Welcome to QAPI
The Quality Assurance and Performance Improvement (QAPI) initiative in nursing homes represents a step in moving the quality assurance and improvement y process from one based on assessment of inadequacies to one rooted in quality improvement. This approach is congressionally mandated in the Affordable Care Act. CMS provided notification of the QAPI initiative in an S&C letter, dated April 8, 2011, available on-line at http://www.cms.gov/surveycertificationgeninfo/downloads/SCLetter11_22.pdf.
What is QAPI: Five Defining Elements
QAPI programs are found in all health care settings that fall under the CMS Survey and Certification Group. The QAPI program developed for Nursing Homes will reflect 5 elements that are consistent across all regulated health settings: 1) Design and Scope, 2) Governance and Leadership, 3) Feedback, Data Systems, and Monitoring, 4) Performance Improvement Projects, and 5) Systematic Analysis and Systemic Action. These general categories will, however, have a somewhat different expression and application in each regulated setting. CMS is sensitive to the differences in the nursing home setting where residents live for long periods of time as their place of residence and the unique challenges related to quality of life, environmental quality, and individual choice.
Below is a beginning statement of the 5 QAPI elements, as applied to nursing homes. It is expected that these will be refined and modified as the program evolves.
Element 1: Design and Scope
A QAPI program must be ongoing and comprehensive, dealing with the full range of services offered by the facility, including the full range of departments. When fully implemented, the program should address clinical care, quality of life, resident choice, and care transitions. It aims for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents (or resident’s agents). It utilizes the best available evidence to define and measure goals. Nursing homes will have in place a written QAPI plan adhering to these principles.
Element 2: Governance and Leadership
The governing body and/or administration of the nursing home develops and leads a QAPI program that involves leadership working with input from facility staff, as well as from residents and their families and/or representatives. The governing body assures the QAPI program is adequately resourced to conduct its work. This includes designating one or more persons to be accountable for QAPI; developing leadership and facility-wide training on QAPI; and ensuring staff time, equipment, and technical training as needed for QAPI. They are responsible for establishing policies to sustain the QAPI program despite changes in personnel and turnover. The governing body and executive leadership are also responsible for setting priorities for the QAPI program and building on the principles identified in the design and scope. The governing body and executive leadership are also responsible for setting expectations around safety, quality, rights, choice, and respect by balancing both a culture of safety and a culture of resident-centered rights and choice. The governing body ensures that while staff are held accountable, there exists an atmosphere in which staff are not punished for errors and do not fear retaliation for reporting quality concerns.
Element 3: Feedback, Data Systems, and Monitoring
The facility puts in place systems to monitor care and services, drawing data from multiple sources. Feedback systems actively incorporate input from staff, residents, families, and others as appropriate. This element includes using Performance Indicators to monitor a wide range of care processes and outcomes, and reviewing findings against benchmarks and/or targets the facility has established for performance. It also includes tracking, investigating, and monitoring Adverse Events that must be investigated every time they occur, and action plans implemented to prevent recurrences.
Element 4: Performance Improvement Projects (PIPs)
The facility conducts Performance Improvement Projects (PIPs) to examine and improve care or services in areas that are identified as needing attention. A PIP project typically is a concentrated effort on a particular problem in one area of the facility or facility wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements. PIPs are selected in areas important and meaningful for the specific type and scope of services unique to each facility.
Element 5: Systematic Analysis and Systemic Action
The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. The facility uses a thorough and highly organized/ structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered. Additionally, facilities will be expected to develop policies and procedures and demonstrate proficiency in the use of Root Cause Analysis. Systemic Actions look comprehensively across all involved systems to prevent future events and promote sustained improvement. This element includes a focus on continual learning and continuous improvement.
Taken together, these elements represent a data-driven, evidence-based approach to quality improvement in nursing homes, whereby each facility will establish a process and program to conduct pro-active quality studies and ensure that the results of these efforts lead to sustained quality improvement. To respond to QAPI, nursing homes will need to strengthen their capacities for data collection and analysis and develop problem analysis strategies that can identify the causes of persistent or threatening problems and develop solutions to prevent them.
The requirement for Quality Assessment and Assurance under 483.75 (o) remains in force unless a change is made. Many facilities may decide to use its Quality Assurance Committee as a vehicle for implementation of QAPI.
Contract with University of Minnesota
CMS has contracted with the Division of Health Policy and Management at University of Minnesota (and its subcontractor, Stratis Health, the QIO for Minnesota) to provide assistance over the period of QAPI rollout. Since September 2010, the contractor is engaged in the following tasks:
ØAssisting CMS with ongoing outreach and communication to all stakeholders in the QAPI process, including providers, professions, consumer advocates, actual consumers, and regulators. CMS intends to develop QAPI drawing on input and feedback from the field, and also to develop resources that maximize the role of all stakeholders in the QAPI program.
ØAssisting CMS in convening and consulting a Technical Expert Panel for QAPI.
ØIdentifying and further developing tools that will assist facilities in implementing a QAPI process that conforms to the requirements of the 5 Elements as these evolve.
ØIdentifying and critiquing tools that could be used for concentrated Performance Improvement Projects related to specific areas of nursing home care. These include tools to measure processes and to measure outcomes.
ØDeveloping an on-line resource library with materials for providers, consumers, and regulators. This library will include the tools mentioned above, and other resource material including evidence related to QAPI, best practices, and case study examples.
ØDeveloping and testing training and technical assistance materials for all stakeholders in QAPI.
Ø Prior to national roll-out, developing, conducting, and evaluating a Demonstration Project in 20 nursing homes to help refine prototypes and models for QAPI in a wide range of facilities and to inform the national roll out.
A separate document is available to describe the QAPI Demonstration Project