Element #7- Response to Problem and Corrective Actions

Its been a long journey- going through all the elements of creating an effective compliance program based on the recommendations of the OIG. We have hit the final element- response to problems and corrective actions. We have developed systems to self identify our problems, we find them BUT how will we correct them and put in effective systems to make sure they don’t happen again.

In long term care we are very fond of acronyms-OIG, CMS, ZPIC, QAPI and the list continues. Today I would like to throw PIP into the mix. What is a PIP? It’s a performance improvement plan- the system we put in place to measure success and quantify our improvements plan. A PIP is an essentially part of the quality improvement plan but it’s a process that can be used with any perceived issue in a facility.

A Performance Improvement Project (PIP) is a concentrated effort on a problem in the facility. This can be in one area of the facility or facility wide and isn’t necessarily just clinical or quality of care issues. A PIP can be initiated based on the recommendations of the compliance committee. The process involves gathering information systematically to clarify issues or problems and intervening for improvements. The facility conducts PIPs to examine and improve care or services in areas that the facility identifies as needing attention. Areas that need attention will vary depending on the type of facility and the unique scope of services they provide.

CMS has some great resources and guidance on their website (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/qapitools.html ). The first place I advise clients to start is creating a Storyboard for the problem you are looking to solve. What is a storyboard? It’s a tool that staff can use to simply communicate the story of the proposed PIP. It helps staff drill down to the most essential pieces of information and create clarity for what you are trying to accomplish.

CMS guide to QAPI recommends the following key content to Include in your Storyboard:

1. Problem. One sentence on the issue or opportunity being addressed by this PIP.

2. Aim. One sentence on what this PIP aims to achieve.

3. Intervention(s). Briefly describe what change was introduced to address the problem or opportunity. If there was more than one change, use bullet points to list the multiple interventions.

4. Measures/Indicators. List what measure(s) or indicator(s) are being used to monitor whether the change is effective.

5. Results. One to two sentences on the results. Consider including a graph with notes that gives a picture of the impact of the changes over time, or stories that describe the success.

6. Lessons Learned. Document 1-2 key lessons that were learned through the PIP.

7. Next Steps. Performance improvement is a continuous process. In one to two sentences, describe the next steps (e.g., to further refine the intervention; to introduce the change in other parts of the nursing home; to take steps to standardize the change).

What do I believe makes for a successful PIP?

1) IDT involvement: Get perspective from the entire team-the maintenance man sees things a floor nurse might not.

2) What are we fixing: The team needs to be clear what the problem is and how will we measure the solution? I often encourage the team to drill down smaller and smaller- make your problem very specific so you can feel success and work through the process. Rome wasn’t built in a day.

3) Administration support: Support needs to come from the top. Administration is interested in results and bottom line. There must be buy in to a PROCESS and SYSTEMS.

4) Its not a bandaid: The main point to a PIP is not to be a bandaid- or shorth term fix but rather dig deep and create systems to correct and monitor.

With review of Element 7 we have taken an in-depth look at the OIG recommendations for implementing a Compliance program in a long -term care facility. The next step in this series is examining what CMS is looking for in their mandated compliance program and how it reflects the OIG recommendations. Nothing is simple, right?