Patti GaribaldiLast fall, the Centers for Medicare & Medicaid Services (CMS) released the Final Rule, a three-phased process that revises the requirements that long term/post-acute care centers must meet to participate in the Medicare and Medicaid programs. One of those requirements involves QAPI: Quality Assurance and Performance Improvement.

In phase one of the Final Rule, which started Nov. 28, 2016, nursing centers will continue to follow the current rules and practices while drafting and testing out a QAPI plan. Phase two, which begins Nov. 28, 2017, requires that each facility have a full QAPI plan developed and will be prepared to provide it to the surveying agent at the first standard survey after this date, and phase three requires full implementation of the QAPI process effective Nov. 28, 2019.

So what is the key takeaway here? If an organization has not begun the QAPI process, now is the time to get started.

The Metric Approach

Born out of the Affordable Care Act, QAPI is a data-driven, proactive approach to improving the quality of life, care, and services in nursing centers. Combining Quality Assurance (QA) and Performance Improvement (PI), QAPI encourages nursing centers to review their numbers (QA) and then identify a specific process for improvement (PI). Simple in theory, it is often not so simple in execution.

While the nursing care profession has long paid attention to Quality Impact Reports, QAPI asks facilities to go one step further in not only looking at the numbers, but inferring how to improve upon those numbers by engineering performance improvements. Facilities must also be able to demonstrate that they have implemented a QAPI plan and have documentation demonstrating compliance with the QAPI requirements.

A Case In Point

As a helpful example, consider that the urinary tract infection (UTI) rate at a given nursing center was 98 percent. Prior to QAPI, the course of action would have been to coordinate with the director of nursing services to solve the problem. However, QAPI encourages facilities to investigate on a deeper level and take a holistic approach.

In the case of this center, the information technology team started by looking at the data in order to verify its accuracy. During the evaluation, it found that the electronic health record (EHR) system was automatically prepopulating future assessment item sets with a UTI diagnosis, and staff members were not correcting the data prior to Federal Repository submission.

This inaccurate reporting resulted in the high infection rate and mistakenly insinuated that these residents had contracted the UTI while staying at the center. A simple fix of data modification and staff education on the EHR system brought the facility’s numbers down to below the 75 percent threshold, which was their initial goal.

The facility also reviewed the resident’s functional ability and staff performance surrounding toileting and infection control practices to rule out any other potential root cause issues that resulted in the Quality Measure outcome and coding inaccuracies.

This is one of many examples of how a QAPI program at a center can help enact wide-sweeping change. But, the first step in establishing a stellar QAPI program is pulling together a stellar team.

Build An A-Team

In the previous example, it was in fact the facility’s nurse management team that identified the reporting issue. Too often, centers look to their director of nursing services or their administrator to solve the problem.

In matters of patient health and safety, the root cause can often be found in unexpected places, which means it’s necessary to expand the team to include everyone from the facility’s housecleaning staff to the families of the patients. Even the patients themselves can provide valuable information in determining the root cause of many of the issues that plague nursing centers.

For instance, a series of falls from one particular patient could be attributed to everything from an increase in pain medication, to the layout of a room, to risk-taking behavior by the patient herself. Until multiple parties are aware of the Quality Measure (falls) at issue, the measure cannot be accurately addressed.

Establish Goals That Move The Needle

After a QAPI team is formed, the next step is to use data from the facility’s most recent Quality Measure Report to institute a set of goals for the facility. These focused goals may include anything from reducing unnecessary hospital readmissions to decreasing the percentage of short-stay residents using antipsychotic medications.

After the QAPI team has identified and clearly defined three or four attainable goals, it is up to the internal communication team to make all employees aware of them. This might be done through posted notices, group and individual education, or an internal email campaign with incentives tied to the goals being met.

Whichever method is used, it is important to ensure that the goals are clearly defined and that all facility employees, families, and patients understand what to look for in their day-to-day processes.

Get To The Root Cause

Once the QAPI goals have been relayed to all internal stakeholders, the team should start receiving a slew of insights. Adverse events must be investigated every time they occur, and systematic action plans implemented and documented to prevent recurrences and show the center’s compliance with the QAPI requirements.

Continually asking the question “why” can lead to answers that previously may have been overlooked. Whereas “What?” gives staff the contextual landscape of the adverse event, repeatedly asking the question “Why?” helps get the team to the root cause.

After a previous system has proven faulty, it’s important to scale any learnings companywide. These learnings, or best practices, might be proprietary to the organization, or they might be employed from multiple best practice sites, including the website.

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Patti Garibaldi, RN, BA, is director of clinical consulting at Consonus Healthcare, Milwaukie, Ore. She can be reached at