Note: This is the third blog in our multi-part blog series on the CMS Requirements of Participation.

Nov. 28, 2019 is quickly approaching, and with that will come Phase 3 of the Centers for Medicare and Medicaid Services’ (CMS’) Requirements of Participation. As part of this, a fully integrated QAPI program will be required on this date. This should come as no surprise since some of the QAPI components should have already been implemented by your long-term post-acute care (LTPAC) facility, as stated below. This requirement is not going away and should be implemented soon rather than later. 

Quality assurance and performance improvement (§483.75)

Requirements will be implemented in Phase 3 except for:

(a) (2) Initial QAPI plan must be provided to State Agency at annual survey (Phase 2)

(g) (1) QAA committee – all requirements (Phase 1) except subparagraph (iv)

(h) Disclosure of information (Phase 1)

(i) Sanctions (Phase 1) QAPI Program – Facilities must develop, implement and maintain an effective comprehensive, data driven program that focuses on systems of care, outcomes of care and quality of life

1. Address full range of care and service
2. Effective systems to identify, collect and use data and information from all departments, including facility assessment, to monitor performance
3. Plans must be actionable, measured and re-evaluated to ensure improvements are achieved and sustained
4. QAPI activities must include medical errors and adverse resident events

Let’s take a moment to review the background of QAPI:

• According to F520 (OBRA 1987), the purpose: of QAA is to provide a framework for facility to evaluate their systems in order to prevent deviation in and correct inappropriate care processes.
• Section 6102(c) of Affordable Care Act (2010) state the purpose of QAPI is to strengthen a facility’s capacity for data collection and analysis, strategy development, and action plans.

When developing your facility’s QAPI plan, use the following outline:

• Each facility’s written QAPI plan should begin with the following:
• This is the QAPI Plan for (Facility name)
• Facility vision
• Facility mission
• Facility guiding values or principles
• Purpose of your organization’s QAPI plan
• Program design and scope
• List of services you provide to residents:
  • Address all systems of care and management practices
  • Include clinical care, quality of life and resident choice
  • Utilize best available evidence to define and measure indicators of quality and facility goals
  • Reflect the complexities, unique care, and services that you provide
• Consider how each service area addresses:
  • Clinical care
  • Individualized goals and approaches for care
  • Quality of life
  • Resident choice
  • Safety
  • Regulations
• Governance and leadership
  • Leadership actively engaged with setting expectations and priorities, including:
    • Systematic approach to gather input from staff, residents, families and stakeholders
    • Adequate resources—time, money, others
    • Ongoing and consistent staff training
    • Accountability for process and results
    • Balance culture of safety and rights
    • Non-punitive culture
  • Responsibility and accountability through the QAPI Steering Team
    • Executive leadership
    • Medical oversight
    • QA/QAA/QAPI Coordinator
    • Interdisciplinary
    • Include front-line staff
  • QAPI needs to be adequately resourced
    • Mandatory QAPI staff training and orientation
    • Framework for QAPI
    • Reporting QAPI activities
    • Fair and just culture
  • Feedback, data systems and monitoring
    • Systems to monitor a wide range of care and services drawing from multiple sources:
      • Data from staff, residents, stakeholders and others
      • Use of goals and benchmarks
      • Ability to analyze, interpret and translate data into meaningful and actionable information
      • Using data to systematically prioritize and select performance improvement projects (PIPs) appropriate for the nursing home
    • Performance improvement projects (PIPs)
      • Conduct PIPs to improve care or services in areas relevant for your residents:
        • Gather information systematically to clarify issues and identify opportunities
        • Test and implement changes
        • Data
        • Identifying topics
        • Prioritizing and selecting PIPs
        • PIP charters
        • PIP teams
        • Documentation and communication
      • PIPs: identifying topics
        • Aspects of care occurring most frequently or affecting large numbers of residents
        • Diagnoses associated with high rates of morbidity or disability if not treated in accordance with accepted standards of care (evidence-based research/practices)
        • Issues identified from demographic and epidemiological data
        • Access to care post-discharge
        • Resident/family expectations
        • Regulatory requirements
        • Availability of data
        • Ability to impact the problem and available resources
        • Critical incidents
        • Near misses
        • Safety concerns
        • Survey deficiencies scope and severity
      • Systematic analysis and systematic action
        • Create real impact and long-lasting improvement as the result of QAPI through:
          • Taking into consideration all aspects of the organization when making changes
          • Addressing errors at the systems level rather than looking at an individual to blame
          • Linking outcomes of QAPI efforts to policies and procedures; staff orientation and ongoing education; performance expectations; and strategic planning
          • QAPI self-assessment every 12 months
          • Resident satisfaction
          • Family satisfaction
          • Staff satisfaction
          • Root cause analysis
            • Five whys
            • Flow charting
            • Fishbone diagram
            • Failure mode and effects analysis (FNEA)
            • Other

Each LTPAC facility, including a facility that is part of a multiunit chain, must develop, implement and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Phase 3 requires the reporting to the governing body. Also included in Phase 3 is the coordination of freedom of abuse and neglect with your QAPI plan and your inclusion of the Infection Preventionist in your QAA meetings.

Remember, it is always better for you to identify your own opportunities for improvement, rather than a surveyor. It will be in your best interest to share your QAPI information with the surveyor if you have already identified an issue they are looking at. In many cases, the surveyor will reduce the severity of the citation, and in some cases, they will not cite the facility at all.

With 2019 upon us, let’s make QAPI everyone’s New Year’s resolution. Your QAPI program should be used in creative and innovative ways rather than just as a regulatory requirement. Encourage innovation through collaboration with state agencies and take advantage of resources available through Advancing Excellence in America’s Nursing Homes.

 Do you have questions about QAPI, Phase 3 Requirements of Participation or other clinical challenges? Call Richter’s clinical education consultants at 866-806-0799 to schedule a free consultation.