Las recomendaciones de la Síndica de Greuges de Barcelona

Based on the Guide to Develop Purpose, Guiding Principles, and Scope for QAPI, indicate the QAPI goals that

your plan will strive to meet. Goals should be specific, measurable, actionable, relevant, and have a time line for

completion. (See Goal Setting Worksheet).

Goals: Reduce unplanned re hospitalizations by 15 % over the next year

Work with collaborative partners on identification of process improvements to influence mutually safe transitions of care and safe handoff of information with transfers

Work with community partners to enhance the application of advanced care planning and the development of a Palliative model to meet the needs of those we serve when comfort takes precedence over cure.

Opportunity Statement: We have an opportunity to reduce unplanned hospitalizations beginning with knowing our baseline and analyzing retrospective data related the root causes behind discharges, and ending with defined criteria on tour scope of care and our current capabilities. (INTERACT FACILITY CAPABILITIES) and PIP’s based on analysis of re hospitalization data. This is important to work on now so that our programs and services, educational programs and competencies, equipment and supply readiness, communication structures, and advance care planning align with the individuals we provide care to, and result in a reduction in unnecessary hospitalizations.

SS: Transitioning of the new admission; discharge planning. Orientation for new resident/family within 72 hours; advance care planning

Admissions: Preadmission evaluation; review with discharge planners the facility Capabilities list Nursing: Preadmission screen; oversight of hand off information and structures to examine unplanned re hospitalizations

Administration: Support of a facility Re hosp team

Physicians and Extenders: Participation in SBAR and pathway education Housekeeping and Activities (Example: Using Stop and Watch and reporting) Others:

b. Describe how the QAPI plan will address:

i. Clinical care:Examples include use of STOP and WATCH, staff huddles, morning reviews, Point Right Care dashboard management, Safe Transitions Team, QM review, etc.

ii. Quality of life: QM review; utilization of Point Right Data; weekly QOL meetings that are

interdisciplinary (See attached agenda) Advanced Care Planning first week of admit with ongoing review; highlighted advance directive component on care plan agenda

iii. Resident choice (i.e., individualized goals for care) Examples include tracking and trending of resident and family feedback from QIS interviews and Observations (See attached documents), person centered care plans, consistent staff, formal and informal satisfaction reviews…

c. Describe how QAPI will aim for safety and high quality with all clinical interventions while

emphasizing autonomy and choice in daily life for residents (or resident’s agents). Example: We will

promote person centered care and advance care planning from the point of admission, with ongoing oversight as a part of daily reviews, weekly QOL and discharge planning as pertinent to the goals of care

d. Describe how QAPI will utilize the best available evidence (e.g., data, national benchmarks, published

best practices, clinical guidelines) to define and measure goals.

Unplanned Re hospitalization data will be tracked and trended and compared to peer groups and national data through data sources such as INTERACT, Advancing Excellence, CMS, Point Right, AHCA and FHCA, and FMDA resources

b. Describe how QAPI will be adequately resourced.

i. Designate one or more persons to be accountable for QAPI leadership and for coordination.

Designated champion/co-champion:

Team members to include external community partners: Hospice, hospitals

ii. Indicate the plan for developing leadership and facility-wide training on QAPI: (Attach meeting

meetings as applicable). Examples: Participation in the National Partnership to Improve Dementia Care, Facility wide INTERACT training with on demand education and

resources…

iii. Describe the plan to provide caregivers time, equipment, and technical training as needed for QAPI.

Example: Establish monthly staff meetings at set times for all shifts. Include QAPI time on each meeting agenda, build discussion on QAPI initiatives into daily shift report and observe that shift huddles occur, periodic Stop and Watch Skills Fair based on QM review and rehospitalization data analysis…)

iv. Indicate how you will determine if resources are adequate for QAPI.

Example: Determine with the team and as part of staff meetings what resources might be needed:

Supplies and equipment: Inventory of vital sign equipment and equipment checks Education and training materials: Review resources as noted through Advancing Excellence, Interact, State Association

Budget for training: Work into Strategic Plan

External resources: Request assistance from Physicians and extenders on SBAR and communication

Protocols and tools: Interact, AMDA, State Association, Advancing Excellence, Pioneer Network

v. Review resource needs as part of budget planning activities

vi. Describe how your caregivers will become and remain proficient with process improvement tools and

techniques. How will you assess their level of proficiency?

Gu id e fo r Developing a QAPI Pla n

i. While everyone in the organization is involved in QAPI, you will likely have a small group of

individuals who will provide the backbone or structure for QAPI in your organization. Who will be part of this group? Many of these individuals may be on your current QAA committee.

Are there other workgroups involved in key elements within the PIP: “Admissions Transitions

Team”

Refer to guidelines for governance section b

ii. Describe how this group of people will work together, communicate, and coordinate QAPI activities.

This could include but is not limited to:

• Establishing a format and frequency for meetings

Designated time and place:

Develop a team agenda (See example)

• Establishing a method for communication between meetings

Who will oversee minutes?

How will staff be informed? (Staff meetings, shift updates, Storyboard of the PIP, etc.)

• Establishing a designated way to document and track plans and discussions addressing

QAPI.

Example: run charts from the INTERACT Transfer log data that is uploaded into the excel file

iii. Describe how the QAPI activities will be reported to the governing body; i.e., Board of

Directors, owner. Best Practice sharing, newsletters, training