In Phase 3 of the RoPs, facilities must develop, implement, and maintain an effective comprehensive, data-driven Quality Assurance Performance Improvement (QAPI) program. They must conduct distinct performance improvement projects, the number and frequency of which must reflect the scope and complexity of the facility’s services and available resources.

Improvement projects must include at least one annual initiative that focuses on high-risk or problem-prone areas identified through data collection.

The Centers for Medicare & Medicaid Services (CMS) has said that QAPI “emphasizes improvement that can not only elevate the care and experience of all residents, but also improve the work environment for caregivers. With QAPI, an organization will use a systems approach to actively pursue quality, not just respond to external requirements.”

A systems approach involves using data to identify quality problems and opportunities for improvement; building on residents’ own goals for health, quality of life, and daily activities; bringing meaningful resident and family voices in to the goal-setting and progress evaluation; involving caregivers in a shared quality improvement mission; developing performance improvement project (PIP) teams that have specific charters or directives; conducting root cause analyses to identify the reason for a problem or situation; undertaking systemic change to eliminate problems at their source; and establishing a feedback and monitoring system to ensure sustained change.

Some providers are ahead of the game in using systems approaches. As Karl Steinberg, MD, CMD, a California-based geriatrician and medical director, says, “Facilities that have been doing QAPI for a while, that have quality improvement as part of their DNA and day-to-day processes, have seen
a real acceleration in the way problems are identified and acted on.”

QAPI can be a powerful tool. For example, he says, “It has helped move the needle on antibiotic stewardship.” AHCA’s Sara Rudow agrees, noting, “QAPI has been around for a while. Phase 2 required a written QAPI plan. Phase 3 mandates the functional QAPI program itself. This is where the rubber meets the road.”

A QAPI plan should guide an organization’s performance improvement activities. This document, a framework for a data-driven program, focuses on metrics that mirror outcomes and quality. Not only is the QAPI plan designed to be a living, breathing guide for an organization, it also will be available for state agencies, surveyors, and CMS on request so they can track a facility’s efforts to address quality improvement.

Elements to a successful QAPI program include design and scope; government and leadership; feedback, data systems, and monitoring; PIPs; systematic analysis; and action. Be sure to have a strategy for collecting and using QAPI data. “If you don’t have data, you don’t know where you’re going. You need data to drive your improvement cycles,” says Amy Lee of Coretactics Healthcare Consulting. Data also enable providers to benchmark and compare their performance with others.

However, Lee notes, “You need to compare to data from reputable sources, such as state and national agencies and associations. This is the only way to truly assess where you are versus where you want to be.”

Data are important, but they are not the only way to identify opportunities for improvement. The team can track trends, but walking around is an important way to identify things the data don’t. For example, it is possible to observe that handwashing hygiene protocols aren’t being followed universally without this fact being significantly reflected in the data.

“QAPI is a team sport, and the name of the game is respect for every member of the team,” geriatrician Michael Wasserman says. ”That includes CNAs [certified nurse assistants] and housekeeping, two of the most important groups of staff who deliver the vast majority of the direct care. Brainstorming and root cause analysis are two key elements of QAPI that all nursing facility staff must be trained to excel in.

“There is also no place for fear-based leadership and management. The survey process already brings significant fear into a facility. Nursing homes beg for servant leadership.”