Setting your goals is a vital part of the Quality Assurance/ Performance Improvement (QAPI) process. The first step entails establishing thresholds. In order to determine your thresholds, you must first collect the relevant data. When collecting data, it is important to ensure that the data is meaningful and not erroneous. Once the appropriate data is gathered, you will use that information to identify a threshold. The QAPI process must include this step for establishing an acceptable threshold, target or goal. Although benchmarks can be set for any threshold, clinical benchmarks should be set based on the consideration of standards of care or best practice for that specific benchmark. Such information can be obtained through professional organizations, research and databases within your industry. Another good source of information is the Centers for Medicare and Medicaid Services (CMS) website.

An example of said benchmarks would be your Certification and Survey Provider Enhanced Reports (CASPER) Quality Measure reports which are available for nursing facility providers. These reports allow you to identify benchmarks on a state or national level and compare them to your own. Every facility is different; therefore, benchmarks should be based on your own individual performance.

CMS has developed a “SMART” formula to assist in the creation of comprehensive goals. When writing your goal based on the SMART formula, keep in mind that it should be comprehensive yet succinct. You want to be able to easily articulate the written goal to your staff. Sharing the goal with your staff will promote a feeling of ownership and pride as you work through the QAPI process.

Once you have set your goals, you must determine how you plan to collect data. Who will be responsible, and how will the data be collected? How will the data be reported? Who will review the data? All of this information should also be included in your Performance Improvement Plan (PIP). After the predetermined period of time has passed, the results should be reviewed to determine whether that goal was met.

Read our blog on Performance Improvement Plans (PIPs) to learn how they can boost performance and results for your LTPAC facility.

The following case study illustrates how one facility utilized QAPI processes and planning to overcome organizational specific challenges.

OPPORTUNITY: The Director of Nursing (DON) was told by the State Ombudsman that the facility has a reputation for discharging residents who have been unhappy with their care and overall outcomes.

TEAM: The DON assembled her administrative nurses to begin an investigation to determine if the allegation was credible.

ANALYSIS: The team selected “Decline in Activities of Daily Living (ADLs)” as the first item for review. They immediately noticed that during the past six months, at least 27 percent of the residents discharged experienced a decline in at least one ADL, and 17 percent suffered a decline in three or more ADLs. After a closer look into the detailed information from each of the measures, the team confirmed that many residents who experienced an ADL decline also did not meet their established rehabilitation goals, were displeased with care, and ultimately transferred to other facilities. The team then shared the results of its analysis with the entire management team. 

GOALS: The management team then devised a proactive plan that implemented interventions to reduce hospital readmissions, increase positive outcomes from both rehabilitation and restorative therapy services, and development of a new customer satisfaction survey.

INTERVENTIONS: The facility trained staff on all shifts regarding the new hospital readmission process, including the Interact process. The Activities Department shared the new plan with the Resident Council. A letter was sent out to all residents and families outlining the plan. Lastly, the Quality Assurance/ Performance Improvement (QAPI) Committee implemented strategies with the goal to see significant reduction in ADL decline on discharge and a significant increase in customer satisfaction over the next quarter.

STUDY: The QAPI Committee was then able to use the same decline in ADL measures the nursing team had identified to pull its data and monitor results.

OUTCOME: This same process was also used to maintain success once the intended results were achieved. The facility continued to monitor this data indefinitely even after it had achieved a positive outcome.

Contact Richter Healthcare Consultants

Do you have questions about a QAPI program and how it can boost performance throughout your LTPAC facility? Call Richter's clinical healthcare consultants at 866-806-0799 to schedule a free consultation.

Want to stay on top of the ever-changing LTPAC industry? Follow us on social media:

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