1. QAPI Implementation: Phase 3 CMS Requirements of Participation

2. CMS Requirements of Participation §483
CMS Requirements of Participation § Quality Assurance and Performance Improvement
Phase 1 – November 28, 2016
Disclosure of information
Sanctions
Phase 2 – November 28, 2017
Initial QAPI Plan must be provided to State Agency Surveyor at annual survey
Phase 3 – November 28, 2019
Implementation of the QAPI Program (including PIPs)
Addition of the (ICPO) Infection Control Prevention Officer
Governing body responsible for QAPI Program

3. Overview: §483.75 QAPI Regulations
Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life.
Maintain documentation and demonstrate evidence of its ongoing QAPI program
The 5 QAPI Program Elements:
Design and Scope
Governance and Leadership
Feedback, Data Systems, and Monitoring
Performance Improvement Projects (PIPs)
Systematic Analysis and Systemic Action

4. Overview: §483.75 QAPI Regulations
The QAPI program is sustained during transitions in leadership and staffing
The QAPI program is adequately resourced, including ensuring staff time, equipment, and technical training as needed
QAPI program identifies and prioritizes problems and opportunities
Corrective actions address gaps in systems, and are evaluated for effectiveness
Clear expectations are set around safety, quality, residents’ rights, choices, and respect.
The governing body and/or executive leadership is responsible and accountable for ensuring that:
An ongoing QAPI program:
Is maintained and addresses identified priorities
Is sustained during transitions in leadership and staffing
Is adequately resourced, including ensuring staff time, equipment, and technical training as needed

5. QAA Committee
The QAA committee must meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI Program
Regularly review and analyze data collected to make improvements.
A facility must maintain a quality assessment and assurance (QAA) committee consisting at a minimum of
Director of nursing services
The Medical Director or his/her designee
At least three other members of the facility staff, at least one of whom must be the administrator, owner, a board member, or other individual in a leadership role
The Infection Control and Prevention Officer (11/2019)

6. What is the QAPI Plan?
A QAPI plan is the written plan containing the process that will guide the nursing home’s efforts in assuring care and services are maintained at acceptable levels of performance and continually improved.
The plan describes how the facility will conduct its required QAPI and QAA committee functions.
Each nursing home, including facilities which are a part of a multi-chain organization, should tailor its QAPI plan to reflect the specific units, programs, departments, and unique population it serves, as identified in its facility assessment.
If the facility, through its QAA committee, has identified and made a good faith attempt to
correct the same issue identified by the survey team during the current survey, the facility will
not be cited for QAA (it may however, still be cited with deficiencies related to actual or
potential issues at other relevant tags).

7. Key Components of the QAPI Plan
Tracking and measuring performance
Establishing goals and thresholds for performance measurement
Identifying and prioritizing quality deficiencies
Systematically analyzing underlying causes of systemic quality deficiencies
Developing and implementing corrective action or performance improvement activities
Monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed.
Vision, mission, purpose statements and scope

8. QAPI Plan I. QAPI Goals: What do we want to accomplish?
Goals should be specific, measurable, actionable and relevant
Need timeline for completion
II. Scope: How QAPI will be integrated into all aspects of care and services
III. Governance and Leadership: QAPI Structure
How responsibilities of top-level leadership are integrated into QAPI
Ensure that QAPI activities receive adequate resources
IV. Feedback, Data Systems, Monitoring
How data will be collected and analyzed

9. QAPI Plan V. Guidelines for PIPs
Criteria for prioritizing and selecting PIPs
Team formation
Report format
Documentation of PIP activity and findings
VI. Systematic Analysis and Systemic Action
Focus on ways to bring about improvement
VII. Communications
Methods of communicating what was learned
Who should receive the information?
VIII. Evaluation

10. Quality Impact On Reimbursement: Priceless
VBP
5Star
NHQI
QRP

11. Performance Improvement
The proactive, continuous study of processes with the intent of preventing or decreasing the likelihood of reoccurrence of issues through identification of opportunities for fixing underlying causes of persistent problems
Performance improvement activities must track medical errors and adverse events, analyze their causes, implement preventive actions and mechanisms that include feedback and learning

12. What is a PIP?
Performance Improvement Projects are concentrated effort on a particular problem identified in one area of the facility or facility-wide
All identified problems need attention but not all require a PIP
Select PIPs based on high-risk, high-volume and/or problem prone areas in your facility

13. PDSA Cycle

14. Root Cause Analysis & Contributing Factors
The team needs to clearly understand what went wrong in order to systematically find out why it went wrong.
Human factors: communication, training, distraction or bias
Rules, policies, or procedures: Was there a problem with current policies procedures? Are there no policies/procedures for addressing this particular issue?
Environment/Equipment
Barriers: Was this a breakdown in a barrier or a defensive mechanism that was intended to prevent the problem/

15. 5 Whys for Root Cause Analysis
Keep asking/answering until arrive at answer revealing incident would have been prevented if the identified causes and contributing factors had not been present
Source:

16. Problem: In June, Nursing Home X began to see an increase in pressure injuries among its high-risk residents (> 10%)
Root Cause Analysis:
Why?  Residents at risk for developing pressure injuries were not being identified on admission.
Why?  Complete body assessments were not always completed on admission. In other instances, residents at risk were not properly captured on the admission assessment.
Why?  Staff members completing the admissions were not very familiar with the facility’s admission process and protocol.
Why?  During the summer months, the facility was experiencing a surge of call-outs and multiple FT staff on vacation at the same time.

17. Goals: Interventions:
By August, 100% of new admissions will have a comprehensive pressure injury risk assessment completed.
New admissions who are determined to be high risk will be followed by the wound care nurse on a weekly basis and reviewed at the morning QA meeting.
By September, 100% of high risk residents will have the appropriate preventive devices in place.
The occurrence of pressure injuries in high-risk residents will be less than 5% by December.
Interventions:
Redesign admissions packet to include the comprehensive pressure injury risk assessment form, to be completed within a resident’s first 24 hours of admission
Require a half day in-service training for all nursing assistants and licensed nursing staff on assessment for pressure injury risk and prevention, including education on preventive devices.
Review all new admissions at the morning QA meeting.

18. Source: aadns-ltc.org

19. Helpful Links QAPI Five Elements
Performance Improvement Project Charter
Prioritization Worksheet for PIPs
QAPI Goal Setting Worksheet
PIP Inventory
5 Whys