Note: Do you want to learn more about Quality Assurance and Performance Improvement (QAPI), or have questions about how QAPI can help your LTPAC facility? Read our blog: What IS QAPI? Your Guide to the new LTPAC and Skilled Nursing Facility Standard for Quality Assurance and Performance Improvement.

What is a Performance Improvement Project in a skilled nursing or LTPAC facility?

A Performance Improvement Project (PIP) is a focused effort on a specific problem in one area of a long term post acute care (LTPAC) facility or agency, or for the entity as a whole. The process involves methodical gathering of data to bring additional clarity to facility issues or problems. The facility initiates a PIP to examine and improve care and/or services in areas that the facility has identified as areas of concern. Areas of concern will vary depending on the type of facility or agency and the distinctive scope of services provided.

How do you know when a PIP is warranted?

The short answer is to complete a PIP for any areas or practices where you have determined a need for improvement. PIPs should be directed by your organization’s Quality Assurance/Performance Plan (QAPI) Steering Committee. This committee is responsible for prioritizing opportunities for improvement from its ongoing structured review of facility performance. Furthermore, you should prioritize those items that affect residents or are high-risk items, and complete PIPs for those items first. You should then move on to medium- and low-risk items.

Careful planning of PIPs entails identifying areas to work on that are meaningful and important to your residents through comprehensive data review. It is important to focus PIPs by defining their scope so that they do not become overwhelming. Some opportunities are not global enough to create a PIP. Corporations or facilities may have a desire to document smaller scoped projects of shorter term. Check with your Steering Committee for guidance on selection of PIPs versus Improvement Activities (IAs).

Once you have determined you want to initiate a PIP, you will want to use what is called the Plan-Do-Study-Act (PDSA) Cycle. PDSA is a four–step model for carrying out change. Just as a circle has no end, the PDSA cycle should be repeated again and again for continuous improvement.

We describe each PDSA step below.

Plan: Recognize an opportunity and plan a change.

During the Plan step, assemble a team that has knowledge of the problem or opportunity for improvement. When choosing the staff, consider the strengths each team member brings to the table—look for engaged, forward-thinking individuals. Once you have recruited your team members, identify roles and responsibilities, set timelines and establish a meeting schedule.

Describe what it is you want to accomplish in an “aim” statement. Try to answer three basic questions:

1. What are we trying to accomplish?
2. How will we know that a change represents an improvement?
3. What change can we make that will result in improvement?

Using the aim statement, describe your desired accomplishments, and use data and information you have gathered to measure how your organization does not currently meet the accomplishment criteria. By means of root cause analysis, identify the cause(s) of your problem. Examine your process by asking these questions:

1. Is this process efficient? What is the process costing, including money, time or other resources?
2. Are we doing the right steps in the right way?
3. Does someone else conduct this same process in a different way?

Finally, develop alternatives that could mitigate your root causes. Choose one or two alternatives that you believe will best help you reach your aim(s).

Do: Test the change. Carry out a small-scale study.

In the Do step, you will begin implementing your action plan. Collect data as you go to help you evaluate your plan in the Study step of the cycle. Your team may want to use a check-off sheet, flow chart, swim lane map, or run chart to capture data/occurrences as they happen, or over time.

Your team should also document problems, unexpected effects and general observations throughout this process.       

Study: Review the test, analyze the results and identify what you’ve learned.

The Study step will include the aim statement from the Plan step, as well as data gathered in the Do step. You will use that information to answer the following questions:

1. Did your plan result in an improvement? By how much/little?
2. Was the action worth the investment?
3. Do you see trends?
4. Were there unintended side effects?

Act: Take action based on what you learned in the Study step.

If your efforts have yielded a positive outcome, you will want to integrate your results into a daily process. Then, you should return to the Plan step and review your process to determine if any further improvements are warranted.

If your efforts have given you a negative outcome, return to the Plan step and develop a new plan to work toward ultimate success.

No matter the outcome, it is important that you share outcomes with your staff. This offers a perfect opportunity to develop dialogue with staff members who were not directly involved in the process. You never know where that next great idea might come from.

Contact Richter Healthcare Consultants

Do you have questions about Performance Improvement Projects (PIPs) in a skilled nursing or LTPAC facility, or need help understanding how PIPs and a QAPI program can boost performance? Call Richter’s clinical healthcare consultants at 866-806-0799 to schedule a free consultation. 

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Jennifer Leatherbarrow, RN BSN, RAC-CT, QCP is a Clinical Consultant with Richter Healthcare Consultants.