MDS Alert

Published on Tue Jul 16, 2013 PDF

Create vision and mission statements if you don’t already have them.

Defining the purpose, guiding principles and scope for Quality Assurance & Performance Improvement (QAPI) in your organization is a critical first step in creating a cohesive — and useful — QAPI Plan. Senior leadership, staff and even caregivers can help you to complete the following six steps.

1. Identify your organization’s vision statement. If you don’t already have one, create a vision statement for your organization that describes your inspiration and the framework for your strategic planning. The Centers for Medicare & Medicaid Services (CMS) gives the example of Good Samaritan Society’s vision statement, “To create an environment where people are loved, valued and at peace.”

2. Identify your mission statement. Again, if you don’t already have one, create a mission statement, which is different from your vision statement. Your mission statement should describe your organization’s purpose.

“The mission statement should guide the actions of the organization, spell out its overall goal, provide a path, and guide decision-making,” CMS explains. “It provides the framework or context within which the company’s strategies are formulated.”

Example: CMS gives the following example of a mission statement: “Meadowlark Hills is each resident’s home. We are committed to enhancing quality of life by nurturing individuality and independence. We are growing a value-driven community while leading the way in honoring inherent senior rights and building strong and meaningful relationships with all whose lives we touch.”

3. Develop a QAPI purpose statement. Your purpose statement should describe how QAPI will support your organization’s overall vision and mission.

Example: CMS also provides the following example of a purpose statement: “The purpose of QAPI in our organization is to take a proactive approach to continually improving the way we care for and engage with our residents, caregivers and other partners so that we may realize our vision [reference aspects of vision statement here]. To do this, all employees will participate in ongoing QAPI efforts which support our mission by [reference aspects of mission statement here].”

4. Establish your guiding principles. Your guiding principles should describe your organization’s “beliefs and philosophy pertaining to quality assurance and performance improvement,” CMS states. “The principles should guide what the organization does, why it does it and how.”

Although there’s no set number of guiding principles that you must have, you should use the five QAPI elements (see story on page 74) to help capture the principles for your organization, CMS recommends. And include any additional guiding principles that are important to your organization. The five QAPI elements include:

1.  Design & Scope

2.  Governance & Accountability

3.  Feedback, Data Systems & Monitoring

4.  Performance Improvement Projects (PIPs)

5.  Systematic Analysis & Systemic Action

5. Define the scope of QAPI in your organization. When defining the scope, outline what types of care and services your organization provides that impact clinical care, quality of life, resident choice, and care transitions, CMS instructs. Identify and list all care and service areas in all departments, and then determine how each area will use QAPI to access, monitor and improve performance on an ongoing basis.

6. Put it all together. Finally, pull all these elements (1 through 5 above) together and assemble them into a single document. You’ll use this document as a preamble to your QAPI Plan.

Source: CMS’s “Guide for Developing Purpose, Guiding Principles, and Scope for QAPI” http://cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/QAPIPurpose.pdf