Culture Change at the Core of QAPI

This past Friday I attended the 2014 Katz Policy Lecture at the Benjamin Rose Institute. Peter Kemper, PhD, Professor Emeritus of Health Policy, Administration and Demography from Pennsylvania State University gave the lecture on Expanding Culture Change to All Nursing Homes: Challenges and Policy Approaches.

Professor Kemper acknowledged early on what is often the opening salvo of critics of culture change – that defining exactly what it is can be a formidable challenge. In fact, as he noted, it may be preferable to think of culture change as a movement instead of a model. This perception would be consistent with the concept of continuous quality improvement where it is recognized that while operational perfection is inherently unachievable, evidence shows its pursuit drives measurably better outcomes.

Cutting through the theory and research, at its core culture change is the ability to create an organizational environment in which individuals are empowered, trusted and valued: and this must be true for both patients and the workforce caring for them. What does this look like? Well, in listening to the lecture I found that we need look no further than the five elements of Quality Assessment Performance Improvement (QAPI).

Element 1: Design and Scope: Culture change can only take place if there is a shared commitment to be cognizant and aware of how each individual’s role and responsibilities support achievement of the organization’s future state vision. To accomplish this there must be an understanding and pragmatic recognition that the approach needs to be comprehensive, inclusive and constantly evolving.

Element 2: Governance and Leadership: It is the organizational leadership’s primary responsibility to create the environment by owning (without controlling) the design and scope process, while the role of governance is to ensure sustainability and accountability of that environment once created.

Element 3: Feedback, Data Systems & Monitoring: The old adage of you can’t manage what you can’t measure, however incomplete in its ability to capture the full essence of organizational behavior, nonetheless is the primary means of incenting desired behavior while discouraging unwanted behavior (i.e., accountability). This must be a fundamental element of culture change, particularly from the standpoint of sustainability.

Element 4: Performance Improvement Projects: The key concepts attributable to culture change here are prioritization and ability to impact. The important nuance that many PA/LTC organizations have difficulty understanding is that PIPs don’t have to be directed retrospectively. They can (and should) be borne out of a comprehensive design and scope process (i.e., Element 1). This is a key element of intersection between culture change and QAPI programming that must be embraced and understood.

Element 5: Systematic Analysis and Systemic Action: Socrates noted that, “the unexamined life is not worth living.” I contend that an organization committed to culture change will continuously assess and examine whether and how well it is able to achieve its vision while fulfilling its mission and always reflecting its core values. This brings us full circle to the concept of continuous quality improvement noted at the beginning of this post.

As Professor Kemper also noted during his lecture, there is nothing necessarily innovative or revolutionary about culture change in PA/LTC. My observation is that it is really a matter of borrowing – or adopting – proven best practices of organizational behavior from other industries and research that dates back to the early 1900s. But going from theory and research to realized benefit takes the type of leadership that isn’t as easy to import. That’s where a lot more work needs to be done before either culture change or QAPI can achieve meaningful and lasting improvement in patient outcomes and life enrichment of the individuals served.




Picture Credit: Provider Magazine

SNF Value-Based Purchasing Under SGR Extension

Earlier this week President Obama signed into law H.R. 4302, the Protecting Access to Medicare Act of 2014. The sole impetus of this legislation was to once again avert – by one year – the nearly 24% cut to the Medicare physician fee schedule that was initiated as part of the Balanced Budget Act of 1997 under the Medicare Sustainable Growth Rate (SGR) methodology. This marks the 17th time in 11 years now that the automatic cut has been averted by legislative action. Congress knows how to kick a can.

Just a few weeks back there was a fair amount of optimism the SGR might be fully repealed and replaced with a “permanent” payment methodology. There was bipartisan support in both the House and Senate, but as you might expect, wide differences in how to pay for the repeal. While Republicans sought repeal of the individual mandate, Democrats wanted to tap into unused military spending. And there you have it then.

In about 11 months from now Congress will be back to the same spot of having to deal with a pending fee cut, but it will be a different Congress.  Just how different of course should make for a fascinating late summer/fall entertainment for political wonks. In the interim, however, there are a number of non-physician related items included in this Act that are worth noting, including a delay in the implementation of ICD-10; acceleration of LTCH moratorium; changes to Medicaid disproportionate share hospital (DSH) payment reductions; limitation on the two-midnight rule enforcement; as well as other provisions.

SNF Value-Based Purchasing
In addition, the Act calls for the establishment of two hospital readmission-related measures for skilled nursing facilities (i.e., value-based purchasing for SNFs). The first measure is an, “all-cause all-condition” hospital readmission measure; and the second is to encompass, “all-condition risk-adjusted potentially preventable hospital readmission rate.”

The implementation of this program is a few years off: actual reductions in Medicare reimbursement based upon comparative readmission performance won’t take effect until FY 2019 (i.e., SNFs with fiscal years beginning on or after October 1, 2018). But when it does take effect, those organizations with relatively lower hospital readmission performance will be penalized two-percent of their otherwise Medicare reimbursement. In turn, up to 70% of the savings achieved from this penalty will be redistributed to those organizations achieving relatively better readmission performance.

No doubt the process for developing these measures will be contentious despite assertive measures to avoid bias and/or misrepresentation of care indicators included in the Act. And with penalties not starting until four-plus years from now who knows just how (or even whether) the program will be implemented.

Clearly the sentiment in Washington – at least today – is to shift reimbursement from post-acute/long-term care to acute care. And the preferred means of accomplishing this will be to focus on perceived opportunities for cost savings while improving, or at least without impacting, quality care. The value paradigm: quality divided by cost.

In advance of the value-based purchasing program will be the QAPI initiative, regulations for which are anticipated later this summer. SNF organizations will have to be able to develop quality assessment and performance improvement programs that support being able to predictively monitor and model hospital readmissions given a variety of qualitative and quantitative indicators requiring real-time operational and clinical adjustments.

For many smaller SNF organizations this is going to be a daunting task because of the investment requirements. They will be caught in the unenviable spot of having to make substantial capital investments to maintain cash flow levels that already cannot support capital accumulation. As such, within the next few years they will be faced with closing, merging or selling.

So although the revenue impact of value-based purchasing is still several years away, all SNFs would do well to begin understanding and assessing their short and long-term financial viability in lieu of these forthcoming requirements – while there are still choices available.