Following over a decade of development, the Centers for Medicare and Medicaid CMS started the national rollout in While Federal funding cuts temporarily delayed the banded roll-out, have no fear, QIS is still coming your way.
Over the past several years, CMS has been moving in this direction with the introduction and subsequent refinement of a resident assessment instrument RAI , better known as the Minimum Data Set MDS , in addition to case-mix adjusted reimbursement, standardized resident assessment protocols and the electronic transmission and storage of resident data.
So, why the need for this landmark change from a traditional survey model to QIS? Some of the main objectives of the QIS process are to:. In the nutshell, QIS is a computer assisted long-term care survey process used by selected State Survey Agencies and CMS to determine if Medicare and Medicaid certified nursing homes meet Federal guidelines for nursing home care. Based on a two-stage quality assessment approach first developed at the University of Colorado in , surveyors systematically review specific nursing home requirements and objectively investigate any regulatory areas that are triggered.
Understanding the QIS structure and survey process, particularly as it applies to how providers manage and improve MDS data, is key to ensuring good survey outcomes and preventing unintended consequences, such as a reduction in Five-Star rating, major fines and citations, negative publicity, to name a few.
The generic QIs are applicable to all surgical training placements, regardless of their specialty or level. The remainder of the QIs are divided into two groups: those for all placements within each surgical specialty; and those relevant to training placements at specific levels. From August , a new set of QIs will be implemented to coincide with the new curricula. The generic QIs and specialty-specific QIs have been considered to ensure that they align with the new curricula.
Step 2: Manage data for performance improvement. Analyze how the facility is collecting, tracking, analyzing, interpreting, and acting on the data. Include the information technology department to facilitate electronic data collection when possible.
Identify baselines and set targets for improvement. Step 3: Identify potential barriers related to the problem or process to improve. Barriers can relate to characteristics of the clinicians, the work environment, the culture within the organization, available resources, and many other factors.
After the team understands the underlying reasons for the barrier, develop a plan to mitigate the barrier. Step 4: Write and finalize the specific QAPI plan based on the selected priorities, barrier mitigation, and corrective actions steps the team has developed. Include lessons learned along with other outcomes in the report. Take steps to celebrate successes. In addition to being a regulatory requirement, data collection assists the IP in:.
When a problem is identified, a standard approach to address the problem is helpful. The PDSA model for improvement is a process commonly used to analyze a problem, develop solutions, implement improvement and evaluate the results. The plan must be flexible to facilitate alteration in response to unexpected disease processes or environmental issues and yet contain specific, realistic, and measureable goals. As seen in Figure 1, quality improvement efforts typically involve five steps.
The best way to involve people and their talents appropriately is to develop the plan using a team approach by engaging people in the Infection Prevention Committee. Multidisciplinary teams increase problem identification and solution development.
A full evaluation of the IPP should be done annually. Additional staff members may be asked to provide input or join the committee as issues arise. Find or create a list of the members of your infection prevention committee or the committee that reviews the infection prevention data and antibiotic use.
Is there appropriate representation on the committee? Scientific and credentials? Various key areas such as pharmacy, lab, ICU? Note: If you do not have an infection prevention committee or a committee who reviews the infection prevention data and antibiotic use, talk with your supervisor regarding staff that would be appropriate to work with you. The infection prevention program involves many stakeholders, both on and off of the infection prevention committee.
Roles and responsibilities for how the regulatory bodies, IP and IP Team work together to create or update a plan are shown in Figure 2. To read the work flow, begin in the upper left corner of the top IP Team role lane. Follow the arrows. Joint actions appear in Figure 2 as action-step boxes that straddles the line between two or more roles. Figure 2. Individuals delivering clinical and care-related services are frequently not on the infection prevention committee.
The team and relationships the IP builds in the facility assure individuals will take the risk of infection seriously and facilitate their engagement. Their collaboration and behavior are very important to reduce or eliminate risks of infection. Identifying the risks is not enough to prevent infections. Risks must be analyzed for severity and the actual frequency of occurrence in a facility. This analysis helps the committee prioritize the risks identified during plan development or update.
The IP and the committee have a finite amount of time and resources and are more likely to be successful in reducing risks if they focus on a few key items. There are many tools available to help identify and prioritize infection risks. Appendix B provides examples of these tools. A team-based review of the priorities by the infection prevention committee is helpful. Documenting the prioritized risks and rationale for selection helps people outside the team accept and spread improvements throughout the facility.
The more people engaged with the goals, the better. Locate the risk assessment and infection prevention plan that was created for your facility. Review infection data for the past years. Are there patterns? Recurring incidents? Note location, type, severity and frequency.
Compare your analysis to the Infection Prevention Plan section regarding risks. Does the plan describe actions that are consistent with experience? Use one of the 3 templates in Appendices B, C and D to create a draft risk assessment and plan for your facility. Once a risk is identified and prioritized for action, a quality improvement solution is designed using a quality improvement model.
The PDSA model for improvement 18 is a four-step method used to implement a guideline or work flow change and process improvement. A team is established based on the risk or problem that needs to be improved.
Following the prescribed four steps 1 plan, 2 do, 3 study, and 4 act guides the thinking process. Each step helps assure good results, breaking down the task into reasonable steps, evaluating the outcome, improving on it, and testing again.
Each element of the Nursing Process corresponds with one or more of the initial questions and steps of the PDSA improvement model in Table 1. After one cycle of all four steps, a new PDSA cycle begins from that point. Figure 4. Sequential use of the PDSA model for improvement. Review the examples and template. Identify a problem to work through and complete the template.
Please download the printable PDF Version of this section, linked at the top of the page to see the Appendices. PLAN Background: the problem statement and the result desired. Describe the solution to be tested: keep this specific. List of tasks: pre-work before testing, what needs to be done, people to be informed and involved.
0コメント