Quality Assurance/Performance Improvement (QAPI) regulation was advanced as a part of the Affordable Care Act (ACA) of 2010, but the basic premise is not entirely new to long-term post-acute care (LTPAC) providers. The initiative expanded the existing Quality Assessment and Assurance (QAA) provision, thus “reinforcing the critical importance of how nursing facilities establish and maintain accountability…in order to sustain quality of care and quality of life for nursing home residents.” The Centers for Medicare and Medicaid Services has linked these initiatives to reimbursement, furthering the underlying tenet of value-based purchasing-paying for performance based upon resident-centric outcomes.

QAPI takes the QAA regulations further by incorporating root cause analysis and performance improvement guidelines. While Quality Assurance QA is the assessment of how well the facility is doing, Performance Improvement (PI) is the application of corrective actions and improvement of performance in a monitored and measured approach. The expectation is that LTPAC providers will continue to question and refine processes until optimal outcomes are met. The goal of QAPI is to improve processes in the delivery of care and ultimately improve patients’ quality of life, as well as overall quality of care.If you work in a Long Term Post-Acute Care (LTPAC) setting, you know that in our field the only constant is change. There is, however, one process that has been with us, in one form or another, for quite a long time. Until recently, Quality Assurance and Performance Improvement were two separate processes. These have since been streamlined into what we now know as the QAPI (Quality Assurance/Performance Improvement) process.  Let’s start off with the CMS definition of QAPI:

“QA is a process of meeting quality standards and assuring that care reaches an acceptable level.  Nursing homes typically set QA thresholds to comply with regulations.  They may also create standards that go beyond regulations.  QA is a reactive, retrospective effort to examine why a facility failed to meet certain standards.  QA activities do improve quality, but efforts frequently end once the standard is met.

“PI (also called Quality Improvement - QI) is a pro-active and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems.  PI in nursing homes aims to improve processes involved in health care delivery and resident quality of life.  PI can make good quality even better.”

The Five Elements of QAPI

QAPI is then further divided into five elements as defined by CMS below. Each of these five elements must be an integral part of your QAPI process in order to build a successful program.

Element 1: Design and Scope

A QAPI program must be ongoing and comprehensive, dealing with the full range of services offered by the facility, including the full range of departments. When fully implemented, the QAPI program should address all systems of care and management practices, and should always include clinical care, quality of life, and resident choice. It aims for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents (or resident’s agents). It utilizes the best available evidence to define and measure goals.

Element 2: Governance and Leadership

The governing body and/or administration of the nursing home develop a culture that involves leadership seeking input from facility staff, residents, and their families and/or representatives. The governing body assures adequate resources exist to conduct QAPI efforts. This includes designating one or more persons to be accountable for QAPI, developing leadership and facility-wide training on QAPI, and ensuring staff time, equipment and technical training as needed. The Governing Body should foster a culture where QAPI is a priority by ensuring that policies are developed to sustain QAPI despite changes in personnel and turnover.

Element 3: Feedback, Data Systems, and Monitoring

The facility puts systems in place to monitor care and services, drawing data from multiple sources. Feedback systems actively incorporate input from staff, residents, families, and others as appropriate. This element includes using Performance Indicators to monitor a wide range of care processes and outcomes and reviewing findings against benchmarks and/or targets the facility has established for performance. It also includes tracking, investigating, and monitoring Adverse Events that must be investigated every time they occur and action plans implemented to prevent recurrences.

Element 4: Performance Improvement Projects

A Performance Improvement Project (PIP) is a concentrated effort on a particular problem in one area of the facility or facility-wide; it involves gathering information systematically to clarify issues or problems and intervening for improvements. The facility conducts PIPs to examine and improve care or services in areas that the facility identifies as needing attention. Areas that need attention will vary depending on the type of facility and the unique scope of services they provide.

Element 5: Systematic Analysis and Systematic Action

The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. The facility uses a thorough and highly organized/ structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered. Additionally, facilities will be expected to develop policies and procedures and demonstrate proficiency in the use of Root Cause Analysis. This element includes a focus on continual learning and continuous improvement.

The Twelve Steps of QAPI

In order for any QAPI process to be effective, it is recommended that you use the twelve steps as developed by the Centers for Medicare and Medicaid Services (CMS).  To begin the QAPI process in your building, you should begin with step one of the twelve step process from CMS, and work your way through to step twelve. It may take anywhere from six to twelve months to get your program up and running. Remember, this is a process that requires a team approach to work through. Below is the basic framework you will need to build a successful QAPI process in your facility process.

1. Leadership Responsibility and Accountability - Support must come from the top/ Provide resources for your staff.
2. Develop a Deliberate Approach to Teamwork - Have a clear purpose/ have defined roles/ have a commitment to active engagement.
3. Take Your QAPI "Pulse" with Self-Assessment - Use the CMS self-assessment tool to determine areas you need to work on.
4. Identify Your Organization's Guiding Principles - This will unify the facility by tying the work being done to a purpose or philosophy.
5. Develop Your QAPI Plan - Tailor your plan to fit your facility/ Scope will be based on the unique services you offer.
6. Conduct a QAPI Awareness Campaign - Inform everyone about QAPI and your organization’s QAPI plan.
7. Develop a Strategy for Collecting and Using QAPI Data - Effective use of data will ensure that decisions are made based on full information.
8. Identify Your Gaps and Opportunities - Use this time to observe for any areas where processes are breaking down.
9. Prioritize Quality Opportunities and Charter PIP - Prioritize opportunities for more intensive improvement work.
10. Plan, Conduct, and Document PIPS - PIP teams should use a standardized process for making improvements.
11. Getting to the "Root" of the Problem - Determine all potential root cause(s) underlying the performance issue(s).
12. Take Systemic Action - Implement changes that will result in improvement of overall processes.

Setting your QAPI Goals

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.

If you are ready to institute QAPI in your organization and are not sure how to begin, or if you have begun the process, but are not sure of next steps contact Richter Healthcare Consultants – we will get you on the right path for QAPI.

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