Quality Assurance and Performance Improvement (QAPI) is a hot topic for long term care providers. The Affordable Care Act of 2010 introduced QAPI to the long term and post-acute care community. The statute requires nursing homes to have an acceptable QAPI plan within a year of the promulgation of the regulation.
While the regulations are still outstanding, the Centers for Medicare & Medicaid Services has provided initial direction and guidance on QAPI through its publication of “QAPI at a Glance.” This document provides an overview of QAPI features, details the five elements of QAPI, describes action steps for implementing QAPI principles, and provides tools and resources that nursing centers may use as they further develop their systems.

Concepts To Build On

The concepts that support QAPI are not all new. Continuous quality improvement has always been a focus of the profession and of the American Health Care Association/National Center for Assisted Living (AHCA/NCAL).

In 1996, to meet the growing demand from members for quality-focused programs, AHCA/NCAL developed its National Quality Award Program. The program criterion, based on the Malcolm Baldrige Health Care Criteria for Performance Excellence, encourages organizations to take a systematic approach to quality improvement.

Organizations apply for recognition at three increasingly rigorous and demanding levels, characterized as Bronze, Silver, and Gold. The criteria for each level require a more comprehensive and rigorous evaluation of the participating organization’s quality, service to residents and families, process improvement, and performance outcomes that are critical to success. Since the program’s inception, more than 3,000 centers have earned Bronze recognition, 350-plus have earned Silver, and 24 have earned Gold.

Organizations interested in using QAPI will benefit from applying the Quality Award Criteria because they are aligned with the QAPI principles. This article summarizes the key linkages among the first two QAPI features, as defined in “QAPI at a Glance,” and the criteria requirements at the Bronze, Silver, and Gold award levels.

Relationship To The Bronze

At the Bronze award level, applicants focus on basic elements underpinning the success of their organization, such as defining the vision, mission, and core competencies in which they excel. They also describe their principal customers, such as residents/patients and families, and their requirements for health care and other services. This aligns with QAPI’s emphasis on improvements that elevate the care and experience of all residents and enhance the work environment for caregivers.

This understanding of their customers’ desires and expectations helps organizations emphasize improvements that elevate the care and experience of all residents and improve the work environment for caregivers.

QAPI also encourages organizations to use a systems approach to actively pursue quality, not just respond to external requirements. At the Bronze level, applicants describe their main health care service offerings—the things most important to the success of their businesses—and also describe the key elements of their performance improvement system, including processes for evaluation and improvement of key organizational projects and processes.

Relationship To The Silver

At the Silver award level, applicants demonstrate the use of effective processes to enhance performance excellence. The systems approach used by senior leaders to pursue quality must also create an environment for resident and other customer engagement, for innovation and for high performance—processes essential to organizational sustainability.

The organization must develop a strategy with clear outcome-based objectives and goals to address strategic challenges and leverage strategic advantages and opportunities.

To enhance the work environment for caregivers, the organization must manage workforce (caregiver) capability and capacity to accomplish the organization’s work and maintain a supportive and secure work climate.

Furthermore, organizations must deliver health care services that achieve value for residents and other customers, achieve organizational success and sustainability, and innovate for the future. This provides both a look at the current environment and future opportunities.

Lastly, organizations are required to implement fact-based, systematic evaluation and improvement and show evidence of organizational learning, including meaningful, value-added change. These themes are critical to sustain the success of organizations as they face future challenges, such as aggressive competitors, additional government regulations, lower reimbursement rates, and more discerning and demanding customers.

Relationship To The Gold

At the Gold level, applicants demonstrate even more comprehensive systems for many of the same factors they put in place at the Silver level.

For example, senior leaders of top-performing organizations create the following:
■ An environment for performance leadership and organizational and personal learning;
■ A workforce culture that fosters engagement and delivers a consistently positive experience for residents and patients;
■ A culture of safety;
■ A motivated workforce to reinforce high performance; and
■A focus on action that will achieve the organization’s objectives, improve its performance, enable innovation, and create value for residents and patients.

As a part of strategy development, the organization creates an environment that supports innovation, identifies strategic opportunities, and decides which intelligent risks are worth pursuing.

Also at the Gold level, organizations address workplace environmental factors to improve health, security, and accessibility. They assess workforce engagement and satisfaction and take steps to improve.
From an operations perspective, organizations address each resident’s expectations through effective processes that explain health care service delivery and set realistic patient expectations. They also factor resident/patient decision making and preferences into the delivery of health care services.

In addition, top-performing organizations take effective steps to improve health care ser-vices and performance and reduce variability. To do this, organizations might implement approaches such as a Lean Enterprise System, Six Sigma methodology, ISO quality system standards, and Plan-Do-Check-Act methodology.

A Voice Of Experience

The linkages between QAPI and the AHCA/NCAL National Quality Award criterion are best explained through the words of an organization that has completed its journey through the Bronze, Silver, and Gold award levels.

Nina Willingham, senior executive director of Life Care Center of Sarasota, a 2013 Gold recipient, shared her experience with the Quality Award program and how it has helped her center prepare for the QAPI regulations.

“Our senior leadership team saw a dramatic improvement in our organizational results following the implementation of the AHCA/NCAL National Quality Award criteria,” she says. The Silver criteria and feedback taught the company the importance of identifying its strategic challenges, advantages, and opportunities as it focused on its strategy for the future, Willingham says.

“Planning became more deliberate, with measurable outcomes expected and evaluated. We considered new aspects for root cause analysis and the evaluation of our data in our problem solving. The resulting improvement in outcomes led to the implementation of meaningful changes for our residents, patients, and for the organization as a whole,” she says.

As Life Care Center of Sarasota moved into the Gold criteria, staff began to review their processes and systems more routinely, which ultimately led to meaningful change. They also focused on workforce engagement and satisfaction, which has a direct impact on the satisfaction and engagement of their customers, Willingham says.

“The implementation of QAPI will be almost seamless in our organization,” she says, as all the components are already in place, thanks to the Quality Award criteria and the feedback received through the application process.

Barbara Baylis, RN MSN, vice president of clinical services at Sava Senior Care Consulting, is a nurse executive accomplished in clinical and quality improvement systems. She serves as an AHCA/NCAL Quality Award Examiner as well as a member of the Quality Award Board of Overseers. Mark Blazey, PhD, is a leading expert in the application of the Baldrige criteria for performance excellence. Blazey is currently serving as a member of the AHCA/NCAL Quality Award Panel of Judges and is a member of the Quality Award Board of Overseers.