​The Centers for Medicare & Medicaid Services (CMS) recognizes that outcomes are not often monitored or analyzed correctly, which is why new rules are on the way to enforce quality tracking and management. The Quality Assessment and Performance Improvement (QAPI) initiative will soon be circulated by CMS as proposed rules for nursing homes.
According to a provision of the Affordable Care Act, CMS must “establish QAPI standards and provide technical assistance to nursing homes on best practices to meet these practices.”

Demonstration Underway

A demonstration project is currently underway, led by the University of Minnesota and Stratis Health, across 17 nursing homes in four states: Florida, Massachusetts, California, and Minnesota. The demonstration, which began in September 2011, will wrap up in early 2013, with regulations to follow.
According to Jennifer Lundblad, PhD, president and chief executive officer of Stratis Health, “This work will take nursing homes beyond compliance with rules; it will engage whole organizations in programs that aspire to ever-improving quality.”
CMS distributed a 20-minute questionnaire in June to more than 4,000 randomly selected nursing homes. According to the agency’s 2012 Nursing Home Action Plan, the results of the survey will be used to establish a baseline of QAPI practices in nursing homes and gather information on the challenges and barriers to implementing effective QAPI programs.
Also on tap for QAPI’s rollout are new technical assistance tools for nursing homes; resources for consumers, including training materials aimed at empowering “consumers and advocates in their roles in nursing home QAPI;” and tools and education for nursing home surveyors.
In addition, CMS will launch an online resource library that includes case studies, six self-study modules, and a quick reference guide for nursing homes.

The Five Elements Of QAPI

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Best Practices Support Efforts

CMS’ tinkering with quality improvement mandates is nothing new. According to F-tag 520, nursing homes are required “to have a committee and process in place to identify quality deficiencies, develop and implement plans to correct these deficiencies, monitor the effects of the changes, and make needed revisions to the plan in order to assure ongoing compliance.”
Surveyors may ask for minutes and documentation to show a facility is holding monthly quality assurance meetings, for example.
Today, many providers drive quality improvement compliance manually. Now with outcomes reporting, facility staff can automate monitoring and tracking and see real results of their programs.
QAPI takes continuous improvement one step further by providing the opportunity for CMS to mobilize best practices in nursing homes. It pushes facilities to continuously identify and correct quality deficiencies, as well as sustain performance improvement.
Providers will need powerful reporting capabilities to get them there. What they can see they can measure, and they can improve.

A QAPI Case Study

In a conference with the state ombudsman, the director of nursing (DON) heard that the organization is earning a reputation for discharging dissatisfied residents. The DON conducted an investigation to determine if the allegation was credible.
The first measure the DON selected for review is “Decline in Activities of Daily Living (ADLs),” which quickly led her to notice that during the past six months at least 37 percent of the residents discharged experienced a decline in at least one ADL, and 30 residents, or 14.8 percent of the residents discharged, suffered a decline in three or more ADLs. She knows that residents and their families expect an improvement, not a decline in ADLs.
Digging deeper into the detailed information from each of the measures, the DON confirmed that many of the residents that experienced ADL decline were also the same residents that did not meet their established goals, were displeased with care, and had transferred to other facilities.
The DON quickly shared the results of her analysis with the management team and confirmed the ombudsman’s allegation that the facility was not achieving its intended results. The team devised a prevention plan that incorporated the Interventions to Reduce Acute Care Transfers (INTERACT) II tools, aggressive rehab and restorative measures, and a new customer satisfaction survey.
They trained staff on all shifts, shared their new plan with the resident council and quality improvement committee and implemented the strategies with the goal to see significant reduction in ADL decline on discharge and a significant increase in customer satisfaction over the next quarter. 
They were able to use the same measures to monitor their results and maintain success once intended results were achieved.
Six Steps To Prepare For QAPI
1.      Use data at a high level to identify major areas of opportunity to prevent readmissions to the hospital.
2.      Analyze what the facility is doing right and where it can improve.
3.      Focus on one area of improvement.
4.      Develop quality improvement processes, training programs, and accountability measures. In parallel, start collecting data on the new processes to track improvement.
5.      Continuously alter internal processes and analyze the data to ensure continuous quality improvement and to demonstrate that the facility does not contribute to issues such as the rehospitalization of residents.
6.      Monitor, identify, and mitigate high-risk areas, such as falls and injuries, restraint use, pain, pressure sores, wandering, and weight loss.

Bottom Line Benefits

Continuous quality improvement monitoring and reporting has many uses. As a marketing tool, a quality improvement program can showcase a nursing home to family members and to hospitals that are examining facility readmission rates.
In addition, facilities that follow this path will meet the requirements of QAPI. So, while QAPI will soon become law, there’s a real opportunity to drive continuous improvement in every corner of a facility’s operations.
Efforts will have to be fact-driven, and reports derived from clinical systems will be mission-critical for success. 
Maria Arellano, MS, RN, is clinical designer, American HealthTech, Ridgeland, Miss. She can be reached at: (800) 489-2648.