QAPI Implementation: Phase 3 CMS Requirements of Participation - PowerPoint Presentation

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QAPI Implementation: Phase 3 CMS Requirements of Participation

CMS Requirements of Participation

§

483.75 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

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

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

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

I

nfection Control

and

Prevention Officer

(11/2019)

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.

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.

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

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

Quality Impact On Reimbursement: Priceless

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

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

PDSA Cycle

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/

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: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/FiveWhys.pdf

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.

Goals

:

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.

Source: aadns-ltc.org

Helpful Links

QAPI Five Elements

https

://

www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/qapifiveelements.pdf

Performance Improvement Project Charter

https

://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/PIPCharterWkshtdebedits.pdf

Prioritization Worksheet for PIPs

https://

www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/PIPPriorWkshtdebedits.pdf

QAPI Goal Setting Worksheet

https://

www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/QAPIGoalSetting.pdf

PIP Inventory

https://

www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/PIPInventorydebedits.pdf

5 Whys

https://

www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/FiveWhys.pdf