“Quality Assurance Process Improvement (QAPI) QAPI is the coordinated application of two mutually reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI).” – Centers for Medicare and Medicaid Services.

By now, most of us who work in the post-acute care realm have had some familiarity with QAPI. However, understanding how to really benefit from your QAPI program remains a mystery to many. The Centers for Medicare and Medicaid Services’ (CMS’) Long-Term Care Final Rule (Final Rule) became effective on November 28, 2018. The Final Rule requires that post-acute care facilities have an Infection Preventionist in place and maintain a QAPI plan that includes Infection Prevention.

It is important to remember that QAPI is far more than just a meeting that’s held once per month. What should a skilled nursing facility (SNF) Infection Control QAPI plan consist of? It should be proactive, data-driven and comprehensive with systematic interventions. It should include a continuous process of identifying improvement opportunities, address gaps in your systems and decrease the risk of infection among residents and staff. Your QAPI program should involve staff from all departments in order to best identify facility opportunities for improvement.

Here are five steps to establish a winning QAPI program in your SNF:

Step 1: Determine what area you want to improve

You and your team should discuss what area of infection prevention the facility will focus on and then identify staff using or impacted by the current process. Consider some specific items on which to focus:

• Monitor facility infections and employ applicable preventative measures
• Recognize and improve issues related to infection prevention practices
• Reduce potential exposure to pathogens in the facility
• Decrease the infection risk associated with devices and medical equipment
• Maintain infection prevention compliance with state and federal regulations

Step 2: Establish goals, measures and benchmarks

The time is now to analyze how your facility collects, tracks, monitors, investigates and acts on the data you already have. Do you have the data you need for the area you are focusing on? Do previous plans exist that you can analyze? Also, make sure you know who will gather the data, the frequency by which the data will be collected and the means by which you will report the data. Establish goals, measures and benchmarks based on those key priorities. Try to include measures that are aligned with your facility’s mission, vision and values. Don’t forget to leverage the appropriate technology in your toolkit as part of your data collection efforts.

In this regard, consider utilizing some relevant measures:

• Outcome measure, which tells you if change is happening
• Process measure, which tells you if you have an improved system
• Balance measure, which will help you ensure that any changes you make to one part of the system don’t negatively impact another part of the system

Step 3: Identify and mitigate potential barriers

Identify the potential barriers related to the problem or process you are trying to improve. Your QAPI team should systematically identify and prioritize these barriers. They can include the type of clinicians, the work environment, education/training, organizational culture and available resources, just to name a few. It is the QAPI team’s responsibility to understand the underlying reasons for any barriers and to develop a plan to mitigate them.

RELATED E-BOOK: QAPI—Your Guide to the New LTPAC and SNF Standard for Quality Assurance and Performance

Step 4: Finalize your QAPI plan

Finalize your QAPI plan based on facility priorities, mitigation of barriers and action steps the QAPI team has determined. After gaining approval from your administration, you are now ready to implement your plan. Provide any additional education for staff if you are implementing a new process or changing the existing one.

Step 5: Analyze your data

Obtain relevant data to assess the success of your SNF’s QAPI plan at a designated point in time (e.g., daily, weekly, monthly, quarterly, annually). As you monitor your progress, report results of the QAPI plan to key stakeholders at pre-specified intervals. Based on the analysis, determine the next steps. These can include:

• Continue the process with no changes
• Continue the process with modifications to interventions or barriers to mitigation
• Continue the process with new quality indicators
• Stop the process

The collection of data and use of data are key to achieving high-quality outcomes and safety for residents, visitors and staff. Decision-making based on data improves the overall quality of services provided to residents. Remember: In order to improve, you must measure!

Learn More About Richter’s Skilled Nursing Facility Consulting Services

Do you have questions about developing a winning QAPI program, or other LTPAC clinical challenges? Learn more about Richter’s skilled nursing facility consulting services by contacting us here, or call 866-806-0799 to schedule a free consultation.