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 The Quality Forum

How should we begin to address the requirements in the CMS proposed rule for participation in Medicare and Medicaid?

 

Andy Kramer, MD
I understand why the far-reaching proposed rule changes for skilled nursing facilities/nursing facilities (SNFs/NFs) might seem overwhelming. That said, a solution to addressing the wide range of issues in the proposed rule is actually embedded in the rule itself. Virtually all of the requirements in the rule can be addressed through robust Quality Assurance and Performance Improvement (QAPI): Develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on systems of care, outcomes of care, and quality of life (section 483.75).

Even while the rule is still in the “proposed” period, you can begin conducting comprehensive assessments of your resident care, engaging staff, and implementing all aspects of QAPI. If you start there, you will not only begin to address the QAPI regulations when they are final, but you will begin improving quality to meet all the standards of the revised rule.

Most of the concepts in the proposed rule are not new to the evolving expectations of care for persons needing post-acute or long term care. Between the content contained in QIS, the Affordable Care Act, questions being asked by hospitals or networks in your area, and growing expectations of residents and family, many of you have already begun elevating your game in many sections of the proposed rule. And if you haven’t, then the time to start is now.

QAPI has a long history in industry and a growing evidence base in health care, such that the Office of Inspector General recommended it in its February 2014 report to reduce adverse events in SNFs. The Centers for Medicare & Medicaid Services has been articulating QAPI approaches for SNFs/NFs in their “QAPI at a Glance,” among other publications, since 2012. Also, there are many other resources available to learn about the principles and implementation of QAPI programs.

QAPI can, and should, be an essential part of your evolving care. We have provided QAPI training, systems, and accreditation to nursing centers and have been able to demonstrate quality improvements in national studies of hundreds of nursing centers. With over 1,300 centers accredited based on meeting measurable standards for QAPI processes, we have observed struggling centers improve to at least average in survey performance. And with a comprehensive QAPI approach, we have observed statistically significant improvement in quality and occupancy among average and high-performing centers.

QAPI provides the ideal starting place to meet the new regulatory standard and growing expectations of long term and post-acute care providers. It can help you improve in a wide array of quality domains, and help you overcome varied challenges.

But QAPI is not just another program: It only works when it is adopted into an organization’s culture and daily routine, when you implement data-driven systems that accompany all of the care you provide, and when you engage all types of staff in the QAPI process. And when leadership exemplifies and commits to a QAPI philosophy throughout your organization.

Andy Kramer, MD, is a long term care researcher and professor of medicine who was instrumental in the design and development of the Quality Indicator Survey (QIS).
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