One response to adverse events is the “crackdown” or, as David Marx from the Just Culture Community puts it, “getting whacked.” The more productive response is to learn from the events and improve systems and staff performance. In a call on March 13, CMS indicated that it plans to respond to the high number of LTC adverse events outlined in the recent OIG report by doubling down its support of QAPI. This focus on improvement rather than punishment is reassuring and will lead to better care for LTC residents. This is SUCH good news! The call was reported by McKnight’s Long-Term Care News, and is available HERE.
The OIG report, “Adverse Events in Skilled Nursing Facilities: National Incidence among Medicare Beneficiaries[i]” has made quite a splash. Of course, the Center for Patient Safety is excited that it recommends increased participation with Patient Safety Organizations. But the report is a treasure trove of good information that can help to support safety efforts and QAPI program development.
The report found that 15% of Medicare SNF residents have preventable adverse events that cause greater than temporary harm. In addition, 11% of residents had temporary harm. The OIG used a trigger tool to help them identify medical records that reflected adverse events. The report contains a good discussion of trigger tool methodology.
Administrators and directors of nursing should consider reading the report, which is less scary than it looks at first blush. Here are some impressions:
- There is one clear limitation to the report. First, the OIG only looked at Medicare residents in the first 30 days of their stay, and then only looked at the first 30 days of care. This probably minimized the number of events they found.
- On the other hand, it has some other powerful information, both in the data it contains and the light it sheds on HHS’ (and CMS’) thinking about adverse events, Patient Safety Organizations and QAPI.
- The trigger tool itself and the description of its use can shed light on how to identify those unreported things in your home that surveyors will probably be looking for. This supports QAPI’s requirement to identify areas for improvement.
- The description of how the authors and their physician experts distinguished preventable and non-preventable events offers tremendous insight into how providers can evaluate and document the preventability their own events. For example, the report did not consider pressure ulcers preventable if all recommended evidence-based care was delivered or attempted, AND the ulcer developed anyway due to co-morbidities that made evidence-based care difficult to provide or ineffective.
- LTC providers need to improve identification and reporting of adverse events so that they can be studied and prevented. The report recommends participation with Patient Safety Organizations to help accomplish that goal, and to allow for broader study and learning.
- CMS needs to develop methods to encourage and the identification of events and the implementation of improvements. Expect this to be a survey focus going forward. The detailed information in the report about events it identified
The report is available at https://oig.hhs.gov/oei/reports/oei-06-11-00370.asp. The trigger tool is included as an appendix in the report. More information about the Center for Patient Safety’s Long-Term Care PSO services can be found at www.centerforpatientsafety.org/ltc-pso.
CPS will have a booth at the LeadingAge Missouri Fall Annual Conference September 18-20 at Lodge of the Four Seasons. Come see us and let us know how we can help your Missouri-licensed long term care organization improve resident safety and support your compliance with the anticipated QAPI regulations!
DHSS has included the Center for Patient Safety (CPS) in its regional Long-Term Care Provider Meetings. Kathy Wire, JD, MBA, CPHRM, is a Project Manager for CPS and is presenting “How CPS Can Help You Implement QAPI in a Confidential Environment.” The handouts from the presentation, which describe CPS’ LTC offerings, are available on the DHSS website at http://health.mo.gov/blogs/ltcblog/category/provider-meetings.
Even though there is no timeline for the publication of draft regulations for the LTC Quality Assurance and Performance Improvement (QAPI) provisions of the Affordable Care Act, CMS has started to train surveyors about QAPI. In an Open Door Forum call on June 20, officials confirmed that surveyors will not evaluate homes on QAPI until regulations are available. However, they emphasized that the law technically required homes to begin implementing a QAPI program in March.
The Center for Patient Safety offers a number of tools to help LTC organizations develop programs that will support QAPI, available to Missouri licensed facilities at no charge. Participants in Primaris’ “Show Me Quality” network will also be able to participate in interest groups related to CPS programs. Programs such as TeamSTEPPS for long-term care, Just Culture and the AHRQ Survey on Patient (Resident) Safety Culture can help long-term care leadership and management move to the sort of safety culture required in a QAPI environment. They don’t replace specific program on falls, medication safety or other risks to residents–they make them better!