In my previous 2 blogs I discussed the five elements of QAPI, and the twelve steps of the QAPI process. In QAPI Part 3, I am going to delve into the process once you have gathered your data and you're ready to compare and interpret that data based on benchmarks that you have obtained from CMS and other sources in order to set your goal.

QAPI Process - Establishing Thresholds Based on Data

We are going to start by establishing thresholds. This is where you will be collecting data. Collecting data just for the sake of having it is not meaningful.  What you do with the data once it has been gathered is crucial.Once the data is gathered you will use the data to identify a threshold. The QAPI process must include this step for establishing an acceptable threshold, target or goal. The benchmarks can be set for any threshold. However, for clinical items the benchmark should be set based on the consideration of standards of care, or best practice for that specific issue. Such information can be obtained through professional organizations research and databases within your industry. Another good source of information is the CMS website. An example of said benchmarks would be your Casper Quality Measure Reports which are available for nursing facility providers.  These reports will allow you to identify benchmarks on a national as well as state level and compare them to your own.

When you are setting your goals each goal should be looked at individually and have its own thresholds. Every facility is different; therefore, the most important benchmarks are often based on our own performance. When you begin writing your Performance Improvement Plan (PIP), remember it should always include a goal. In order to communicate the goal to all of your staff, your goal should always incorporate all of the parameters related to the problem being studied. Your goal must also be specific enough to target the actual problem.  Once you have set your goal, you will then communicate the goal to all of your staff and contractors.

CMS has developed a SMART formula to assist in the creation of comprehensive goals. When writing your goal based on the SMART formula, the goal needs to be comprehensive, whilst still being succinct. You want to be able to easily articulate the goal you have written to your staff.  Sharing the goal with the staff will promote a feeling of ownership and pride as you work through the QAPI process.

Now that you have set your goals you need to determine your plan the plan for the collection of data. Who and how is the data to be collected? How will the data be reported? Who will review the data? All of this information should also be  included in your PIP. After the predetermined period of time has passed, the results should be reviewed to determine whether that goal was met.