Health Information Compliance Alert

Don’t lag behind other facilities while drafting this ‘living document.’

It’s time to get started on defining your Quality Assurance & Performance Improvement (QAPI) program, if you haven’t already done so. The Centers for Medicare & Medicaid Services (CMS) expects you to stay on track in developing your QAPI plan.

Officially Phase 3 (the final phase) of the national QAPI roll-out began in fall 2012. And as part of Phase 3, CMS has released a slew of QAPI training materials and tools, in part based on the results of its QAPI nursing homes pilot demonstration.

Ask 4 Questions to Get Started

Your QAPI plan outline “assists you in achieving what you have identified as the purpose, guiding principles and scope for QAPI,” according to a presentation by Thomas E. Hamilton, director of the CMS Survey & Certification Group. It also “helps you to understand how QAPI will be used and integrated into your organization.”

Prepare: According to state Medicare Quality Improvement Organization Ohio KePRO, you can kick off your QAPI plan work by asking the following probing questions for team discussion:

1. What goals do we have for how QAPI will work?

2. How will QAPI be integrated into leadership’s accountability?

3. How will we strive to use data and performance improvement teams?

4. How will direct-care staff be involved in QAPI and Performance Improvement Projects (PIPs)?

After you’ve answered these questions, you can move forward with drafting your QAPI plan, which has the following nine major components.

1. Develop Your QAPI Goals

State the QAPI goals you’ve developed. “Goals should be specific, measurable, actionable, relevant, and have a time line for completion,” CMS states.

2. Identify the Scope

When you identify the scope, you’re essentially describing how you’ll use QAPI in all parts of your organization. Specifically, in your scope, you must describe how QAPI will:

• Be integrated into all care and service areas of your facility;
• Address clinical care, quality of life, and resident choice (i.e., individualized goals for care);
• Aim for safety and high quality with all clinical interventions while emphasizing residents’ autonomy and choice in daily life; and
• Utilize the best available evidence, including data, national benchmarks, published best practices and clinical guidelines, to define and measure goals.

3. Take 3 Steps to Create Governance & Leadership Guidelines

If you want to have a successful QAPI program, you must have specific individuals at your facility who are in charge of overseeing, carrying out and tracking your goals and practices. CMS recommends that you take the following three steps to develop your QAPI governance and leadership:

I. Determine how you’ll integrate QAPI into the responsibilities and accountabilities of top-level management and the Board of Directors.

II. Decide how you’ll adequately resource QAPI, including:

    a. Designating one or more individuals who will be accountable for QAPI leadership and coordination;

    b. Develop a plan for developing leadership and facility-wide QAPI training;

    c. Develop your plan to provide caregivers time, equipment and technical training as needed for QAPI;

    d. Decide how you’ll determine if you have adequate resources for QAPI; and

    e. Determine how caregivers will become and remain proficient with process improvement tools and techniques, as well as how you’ll assess caregivers’ level of proficiency.

III. Determine who will serve as your QAPI leadership, selecting a small group of individuals who will provide the backbone or structure for QAPI in your organization. Determine how this group will work together, communicate and coordinate QAPI activities, including (but not limited to) establishing:

    a.  A format and frequency for meetings;

    b.  Communication methods between meetings;

    c.  A designated way to document and track plans and discussions; and

    d.  How the group will report QAPI activities to the governing body, such as the Board of Directors or facility owner.

Strategy: “Institute an ‘open-door’ policy for all levels of leadership to establish presence and consistent availability for staff,” Ohio KePRO suggests. You should also make provisions to offer training and gain staff, resident and family member commitment for your QAPI initiatives.

4. Develop Procedures for Feedback, Data Systems & Monitoring

You also need to decide on the overall system you’ll put in place to monitor care and services, CMS states. You should draw on multiple data sources, such as adverse events, performance indicators, survey findings, complaints, and input from caregivers, residents, families and others.

And to develop your data procedures, work with your team to answer the following questions:

• What is your process for collecting this information?
• How will you analyze this information?
• How will you review findings against benchmarks and/or your established targets?
• How will you communicate this information? What types of reports will you use?
• Who will receive this information (i.e., executive leadership, QAPI leadership, resident/family council, caregivers, etc.)?
• In what format and how frequently will you disseminate this information?

5. Craft Guidelines for PIPs

You need to develop an overall plan for conducting Performance Improvement Plans (PIPs) to improve care and services, CMS instructs. Your plan should include how you’ll identify potential PIP topics, as well as how and when you’ll develop PIP charters.

Additionally, identify the criteria for prioritizing and selecting PIPs — “areas important and meaningful for the specific type and scope of services unique to the facility, requires a concentrated effort on a particular problem in one area of the facility or facility wide,” CMS explains.

Tip: “Get everyone involved in setting goals: residents, staff, family members, and board members,” Ohio KePRO recommends. But for each PIP, select a “change agent” — someone who will act as “a cheerleader and/or key facilitator of change in your facility.”

You may also want to assemble PIP teams, which may include interdisciplinary members, CMS notes. Decide how you’ll designate PIP teams and how the teams should document and report their work.

Decide on a process for documenting PIPs, including progress and lessons learned. Finally, determine your process for reporting PIP results, including who will receive this information, in what format, and how frequently.

6. Decide How You’ll Handle Systematic Analysis & Systemic Action

When you’re making a change to a specific system or process, understand that you could experience “unintended” consequences, CMS warns. Any change has the potential to create a broader impact than intended. So be sure you have a process to identify such consequences, which could be either positive or negative.

Also, determine how you’ll ensure that you’re addressing the underlying causes of issues, “rather than applying quick fixes that address symptoms only,” CMS advises. “Describe how you will monitor to ensure that interventions or actions are implemented and effective in making and sustaining improvements.”

Best bet: “Before initiating a change in the organization, meet with any staff and residents that will be impacted by the change in order to gain their support, buy-in and feedback,” Ohio KePRO recommends.

And to ensure that you’re tackling the underlying causes, CMS wants you to use the Root Cause Analysis (RCA), which begins with the “five whys”:

1. Why is this happening?

    a. Because X.

2. Why did X happen?

    a. Because Y.

3. Why did Y happen?

    a. Because Z.

4. Why did Z happen?

a: Because of the following root cause: __________.

7. Outline Your QAPI Communications

What good is gathering all this QAPI information if you don’t share it? CMS recommends that for your QAPI communications, you need to decide:

• Who will receive communications;
• How often you’ll send communications (frequency); and
• What format you’ll use for the communications.

8. How Will You Evaluate?

The purpose of evaluation is to help your facility to expand your skills in QAPI and increase its impact in your organization, CMS says. You should flesh out a process for assessing QAPI in your facility on an ongoing basis. Use the “QAPI Self-Assessment Tool” as a template for these regular assessments (www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/QAPISelfAssessment.pdf).

Strategy: “Set the expectation for leaders and staff to look for and share ideas for ways to grow and innovate,” says Ohio KePRO. Encourage clinical leaders to keep track of opportunities for improvements, and bring those to the QAPI team.

9. Establish Your Plan

Finally, label your plan with the current date and decide when you will revisit the plan. You should review your QAPI plan at least annually, CMS says. Also, determine how you’ll track any updates or changes to the plan. Remember, your QAPI plan is a “living document.”

Resource: You can view all of CMS’ QAPI tools at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/qapitools.html. To view Ohio KePRO’s QAPI companion guide, visit www.ohiokepro.com/shopping/pdfs/8772.pdf.