familiar With:

Terminology You Should be Familiar With Quality Improvement : The efforts taken to increase efficiency of actions and procedures with the purpose of achieving greater benefits for the health care organization as well as for the therapy patient/client. Staff/therapists identify the outcomes that they believe measure quality and identify how to measure them. Focus is on improving quality outcomes rather than just improving the processes designed to improve outcomes of therapy services.

Measures of Quality (Donabedian Model 1980):

Measures of Quality ( Donabedian Model 1980) There are 3 types of measures used in quality work: Structure: types of personnel, staff qualification and training needs, licensing for staff, record keeping, staffing and supervision ratios, equipment, administrative policies Process: How care is delivered-kinds of services and treatment procedures ****Outcomes: Desirable results for clients-positive outcomes (improvement in function) or negative to be avoided (hospitalizations ) 19

Focus, Analyze, Develop, Execute, Evaluate (FADE):

Focus, Analyze, Develop, Execute, Evaluate (FADE) There are 4 broad steps to the FADE QI model: FOCUS: Define and verify the process to be improved ANALYZE : Collect and analyze data to establish baselines, identify root causes and point toward possible solutions DEVELOP: Based on the data, develop action plans for improvement, including implementation, communication, and measuring/monitoring EXECUTE: Implement the action plans, on a pilot basis as indicated, and EVALUATE: Install an ongoing measuring/monitoring (process control) system to ensure success.

Plan-Do-Check(Study)-Act (PDCA or PDSA) Cycle:

Plan-Do-Check(Study)-Act (PDCA or PDSA) Cycle PLAN: Design or revise production/business process components to improve results DO: Implement the plan and measure its performance CHECK: Assess the measurements, monitor and evaluate the processes and results against objectives and specifications and report the results to decision makers, AKA (STUDY: Study the results) ACT: Decide on changes needed to improve the process and apply actions to the outcome for necessary improvement. This means reviewing all steps (Plan, Do, Check, Act) and modifying the process to improve it before its next cycle of implementation Study

Contrasting QI and QA:

Contrasting QI and QA Quality Assurance – QA was reactive, retrospective, policing, and in many ways punitive. It often involved determining who was at fault after something went wrong. This term is older and not as likely to be used today. Quality Improvement – QI involves both prospective and retrospective reviews. It is aimed at improvement -- measuring where you are, and figuring out ways to make things better. It specifically attempts to avoid attributing blame, and to create systems to prevent errors from happening. QI activities can be very helpful in improving how things work. Trying to find where the “defect” in the system is, and figuring out new ways to do things can be challenging and fun. It’s a great opportunity to “think outside the box.”

Regulating “Acceptable Levels of Quality”:

Regulating “ Acceptable Levels of Quality ” Internal Review Systems Compliance audits Utilization reviews Chart reviews Peer audits Policy and procedure compliance reviews Patient satisfaction surveys External Review Systems Patient satisfaction surveys Payer denials Referral sources Accreditation Standards Litigation 1. Stewart, D 1993 It’s one challenge to arrive at a consensus on exactly how to define quality but it’s an even bigger challenge to remain accountable to it. 1

Internal Review Systems :

Internal Review Systems Compliance Audits/Surveys Utilization & Retrospective Reviews Review patterns of utilization against normal or established policies May be done externally as well by various payers Policy and Procedures Compliance Reviews Client satisfaction Surveys

Policy and Procedures Manual: Should a Therapy Department Have One?:

Policy and Procedures Manual : Should a Therapy Department Have One? Purposes To meet the requirements of licensing or other agencies that demand them. To minimize relying on memory to assure consistency . To serve as evidence during legal proceedings . To reflect compliance to state and federal laws and regulations . Remember a P and P Manual does not include clinical guidelines and protocols


Policies Policies reflect the "rules" governing the implementation of an organization ’ s processes Examples: Non-smoking facility Non-clinical information is the property of the organization Internal Review Systems

Policy and Procedures Manual:

Policy and Procedures Manual Description of the practice or clinical environment The organization's mission and vision statements and core values. An organizational chart of the practice Human resources Scope of services Facility operations Safety, infection control, and emergency preparedness Patient care/best practice guidelines.


Procedures A particular way of accomplishing an action (a way of implementing a policy) Series of steps to provide details on a particular task Description of how to carry out a policy Examples: Procedure to disinfect treatment tables Method of scheduling a new patient

Client Satisfaction Surveys:

Client Satisfaction Surveys Content Quality Service Delivery Quality Internal Review Systems Clinical Expertise Technical Skills Excellent Service Delivered Appropriately Clinical outcomes Meeting Client Expectations Content Quality Service Delivery Quality

Quality and the Consumer Perspective:

Quality and the Consumer Perspective Degree of choice and autonomy Consistency of services Respectfulness and trustworthiness of workers Timeliness of workers Quality of the task performed Dr. Crossen-Sills 31

Customer Service :

Customer Service Some people say: Good Service is whatever the customer says that it is! How does customer service link to an Agency’s Mission, Vision, and Values? 32

External Accountability via Audits and Evaluations:

External Accountability via Audits and Evaluations Federal Government Agencies (CMS) State Government Agencies (Medicaid) Professional Associations (APTA, OTA) Independent Accrediting Agencies (Joint Commission, CARF, NCQA)

Bottom Line:

Bottom Line Quality is the responsibility of all employees at all levels of an organization So involve them


Accreditation??? Helps providers improve the quality of their services and meet recognized standards. For consumers of health care services accreditation serves to assure that providers are striving to offer high quality services. For payers, referral agencies, and government regulators accreditation helps to demonstrate that providers are accountable and good risks.

Joint Commission (formerly known as JACHO):

Joint Commission (formerly known as JACHO) Provides accredited status to 15,000 health-care organizations that choose to comply with its standards, including: ambulatory health care , hospitals, nursing and rehabilitation facilities, home care, behavioral health care, laboratory svcs , critical access hospitals . Monitors and examines several hundred standards designed to provide safe, high-quality patient care. Goal: performance improvement of member organizations through quite extensive focuses on process and outcomes of patient care service delivery.


Federally sanctioned survey You must pay for it Occurs unannounced every 12-18 months – “ Hospitals should be survey ready at all times ” Looks now at healthcare process being repeatable to maintain safety National Patient Safety Goals (NPSGs) – see web site:http://www.jointcommission.org/standards_information/npsgs. External Accountability

National Committee for Quality Assurance (NCQA):

National Committee for Quality Assurance (NCQA) Evaluates and accredits Health Plans, ACOs, Managed Care Organizations Developed the H ealthcare E ffectiveness D ata & I nformation S et (HEDIS) This measures performance on many dimensions of care and services within healthcare plans. Consumers can compare one health care or managed care plan to another External Accountability http://www.ncqa.org/ReportCards/HealthPlans/HealthInsurancePlanRankings/PrivateHealthPlanRankings20122013.aspx

Commission on Accreditation of Rehabilitation Facilities (CARF) :

Commission on Accreditation of Rehabilitation Facilities (CARF) Private non-profit rehabilitation organization whose mission is to promote quality programs & services for people with disabilities & others in need of rehab. Accreditation for: Adult Day Care Facilities Assisted Living Centers Behavioral Health Facilities Medical Rehabilitation Facilities (48,000 Accredited Facilities through out the US, Canada, Europe)

O.B.R.A. 1987 (Part of the Federal Nursing Home Reform Act):

O.B.R.A. 1987 (Part of the Federal Nursing Home Reform Act) Omnibus Budget Reconciliation Act [ US Congress enacted regulation governing Medicare & Medicaid certified nursing homes Required that each resident “ attain and maintain their highest practical physical, mental, and psycho-social well being ” Emphasis on quality of life and quality of care Key for rehab services: restore and maintain function! External Accountability SNF

Skilled nursing facilities are remaking their image as not just places for long-term patients at the end of their lives but as affordable alternatives for post-surgery rehabilitation:

Skilled nursing facilities are remaking their image as not just places for long-term patients at the end of their lives but as affordable alternatives for post-surgery rehabilitation

OBRA Compliance:

OBRA Compliance Determined by Standardized state annual survey & certification that was established by CMS Unannounced on-site audits Interviews with staff, residents, families. Review documentation (MDS) Extended survey when care is considered substandard Feds can double check state findings External Accountability SNF

OBRA Enforcement Mechanisms & Sanctions:

OBRA Enforcement Mechanisms & Sanctions Failure to meet standards can result in: Fines $$$$$ Denial of payment for new admissions Transfer of residents Closure of facility Survey results are posted on CMS website

Long Term Care Guide for Surveyors:

Long Term Care Guide for Surveyors Guide gives detailed instructions of how a surveyor should look for deficiencies in a SNF Therapies involved in Accuracy of initial and ongoing assessment Restraints Range of motion Skin Physical function & ADLs Communication Assistive Devices

Quality Control in Private Settings:

Quality Control in Private Settings No formal processes exist for periodic reviews Payers often review for: Medical necessity Appropriateness of interventions Reasonableness of services Internal Peer Reviews Utilization Reviews National Clinical Outcomes

What Strategy For Quality Assessment is Appropriate?:

What Strategy For Quality Assessment is Appropriate? WHAT IS WHAT SHOULD BE 1. Identify Indicators Of Inadequate Quality Care 2. Objective Assessment Of Possible Causes 3. Implement Decisions/Actions To Eliminate Problems 4. Monitor Activities To Ensure Desired Results 5. Documentation To Substantiate Quality Improvement (QI) Has Led to Improved Patient Care And Outcomes

What is a QIO?:

What is a QIO? Quality Improvement Organization (QIO) consists of groups of doctors and health care experts who check on and improve the care given to people with Medicare.  QIOs work under the direction of the CMS.  Quality Improvement Organizations (QIO) are designed to improve effectiveness, economy and quality of services delivered to Medicare beneficiaries Dr. Crossen-Sills 47


QIOs Medicare contracts with a QIO (formerly known as Peer Review Organizations or PROs) in each state to monitor and improve the quality of care for people with Medicare. QIOs review your complaints about quality of care provided by:  Hospitals Skilled nursing facilities Home health agencies Medicare managed care plans Ambulatory surgical centers Dr. Crossen-Sills 48

Home Health Best Practice Interventions:

Home Health Best Practice Interventions Hospitalization Risk Assessment Emergency care plans Fall preventions programs Front-loading visits (nursing) Disease management (CHF, COPD) Immunization (influenza, pneumonia) Teletriage & phone monitoring Improving medication management Patient self management (education, goals, action plan) Transitional Care Coordination Telehealth/telemedicine Physician communication (SBAR)

Quality Improvement Across Therapy Settings::

Quality Improvement Across Therapy Settings: 4 principles behind health care QI 1 Have a strong focus on your patients. Adopt a philosophy that there should be continuous improvement of all processes. Involve the entire organization/department in the pursuit of quality. Utilize objective data and team knowledge to improve decision making. 1. Adapted from W. Edwards Deming, 1986


Examples of Indicators and Strategies For Improving Quality in an OP Setting Indicators Strategies Patient Complaints Identify root of problem; create steps to avoid future mistake Lack of Subjective and Objective Documented Clinical Changes Change Rx approach; consult or refer Lack of Short-term or Long-term goal achievements (how frequently PT/OT should write a “weekly” note?) Make goals feasible; change Rx approach Lack of evidence of patient / family communication and education Initiate patient / family education program; require patient / family to recall or demonstrate knowledge


References Patient Safety – Quality Improvement http://patientsafetyed.duhs.duke.edu/index.html Quality Assurance / Performance Improvement: http://www.ahcancal.org/quality_improvement/QAPI/Pages/default.aspx Health Resources and Services Administration http://www.hrsa.gov/quality/toolbox/methodology/performancemanagement/index.html Quality Improvement versus Performance Improvement – what is the difference? http://www.cdc.gov/stltpublichealth/performance/Definitions.html

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