​Nursing home providers will soon be required to implement a Quality Assurance and Performance Improvement (QAPI) program as proscribed by Section 6102(c) of the Affordable Care Act.
Although the Centers for Medicare & Medicaid Services (CMS) has not yet issued the final rule on the QAPI requirements,  providers should be preparing for implementation of a plan. Complying with emerging QAPI requirements provides an opportunity for nursing homes to engage workers and enhance resident outcomes and quality of life.
Ten long term care executives shared their experiences in implementing successful QAPI programs recently via a recent webinar and a roundtable on the topic.

QAPI Builds On QAA

The long term care industry is no stranger to change, especially in light of the many recent modifications in reimbursement, regulation, and reporting requirements. On the surface, it might seem that QAPI is another new requirement; however, as both CMS’ QAPI website (http://go.cms.gov/Nhqapi) and roundtable participants were quick to point out, QAPI actually builds upon the foundation of existing quality assessment and quality assurance (QAA) endeavors.
“Our industry has been looking at data to guide quality improvements, so QAPI’s really not new,” said
Becky LaBarge, vice president of clinical reimbursement for Tutera Group. “We have quality measures and software solutions that help us pull together data and identify problems for improvement. For many of us, we’re already doing QAPI.”
While many facilities have a solid grip on quality assurance, not all understand taking it to the next level of performance improvement. Wayne Brannock, vice president of clinical affairs for Lorien Health System, explained that there is a difference between QA and PI. “The harder part is to improve the process and generate improved performance outcomes,” he said.

QAPI Teams: The Secret Sauce

CMS’ official QAPI website features a useful guide, “QAPI at a Glance2,” which outlines Five Elements for Framing QAPI and recommends Twelve Action Steps. Two of these steps specifically address the importance of teams, with the need to create a leadership steering team and a QAPI work team.  
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Michelle Stuercke, chief nursing officer for NuCare Services, says one of the critical success factors behind her organization’s success with QAPI is leadership buy-in.  Stuercke suggests forming an executive steering committee that includes leaders from administration/corporate management, nursing, and medical directors. Stuercke emphasized the importance of the medical director’s involvement in QAPI. In fact, her organization recently changed the title of their medical director to “QAPI Medical Director.”
During the roundtable, participants also stressed the importance of interdisciplinary participation on QAPI work teams. LaBarge warns against thinking QAPI can be handled by just one person.
Brannock urged providers to resist the temptation to delegate this to the QA staff member, who might be the natural teacher on the team, but not the sole member.
Stuercke suggested taking the best members from previous QA initiatives to form the QAPI team. She contends that a good QAPI team is diverse. “An effective QAPI team can be likened to Pooh Corner, where one team member is the wise Owl, another is the effervescent Tigger, another is Eeyore, for example. They all come together to bring a well-balanced approach,” she said.

Data Driven Approach To Care

The core elements of QAPI include collecting data, analyzing areas for improvement, and implementing performance improvement plans (PIPs). While collecting and analyzing data are within the comfort zone for many facilities, some may struggle with identifying improvements.
Stuercke recommends that skilled facilities create a “no-fault” policy to help empower staff to identify areas for improvement without fear of reprisal. Stuercke also recommends plotting problem areas into a four-

quadrant chart, based on their risk levels and frequency of occurrence (see graphic, above). Some organizations might choose to focus on the high risk/high frequency areas for their PIPs.

Tips On Performance Improvement Plans

The QAPI At A Glance2 website provides a helpful PDSA (Plan-Do-Study-Act) model for PIP problem solving. As a veteran of several successful QAPI PIPs, Stuercke advises that the PIP focus should be on short-term, measurable goals, like reducing the number of facility-acquired pressure ulcers within a specific time frame. By focusing on short-term goals, the QAPI team is more likely to experience quick wins that encourage continual improvements.
Stuercke also suggested limiting the number of PIPs at any given time, explaining that “focusing on a couple PIPs prevents staff from being stretched too thin and sets them up for success.” 

Benchmarking And Referrers

Gathering facility performance data for QAPI programs can also be used to compare facilities against industry benchmarks. Brannock said he looks at CMS Quality of Care and Life Indicators and strives to be under benchmark. LaBarge suggested that readmissions are their key performance indicator. 
Comparisons to benchmark data can also help build credibility with referrers, according to Steve Arndt, consulting chief information officer at Shea Family. “Being able to show that your facility is below benchmark is key to convincing referrers that you’re going to help solve their problems.”

Root-Cause Analysis

Getting to the root cause behind each issue is critical for any PIP. Stuercke said that her QAPI PIP team used the fishbone technique to analyze root causes of pressure ulcers (see case study). The PIP team posted the resulting fishbone analysis in the break room, along with black markers, and asked other staff members to add their thoughts. “Asking for feedback from the organization can help drive QAPI engagement and better outcomes within the facility,” she said.

Communicating QAPI

Communication, both internally and with families, is another key QAPI step that involves sharing progress and soliciting input from various stakeholders. Stuercke shared some successful communication vehicles, such as team member T-shirts and pins that feature slogans like “Ask me about QAPI” or “I’m a QAPI star.”
Brannock suggested posting storyboards in elevators and featuring QAPI updates in the company newsletter, which have been successful communication approaches in his community.

Future Opportunities With QAPI

As centers get their arms around evolving from analyzing data to truly implementing performance improvement initiatives, the current emphasis is likely largely around patient outcomes. Falls, pressure ulcers, weight loss, and infections are likely candidates for QAPI focus in many nursing centers. Arndt believes that future QAPI opportunities will evolve beyond these outcome measures to include more emphasis on resident quality of life. 
Stuercke agrees. “Focusing on QAPI can lead to better care and better quality of life for your residents, with more engagement and job satisfaction for the caregiver team,” she said.
Cory Fosco is vice president of post acute care solutions for WoundRounds, sponsor of the QAPI roundtable discussion and the webinar.