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Déjà vu all over again: A new ligature resistant FAQ!

Using the Hospital FAQ page as the baseline, I reckon we’ve got about a dozen FAQs dealing with ligature resistance with this latest offering. For some reason, the “visual” I get from all of this FAQing is the difference between looking at something from a distance (for example, a celestial body) and seeing that same thing up close and personal. What started out as a sphere of incomprehensibility has become (slowly, ever so slowly, over time) a much more nuanced endeavor—an endeavor that continues to represent survey vulnerabilities for accredited organizations.

One of the interesting things to me is how the narrative has evolved over the last couple of years relative to how hospitals are to deal with all the intricacies of managing ligature risks as a survey vulnerability (which is different than managing the risks to patients, but more on that in a moment). This FAQ reveals some specifics as to what you are required to include in the mitigation strategy for those risks that are not yet removed/resolved/corrected/adjudicated, etc. Now, I don’t know that this is truly ground-breaking stuff, but I think this is cray-cray important because this is what the surveyors are going to be looking for, both in terms of structure, but also as a function of an ongoing process. I’m not going to quote verbatim from the FAQ. I know youse guys are excellent readers and such, so a quick summary:

  • Leaders and staff have to know what risks are currently in the mix and somebody has to be responsible for telling them (and documenting that they were told…)
  • Identification of patients at risk for suicide/self-harm, with appropriate risk-based interventions
  • A process for ongoing assessments and reassessments of organization-defined at-risk behavior
  • Staff education re: management of patient risk and implementation of appropriate interventions
  • Ensuring this whole program/process is integrated into the organization’s quality assurance/performance improvement (QAPI) program (sounds like it might be a good time to include this as a standing agenda item at your QAPI committee meetings)
  • Making sure that any equipment that poses a risk, but is necessary for safe treatment of behavioral health patients (the example given is medical beds with siderails on a geriatric unit), is considered, as a risk, in the patients’ overall suicide/self-harm risk assessments, with appropriate interventions to minimize the identified risks

As I reflect over the seemingly endless amount of survey angst that this topic has wrought over the past couple of years, I keep coming back to the reality that while we can always do better (would we have done as much as quickly without enduring survey bludgeoning?), there is minimal data to support that, while not perfect, hospitals were not doing a good job in managing these at-risk patients. Purely from a risk management perspective, this would be a subject of great interest and concern to any healthcare organization as the burden of managing these patients has shifted over time. I suppose it ultimately gets filed under the “abdication of responsibility” that comes with the disenfranchising of difficult patient demographics and the subsequent “arrival” of those patients in the acute care settings, but it seems to me that (and yes, I recognize that this is part of doing business in healthcare) a little more collaboration during this process (as opposed to pointing fingers and assigning “blame”) might have yielded a better end-product. Hopefully, at some point, we will be given credit for the good work that has been done (and quantified), but I don’t think we are quite there yet.

Come on, I Lean: Do you Lean?

As you are no doubt aware by now, there’s been a wee bit of a shift in this forum away from all things Joint Commission, as the CMSers seem more inclined to assert themselves in the accreditation market place. I personally have had a lot of work this year in follow-up activities relating to CMS visits and one of the structural/organizational vulnerabilities/opportunities that seem to be cropping with some regularity are those relating to the integration of the physical environment program into organizational Quality Assessment/Performance Improvement (hereafter referred to as QAPI, pronounced “Kwoppee”—I think you’re going to find that you’ll be hearing that term a lot in the coming years/decades) activities. This very much goes back to a topic we discussed back in January (it’s funny, when I started looking for the link to this story, I could have sworn that we had covered this within the last month) relative to making sure that organizational leadership is abundantly familiar with any issues that are (more or less) “stuck” in your safety committee. There is no “sin” in admitting that there are or may be improvement opportunities for which traction in making those improvements is a little slippery—you have to have a means of escalating things to point where reasonable traction is possible. So, from a regulatory standpoint, this all falls under §482.21 Condition of Participation: Quality Assessment and Performance Improvement, which includes the rejoinder: “The hospital must develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors.”

Now, I can tell you that this is a very big deal, particularly when it comes to the reporting up of data, occurrence reporting, etc.—even from the likes of our little world of physical environment safety and related topics. And sometimes you have to be willing to throw some light on those process areas that are not performing as you would want them to; improvement doesn’t typically happen in a vacuum and that absence of vacuum tends to require a fair amount of conversation/collaboration (with some resultant caterwauling) in order to make things happen/get things done.

One QAPI topic you will probably be hearing about (if you have not already) is Lean methodology, which pretty much embraces the general concept of reducing “waste” while still delivering positive service outcomes by focusing on what the customer wants (you can find some useful highlights here; the books are worth a look—perhaps your local library can hook you up). One organization that appears to be endorsing the Lean methodology is that kooky bunch in Chicago and while the article focuses on behavioral health, I think there is enough practical information to be worth a look. And, since we know from past experience that TJC tends to adopt a more pervasive stance when it comes to these types of things, I think it would be very useful (at the very least for those of you using TJC for accreditation) to be conversant in Lean. It’s probably going to rock your boat at some point—life preservers mandatory!

Are we there yet? Almost certainly not!

One of the fundamental purposes/charges of any high-reliability organization/program, etc., is to be able to identify improvement opportunities and to act upon those opportunities in a manner that actually results in sustained improvement. In the Boston area, we call that “making things bettah!” So, when it comes to the management of the physical environment, I think we can all agree that sustainable improvement is a good thing and, from an operational perspective, really makes a lot of sense. But it’s not necessarily good sense that drives your performance improvement efforts—it’s also a regulatory requirement.

If you look at the CMS Conditions of Participation, clearly there is an expectation of CMS for the management of the physical environment to be incorporated into the hospital’s QAPI program:

482.41 Condition of Participation: Physical Environment

The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community.

Interpretive Guidelines §482.41

This CoP applies to all locations of the hospital, all campuses, all satellites, all provider-based activities, and all inpatient and outpatient locations.

The hospital’s Facility Maintenance and hospital departments or services responsible for the hospital’s buildings and equipment (both facility equipment and patient care equipment) must be incorporated into the hospital’s QAPI program and be in compliance with the QAPI requirements.

Interpretive Guidelines §482.41(a)

The hospital must ensure that the condition of the physical plant and overall hospital environment is developed and maintained in a manner to ensure the safety and well being of patients. This includes ensuring that routine and preventive maintenance and testing activities are performed as necessary, in accordance with Federal and State laws, regulations, and guidelines and manufacturer’s recommendations, by establishing maintenance schedules and conducting ongoing maintenance inspections to identify areas or equipment in need of repair. The routine and preventive maintenance and testing activities should be incorporated into the hospital’s QAPI plan.

So, that sets things up fairly succinctly, but in looping back to what CMS is calling/looking for in terms of the indicated “QAPI requirements,” I think there may be opportunities to open things up a bit beyond merely tracking compliance rates (which, typically, perform up to/within regulatory/organizational expectations) and start to look at what those compliance rates mean in terms of demonstrating/verifying the effective management of the physical environment. For example, to my mind, monitoring fire drill compliance as a straight X number of drills per quarter, etc., really doesn’t make a great deal of sense, unless you are having difficulties meeting the requirement (and I should point out that if you are having difficulties conducting fire drills, that’s not going to play well with too many regulatory surveyors). Where I think the “gold” might be (continuing the fire drill example) is in working on figuring out how to demonstrate that the fire drills are effective in preparing folks to respond appropriately in the event of a fire, which leads us to the next piece of the CMS expectation:

482.21(a)(2) The hospital must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service and operations.

 482.21(b)(2) The hospital must use the data collected to–(i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement and changes that will lead to improvement.

If you have indicators that are consistently performing at the 100% level, while someone is still going to be monitoring those programmatic aspects, it’s probably time to retire them from the active reporting structure to your EOC Committee. Now I know folks are usually loathe to focus too much on the negative stuff (nobody wants to get in trouble, etc.), but if I may make the suggestion—as a starting point, look at the stuff that you do pretty well, but not perfectly (and if we have learned nothing else over the past couple of years, it’s those things that are not perfect that can cause the biggest problems during a survey). For example, say you are tracking completion rates for non-urgent work order requests, and you are experiencing a pretty solid 90%-95% closeout rate. Now, I would call that a pretty good rate for the non-urgent stuff (presuming that this sterling completion rate is not getting in the way of completing urgent work order requests), but what about that 5%-10% of things that aren’t being completed? Are there any butt-biters in that grouping (things that later resurface to bite you on the backside)? In the interest of putting our best face forward, I think sometimes we focus too much on what has been done and not so much and what hasn’t been done. And I will tell you, the stuff that doesn’t get done will usually cause more trouble than the stuff that did get done.

So when it comes to performance improvement, while it is nice to reflect on the successes of the past, the key metrics “live” in the journey ahead: recognizing that compliance is a journey and not a destination. We ain’t never gonna be “done” with this little pursuit.

For those of you in the northern hemisphere, please enjoy these first days of summah! For those of you at the other end of the globe, wintah is nice, too!