The Four Cs: QIS Methods For QAPI Made Simple
This column offers a bridge between Quality Assurance & Performance Improvement (QAPI) and QIS methods using what I now refer to as the four Cs of implementing QAPI. The four Cs are Comprehensive, Continuous, Coverage, and Corrective. When applied to implementation of QIS methods, these four standards provide a practical and measureable link between QIS methods and QAPI.
“Comprehensive” refers to the very first element of the QAPI program: It must be “comprehensive, dealing with the full range of services provided by the facility.” The six QIS assessments in combination evaluate virtually all aspects of health, quality of life, and daily activities included in QAPI and also identified as being of concern to residents. These QIS assessments both meet regulations and provide a comprehensive basis for a practical QAPI program.
“Continuous” is essential when using QIS methods for QAPI. “Developing a feedback and monitoring system to sustain continuous improvement” is one of the hallmarks of QAPI, referred to in the Centers for Medicare & Medicaid Services (CMS) survey and certification document entitled “QAPI at a Glance,” cited in prior columns.
A continuous process can be accomplished by conducting the full Stage 1 QIS assessments on a valid random sample of residents, alternating each quarter with the conduct of performance improvement activities for identified problems. I have seen many providers successfully implement QAPI systems using this type of alternating and continuous process.
‘The QAPI program must be comprehensive, dealing with the full range of services provided by the facility.’
“Coverage” in monitoring quality of care in a QAPI program requires measuring quality on a sample of residents that is sufficiently large and provides a valid representation of care in the facility. According to “QAPI at a Glance,” Element 3 requires Performance Indicators to “monitor a wide range of care processes and outcomes and review findings against benchmarks and/or targets the facility has established for performance.”
All too often, lack of a rigorous process for coverage of all residents in a facility can lead to misconceptions about how your facility compares with benchmarks, as well as whether you are meeting targets that you set. Sufficiently large random samples are essential to ensure you have a true snapshot of quality in your facility.
The original QIS statistical analysis clearly showed that a sample of 40 residents is the minimum necessary for a valid quality snapshot, unless a facility has less than 40 residents and then all residents should be included. Due to resource constraints, CMS slightly reduced these statistically valid sample sizes for surveys, but that would increase risk of errors in your QAPI program.
“Corrective” involves root cause analysis based on both QIS Stage 1 and Stage 2 data to identify the source of quality problems. A team of engaged facility staff can then be creative about how to address such problems, testing their approach through a Performance Improvement Project. If a solution is readily apparent based on good evidence, then it can be implemented facility wide. Regardless of the corrective action, measuring your impact is crucial, followed by feedback to all involved, often requiring changes in policies.
Our research has found that proper implementation of the four Cs standards works.