The Centers for Medicare & Medicaid Services (CMS) will soon be rolling out early prototypes of tools and resources in response to a requirement under the Affordable Care Act to establish Quality Assurance and Performance Improvement (QAPI) regulations for nursing homes.

The legislation requires CMS to provide quality assurance technical support to facility leaders on the development of “best practices” for continuous improvement of care outcomes. At the same time, the minimum data set (MDS) 3.0–based quality measure (QM) system is up and running, and providers can benefit greatly by linking these two programs together and enhancing their Quality Assurance (QA) Committee processes.
In order to be prepared and to create a coordinated response to these initiatives, facility leaders can focus on staying informed, evaluating their QA committee’s organization, boosting data management, tracking outcomes, and developing enhanced subcommittees.

Elements Of QAPI

Information about QAPI is posted on CMS’ QAPI website. It outlines the purpose, elements, and process of QAPI to assist facility staff in “developing and implementing appropriate plans of action to correct identified quality deficiencies.”

The focus of the regulation is to assist nursing home staff in improving their QA committee functions using the following five key elements:

Element 1: Design and Scope, which looks at an ongoing, comprehensive program that includes all facility departments, coupled with resident-driven care.

Element 2:
Governance and Leadership, which focuses on facilitating input from staff, residents, and families, as well as providing adequate resources for quality initiatives.

Element 3:
Feedback, Data Systems, and Monitoring, which draws data from all available resources and formalizes outcomes monitoring.

Element 4:
Performance Improvement Projects, which utilizes enhanced subcommittee work groups to accomplish goals.

Element 5:
Systematic Analysis and Systematic Action, which includes a process for in-depth identification and analysis of actual and potential care-system problems.

Stay Informed

CMS’ detailed instructions and data specifications for QMs are located on the CMS website. In order to stay informed about nursing facility-level data, access Certification and Survey Provider Enhanced Reporting (CASPER) online reports through the CMS welcome screen on the facility’s Quality Improvement and Evaluation Service (QIES) assessment submission process system for the MDS.

These reports can help staff track and trend outcomes and provide focus for the QA performance improvement processes. Useful reports include the Facility Quality Measure Report, Resident Level Quality Measure Report, and Monthly Comparison Report. Staying informed about national QMs as well as facility-specific data is essential to effective quality management.

Range Of Tools Available

In order to be well prepared for the QAPI rollout, staff should evaluate the QA committee process. An element often missing from committee function is representation from the MDS department. Many MDS coordinators do not provide reporting to the committee, or if they do, they rarely hear about the outcomes of the QA committee activities for MDS system improvement.

Since the MDS processes are vital to quality outcomes, it is important to take time to review the MDS processes and ensure accuracy and teamwork. Having a well-functioning MDS system and interdisciplinary team is crucial to positive outcomes.

When reviewing MDS systems, include supporting documentation, scheduled accuracy audits, validation and error messages, resource utilization group (RUG) trending data, and barriers to interdisciplinary teamwork for care area assessments and care planning.

When preparing for QAPI, facilities should consider how the data are tracked and trended and plan to boost data management.

Not everyone is a statistician, but a range of tools, from simple to advanced, is available to assist staff. Options include developing simple Excel spreadsheets or clinical software reports, or investing in QA Web-based tools that can help monitor facility outcomes.

A vivid example of tracking and trending was the drop in mood-enhanced RUGs at many nursing homes during the transition from the MDS 2.0 to the MDS 3.0. The MDS 2.0 utilized staff input for resident mood on 16 different coding items. In contrast, the MDS 3.0 employs the Patient Health Questionnaire (PHQ-9), the gold standard for gaining resident information. However, facility staff have not connected the decreased mood-enhanced RUG levels to the change in the MDS coding methodology.

If facilities experienced a decrease in mood-related RUGs, it may be due to not following prescribed interview practices. Sometimes clinicians can fall into one of two extremes, either not using the interview script and cue cards, or not using the resident assessment instrument (RAI) user manual-approved therapeutic interview techniques. When a facility has no mood-enhanced RUGs, it may be helpful to ask if there is a break in the facility system when it comes to adequately identifying mood. The data should be reviewed at the facility’s next QA committee meeting.

Be Proactive

Subcommittees and ad hoc workgroups are a dynamic, essential part of a QA committee’s actions. Outcomes-based care suffers when workgroups, such as a Restraint Committee, Falls Risk Review Team, or Psychotropic Use Committee, are not functioning well. It is vital to have strong, supportive leadership to move committee activities along and make necessary changes in facility practices.

At the end of every meeting ask, “What are we going to do?” “Who is going to do what?” and “When are we going to do it?” The most effective system improvements come from those closest to the issue, such as nurse assistants, dietary staff, and housekeepers. Think about the synergy that would be created if every staff member were involved in a QA subcommittee in some form or fashion.

Being proactive is always preferable to being reactive, so utilize the full breadth of the quality-improvement tools and processes.

The Centers for Medicare & Medicaid Services QAPI website resources:
Judi Kulus, NHA, RN, MAT, C-NE, RAC-MT, is vice president of curriculum development for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.