QAPI is the coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving.
As a result, QAPI amounts to much more than a provision in Federal statute or regulation; it represents an ongoing, organized method of doing business to achieve optimum results, involving all levels of an organization.
Five ElementsWe developed a general framework for implementing a QAPI program in nursing homes, based on five key elements of effective quality management.
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 QAPI program should address all systems of care and management practices, and should always include clinical care, quality of life, and resident choice. 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.
The governing body and/or administration of the nursing home develops a culture that involves leadership seeking input from facility staff, residents, and their families and/or representatives. The governing body assures adequate resources exist to conduct QAPI efforts. 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. The Governing Body should foster a culture where QAPI is a priority by ensuring that policies are developed to sustain QAPI despite changes in personnel and turnover. Their responsibilities include, setting expectations around safety, quality, rights, choice, and respect by balancing safety with resident-centered rights and choice. The governing body ensures staff accountability, while creating an atmosphere where staff is comfortable identifying and reporting quality problems as well as opportunities for improvement.
The facility puts systems in place 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.
A Performance Improvement Project (PIP) 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. The facility conducts PIPs to examine and improve care or services in areas that the facility identifies as needing attention. Areas that need attention will vary depending on the type of facility and the unique scope of services they provide.
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.
The existing Quality Assessment and Assurance (QAA) provision at 42 CFR, Part 483.75(o) specifies the QAA committee composition and frequency of meetings in nursing facilities and requires facilities to develop and implement appropriate plans of action to correct identified quality deficiencies. This provision provides a rule but not the details as to the means and methods taken to implement the QAA regulations. CMS is now reinforcing the critical importance of how nursing facilities establish and maintain accountability for QAPI processes in order to sustain quality of care and quality of life for nursing home residents.
In March 2010, Congress passed the Affordable Care Act. The Provisions set forth at Section 6102 (c) of the Affordable Act provide the opportunity for CMS to mobilize some of the best practices in nursing home QAPI and to identify technical assistance needs in advance of a new QAPI regulation. The provision states that the Secretary (delegated to CMS) shall establish and implement a QAPI program for facilities that includes development of standards (regulations) and provision of technical assistance on the development of best practices in order to meet such standards. This new provision significantly expands the level and scope of required QAPI activities to ensure that facilities continuously identify and correct quality deficiencies as well as sustain performance improvement.
Beginning in September 2011, CMS launched a prototype QAPI program in a small number of homes. The demonstration provided us with best practices for helping facilities upgrade their current quality programs. We then combined results from the demonstration with consumer, provider, and stakeholder feedback to establish QAPI tools and resources.