Reg's Blog

Senior and Post-Acute Healthcare News and Topics

QAPI: What’s it all About?

Last week I spoke at two joint provider-surveyor training conferences regarding QAPI or more specifically, how it really works and what it looks like in “real-time”.  QAPI is a new survey requirement for SNFs; fully expanded to Quality Assurance, Performance Improvement.  Up until recently, SNFs were required by federal conditions of participation to have a Quality Assurance function, though the same requirement was ill-defined.  The definition evolving today is QAPI which really isn’t new or all that vogue.

For SNFs that have undergone JCAHO or CARF accreditation, you know what (or should know) QAPI is.  Its core is measurement of key resident care outcomes, tracking the same, and then improving care delivery processes to improve outcomes.  Key areas in SNFs today are Falls, Psychoactive Drugs, Wounds/Pressure Sores, ADL Decline, etc.  QAPI also integrates education, staff input and resident input/satisfaction as elements to identify and measure, performance and improvement.

My first encounter with QAPI (we didn’t call it that at the time) was 20 plus years ago when I was the CEO of a large post-acute/seniors housing system and we tackled JCAHO accreditation.  Briefly, back then, we developed and instituted a process of identifying key resident clinical outcomes, service outcomes, audit steps, and then process improvement/performance improvement teams.  We developed resident/family survey processes, tracking tools, and a committee structure to review performance, identify gaps in service, and conduct education and improvement projects.  Suffice to say, accreditation went famously as did numerous re-accreditation surveys throughout my career.

Since then, I have taken this same system to clients and continue to see similar results, when the system is used appropriately (principally, good compliance and good care outcomes).  It is a bit labor intensive at first but not expensive.  Any organization can use the methodology and modify accordingly, including using it as a core tool for planning, etc.

Below is my core framework for a functional QAPI program (call it whatever you want).  Like any recipe, customization is somewhat required based on the organization’s size, resident mix, etc.

Start

  • Create a simple Mission statement and policy for your committee. This should come from the highest level of management in the organization including the Board or the Ownership elements.
  • Identify a Committee including all elements/disciplines of care – Nursing admin and staff including CNA representation, Administration, Social Work, Dietary, Activities, Therapy, Medical Care/Medical Director, others as warranted.  Add a community member of two as well – an outsider with core health care knowledge is best.
  • Select a committee chair – should be someone who can effectively run a meeting and keep people accountable.
  • Develop a record keeping and minute taking function – a committee coordinator or secretary.
  • First tasks for the Committee: Decide a meeting structure, rules, frequency, roles, etc.
  • Identify, via the Committee, key elements to start monitoring – areas of weakness, opportunities for improvement, etc.

Next

  • Conduct and audit or assessment of the organization, utilizing an outside source to do the work.  I recommend a Mock survey as the best tool to use.  Have the findings reviewed by the Committee.
  • Develop a series of indicators based on the audit findings – a dashboard with benchmarks.  If Falls are identified as a weakness, start with the raw number.  Response times same thing (call light wait times).  Use actual data and unambiguous, easy to understand outcomes that are readily measurable.  I suggest only a few at the beginning and add more as the process progresses.
  • Assign improvement tasks to groups or sub-committees to review processes and recommend changes.  Find the “core” or “root cause” for non-satisfactory results.  Set a time-table for the analysis to be completed and recommendations made to the Committee.
  • Educate the organization staff, all levels, about what the Committee learned from the audit, what it is measuring and where the process is headed.  Be as open and as candid as possible without violating any confidentiality rules. Solicit input during the education sessions.

Up and Running

  • Plan on continual repetition of the above process.  Even when indicators achieve an ideal level of performance, keep monitoring.  Always review and always audit.
  • Integrate feedback loops – resident/family satisfaction surveys.  I suggest starting with paper surveys and focus groups.  I also encourage adding other point-in-time systems such as a customer comment “hotline” and e-mail box.
  • Produce visible results that are open to all staff – show how things work and how they improved.
  • Add focused audits on unique or separate issues highlighted by feedback loops.  Families may identify certain care or service elements that no one else has.
  • Schedule continuous outside audits – annual mock surveys, complaint mock surveys, billing audits, careplan audits, etc.  Run the findings back through the Committee.

Over time, the best practices I have seen focus primarily on education and repeat “testing” mechanisms.  It is impossible for an organization to audit its self so partnerships with an outside resource are critical; a trusted resource that is skilled and efficient (readers who need referrals here, please e-mail me at the address provided on the Author page).

Below and in conclusion, is my “must have” elements to create a really functional, viable QAPI program.

  • Top management engagement including if applicable, ownership or governance.  These folks must buy-in and must be stakeholders.
  • Broad committee representation, not necessarily filled with management personnel.  Front-line individuals must be part of the committee.
  • A methodology for integrating customer feedback.
  • A defined audit partner and a system of audits.  I like to see three routine audits – billing, documentation related to billing (especially Medicare/Medicaid) and compliance.
  • A record-keeping function/communication function.
  • A process that ties in policy review and approval, research, physician performance, education at the committee level (grand rounds, journal club review, etc.).
  • A process that can evolve and tie to compensation for senior management, gain sharing programs, and other reward systems.

My Power-Point presentation from the two-day training sessions is available to readers, for download, on the Reports and Other Documents page of this site.

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September 20, 2013 - Posted by | Skilled Nursing | , , , , , ,

2 Comments »

  1. Reg-
    For my first 30 years in health care, I served as a hospital administrator. My job included QA and then PI. Probably spent 14 years serving on the QA committees. Later became “certified” in the Juran model.. and my hospital won the national quality award.
    One other suggestion to help the SNF’s transition to QAPI (I still use QA) would be to ask a partner (and it should be a partnership) hospital if their QA staffer could help guide the process and develop the agenda. I have been using the lessons learned from my hospital days and they work very well. This could benefit both parties – especially if the agendas are similar. Also, the Medical Director could also contact the Chair of the local hospital QA committee and get guidance (and learn about concerns) as well.
    Thanks again for “thinking like an economist” as you scan the post-acute world.

    Comment by Lucas Snipes, FACHE | October 18, 2013 | Reply

    • Mr. Snipes;

      Right on! Most organizations, especially free-standing SNFs not affiliated with a large system (the bulk of the industry), would be greatly served by finding and using, logical partners as you suggest. There are other good inexpensive resources for Medical Directors such as AMDA (the American Medical Director Association). Thanks for the feedback, the input and being a regular reader!

      Reg

      Comment by Reg Hislop III | October 18, 2013 | Reply


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