MDS Alert

Published on Fri Jul 07, 2017 PDF

Make sure your QAPI documentation holds water to avoid noncompliance.

Further Quality Assurance and Performance Improvement (QAPI) regulations go into effect Nov. 28, 2017; be prepared for how these new requirements will affect your facility and care.

“Whether the facility is a single site or part of a chain, each LTC facility must develop, implement, and maintain a data-driven program focusing on indicators of outcomes related to care, and quality of life,” says Marilyn Mines, Rn, BC, RaC-Ct, Senior Managerat Marcum LLP in Deerfield, Illinois. The plan must be developed and presented to the survey team on the first annual survey after Nov. 28, 2017; total implementation will be expected in November 2019.

If you’re already familiar with QAPI, you know that QAPI is a plan formulated to identify, prioritize, manage, and prevent problems. It’s designed to be proactive, systemic, and data-driven, so your facility is better equipped to assess its performance delivering services, and deal with day-to-day issues, as well as emergencies. The QAPI plan must be shared with the survey team during each annual licensure survey, and it must be made available to any state or federal surveyors who request to see it, as well as to CMS.

Beware: Your facility needs documentation to prove that there’s a QAPI plan in place that meets requirements and is in compliance. Additionally, the plan must include all levels of the facility and must cover all services the facility delivers.

Bottom line: QAPI focuses on care, outcomes, and service; use it to improve the quality of your services and the quality of care for your residents. “This is the major distinction between Quality Assurance (QA) and QAPI. The latter is preventative and takes the entire facility into consideration to prevent problems that may occur secondary to processes. Unlike QAPI, QA is often reactive to problems and more often includes compliance with standards and a few specific disciplines,” Mines says.

Focus on Problem-Prone Areas

You and your team members know your facility’s strengths and weaknesses best. Base your QAPI program on your individual facility’s facility assessment. Consider your problem areas and identify the frequency, prevalence, and severity of your facility’s known weaknesses — those that are high-risk and involve high volumes of residents. With the sea change toward patient-centered care in both surveys and regulations, use the QAPI plan as an opportunity to consider how your potential areas affect resident health outcomes, as well as resident safety, autonomy, and choice. Use this opportunity to identify problem areas, but also set some aspirational goals for improvement.

Establish a Committee or Risk an F-tag

Include all staff in your facility in your QAPI plan — that means contracted providers and volunteers, too — to remain compliant. Surveyors can wield F520 (Quality Assessment and Assurance) to cite facilities that do not have a QAPI plan in place. This F-Tag is issued to facilities to trigger a formal review of policies and procedures (including policies, staffing, and staff training), according to the Centers for Medcaid and Medicare Services State Operations Provider Certification Manual.

“The language related to the QAPI requirement is in addition to the requirements for Quality Assessment and Assurance (QAA). Although there has been some additional verbiage related to the Phase 1 Requirements of Participation, (indicated by italics) the need for a QAA committee is still mandated. The committee must include the director of nursing, the medical director (or designee), at least three staff members (one of which should be an administrator, an owner, board member, or other person who holds a leadership role) and the infection control and prevention officer,” Mines says. The committee must meet quarterly, though more frequent gatherings are permitted.

Committee responsibilities include:

• Report on your facility’s QAPI-designated activities, implement your plan; make sure your facility is meeting all requirements in the QAPI rule
• Use QA activities to identify and evaluate issues or weaknesses
• Develop solutions to correct or resolve any issues or problems
• Evaluate Performance Improvement Projects that are designated as QAPI activities
• Review and analyze data
• Conduct medication reviews

Assess Your Program Performance

The QAPI program involves Performance Improvement Projects (PIPs), and requires the Root Cause Analysis (RCA). Make sure your QAPI plan has distinct areas marked for improvement. Your plan should be able to produce data that you or a team member can analyze to see where you can improve.

Use these tips, from Mines, to use and make QAPI data meaningful:

• Identify what you need to monitor
• Collect, track, and monitor measures and indicators
• Set goals, benchmarks, thresholds
• Identify gaps and opportunities
• Prioritize what will work to improve
• Use data to drive decisions

Enhance Communication and Teamwork

A good leader can do a lot to establish the direction and momentum of projects. Build staff enthusiasm, and involve residents and their families in your communications. But don’t get lost in disorganization; make sure that you and your team share common goals but have defined roles and tasks.

Implement PIPs

Get everyone on board with PIPs more easily by choosing topics or activities that pertain directly to residents and staff, and take a structured approach. Your goals should be establishing a plan, executing the plan, and then measuring, observing, and recording all changes.

Helpful PIP Teamwork Tools

• PIP Launch Checklist
• Plan-Do-Study-Act (PDSA) Cycle
• PIP Inventory
• Sustainability Decision Guide
• Utilize more specific tools for decision-making activities like brainstorming, affinity grouping, and multi-voting tools