You finished your QAPI plan. Now it’s time for implementation.

Ellen Kuebrich, Chief Sales and Marketing Officer

May 1, 2018

Your QAPI plan was due November 28, 2017. But that was just the beginning. Now it’s time for implementation, and that’s where the rubber really meets the road. Yes, it’s true that QAPI won’t be audited in the survey process until November 2019 – but why wait? Use this time to activate your QAPI process and work out any kinks. After all, implementation is the most important aspect of QAPI.

Remember, the goals of QAPI are to:

  • Systematically measure performance across all areas of care and regulation
  • Identify opportunities for improvement
  • Address gaps in systems or processes
  • Develop and implement performance improvement plans (PIPs)
  • Continuously monitor effectiveness of interventions

So, let’s get started. We know QAPI must be systematic. Assess your Final Rule compliance and quality of care the same way every time—using defined measurements. Here are three easy steps to help guide you.

1. Create a list of categories to measure.
  • Take a look at your Facility Assessment, which outlines the types of services you provide for your resident population. Examples might include: special dietary needs, continence management, physical therapy. Place these categories on your list.
  • Also consider adding the general regulatory categories listed in the Final Rule. Why? You are required to measure areas such as Dignity and Resident Choice, which would not likely be listed in your Facility Assessment as a service you provide.
2. Now, decide how you will collect data on the categories above.

You must collect data on each of these categories from multiple sources. The following are some data sources to consider:

  • Resident and family feedback
  • Staff feedback
  • Structured observations of resident care
  • MDS
  • Policy review and execution
  • QMs
  • Facility-level audits
  • Nursing Home Compare data
3. Determine a benchmark for each category.

If your numbers fall below these benchmarks, you will need to look into these areas in order to improve performance during your QAPI meetings. You may even need to create a performance improvement project (PIP) to address some of these issues if they are particularly high volume, problem prone, or high risk.
Look to these resources when determining your benchmarks:

  • Existing industry benchmarks
    • State QM performance
    • Five Star quality ratings
  • Utilizing existing standards and research, create your own benchmarks based on:
    • Acceptable count of negative/positive results
    • Acceptable percentage of negative/positive results
    • Adverse/never events (Any negative results are cause for PI)

Starting to implement QAPI now will give you the advantage of finding any holes in your process before a surveyor does. This way, you’ll know you have the resources and process you need to effectively implement QAPI come Phase 3.

 

Three Phases of QAPI