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Chapter 7

Mary Maven Chapter 7

We Can Do This!

End-of-Chapter Questions  


1. List ways to ensure that all those affected by the project and all those involved in it can be kept informed of your progress towards improvement

Answer: Question 1

Senior leadership sets the tone for interest in QAPI projects, set up regular meetings with leaders and keep them informed.  Use a storyboard display in common area for all to see. Report at team meetings, publish in team newsletters. Be brief.

2. What are the advantages of keeping staff involved and informed about the project? Why involve senior leaders? Why keep them informed?

Answer: Question 2

In most QAPI projects, it is the staff who are asked to change their behavior. It is always easier for people to change when they are part of the change process itself rather than feeling that change was forced on them.

Senior leaders who buy into the need for the change and the process and who are kept informed during the improvement project are more active allies. They are more likely to support the project from a morale perspective, encouraging participation and demonstrating their interest and value that this project will help the organization improve its outcomes. They are also more likely to consider additional resources for the project and allocate resources if needed to sustain positive changes that improve outcomes.  

3.  Discuss the pros and cons of using FEHC and STAR and other standardized tools for outcome and process measures for QAPI projects? What is the role of the Self Assessment in your organization for QAPI projects?

Answer: Question 3

Pros: Standardized outcome and process measures like those contained in the FEHC and the STAR have been tested and are reliable and valid measurement tools. Because they are used by many other hospices, they have the added advantage of allowing you to compare your success/status with others in your state and in the nation who also use these measures.

Cons: For improvement projects, it’s important to know how the changes you are testing affect the outcome and with these tools. For some there may be lag time between the changes you tested and seeing whether or not it made a difference. Over time, this lag becomes less and less important. Sometimes hospices might choose to use an “interim outcome measure” (telephone call surveys a month after death) for more immediate feedback on the outcome.

Role of the Self Assessment System

The QP Self Assessment System is one very good way to perform a 360 degree comprehensive review of your hospice organization as required by CMS. It provides a systematic way to see how you measure up to the NHPCO standards related to the 10 components of quality.  It also allows you to see how well you perform compared to others in your state and nation who have used the self assessment system. When you have finished your self assessment, you will be able to identify and prioritize areas for improvement particular to your hospice.