HCAD 635 long term

Week 5 Assignment 2: AIT Facility Rounding Simulation

Course Objectives for Assignment:

Differentiate the diverse organizations that comprise the long-term care service delivery system including the future challengesfaced by these organizations in the context of long-term care administration.

  • Apply management theory, concepts, and models to examine ethical best practices in long-term care administration and to foster performance excellence.
  • Develop effective written communication skills as applied to the course objectives in long-term care administration.
  • Assignment Instructions – You will complete this week’s task by submitting:

  • A completed AIT QAPI Leadership Rounding Guide
  • Attach Your CMS Comparison Report as from the CMS Compare Site in PDF format/or JPeg format
  • Include APA 7th Edition Reference Page
  • Select a Facility: Select one SNF or HHA CMS 2567 Report from the Options Provided Below. (Note: These are actual SNFs and HHAs CMS 2567 Reports, accessed from the CMS Websites, which consumers, providers, administrators, and the general public have access to in real life.)

    Skilled Nursing Facility (SNF) Survey 2567 Report Options:

  • SNF 1 – CMS Form 2567 Report: Park Point Annual Survey Illinois SNF Provider PDF
  • SNF 2 – CMS Form 2567 Report: Traymore Nursing Center Texas SNF Provider PDF
  • Home Health Agency (HHA) Survey 2567 Report Options:

  • HHA 1 – CMS Form 2567 Report: Pruitt HHA Health Survey – Georgia HHA Provider PDF
  • HHA 2 -CMS Form 2567 Report: Above & Beyond Homecare Complaint Survey – Indiana HHA Provider PDF
  • Identify 2 Citations & Conduct Leadership Rounds:Select on two deficiencies (SNF F-Tags or HHA G-Tags) presented your selected CMS 2567 Report.Apply your two tags (citations/deficiencies) to the report questions, each citation/deficiency will be part your focus for this assignment.You will act as though you are physically rounding your SNF or HHA, identifying potential issues based on your deficiencies, to address the questions in the guide. Access the CMS Compare Site: Include the CMS Compare Site Information with Your Report as a PDF or JpegCMS Comparison Website: Main Page Search for Your Selected SNF or HHA. Complete Section 1 of the AIT QAPI Leadership Rounding Guide, Using the Information from the CMS Compare Site on Your Selected SNF or HHA. Compare Your Selected SNF or HHA to Two Other SNFs or HHA providers. (Note: Up may select up to a 200 mile radius, if desired.)Include the CMS Compare Site Information in Your Report as an PDF Attachment or as a Jpeg Attachment. (Note: See example below provided in the resources section.)APA 7th Edition Formatting:Include a minimum of three APA 7th Edition formatted references with correlating in-text citations.All scholarly references must be from the last five years.Use the SNF Template, if Selecting a SNF CMS 2567 Report – Complete Each Item in the Guide and Submit this Guide:SNF Template: AIT QAPI Leadership Rounding Guide (Word Document)Use the HHA Template, if Selecting a HHA CMS 2567 Report – Complete Each Item in the Guide and Submit this Guide:HHA Template: AIT QAPI Leadership Rounding Guide (Word Document)

    Resources to Assist You with the Report:

    QAPI Guide from CMS:

    CMS QAPI at a Glance: Application for Regulatory Compliance PDF

    HHA G-Tags:

    CMS Information on HHA G-Tags List and SOM -Updated 2018 PDF

    (Note: Once you open the document, you will need to scroll down to view the information on the G Tags, as this document offers additional survey details.)

    SNF F-Tags with SNF Scope and Severity Overview:

    CMS SNF F Tags List – Updated June 2021 PDF

    and

    CMS Scope & Severity Grid Updated 2018 PDF

    State Operations Manuals:

    State Operations Manual SNF Updated 2018 PDF

    HHA State Operations Manual Updated 2020 PDF

    General Resources:

    QIO: Nursing Home Resources Landing Page

    CMS: Regulations and Guidance Landing Page

    Rounding Simulation Tips:

    Act as though you are physically conducting rounds at your SNF or at your HHA, which would include visiting patients’ homes by conducting rounds with other members of your leadership team.

    Visualize your SNF and your SNF’s organization as though you were walking through the facility or visualize your HHA’s organization while visiting patients’ homes as though you were visiting each patient and/or client.

    Review your citations (F-Tags or G-Tags) from your CMS 2567 Report as you tour your SNF or HHA.

    Assess what you can do as a leader, and as a leadership team, to assist with preventing these citations from occurring in the future, using a QAPI approach.

    Review the F-Tag or G-Tag information as you examine how to prevent, reduce, or eliminate these types of deficiencies in the future. Your thoughts will be reflected in the questions presented in the AIT QAPI Leadership Rounding Guide.

    Tips for Conducting Your Research for Your Citations & Ways to Assess Your SNF or HHA QAPI and Leadership Rounding Approaches:

    Identify best practices from scholarly publications located in the UMGC Library or through professional organizations.

    Research your citations, learn more about them, and explore different resources that may assist you by reviewing QAPI processes, the state operations manual, CMS websites, or studies that may support you in addressing your citations.

    Visit the AHRQ’s website for more information on the QAPI processes and identify some of their tools for quality improvement.

    Seek online examples regarding plan of corrections; explore survey preparation processes; access your selected online state’s licensure page or regulatory page; review potential mock survey information; identify checklists on the issues; or visit other public and private regulatory websites as you research and assess your citations.

    Transforming the lives of nursing home residents through continuous
    attention to quality of care and quality of life
    at a Glance:
    A Step by Step Guide to Implementing Quality
    Assurance and Performance Improvement (QAPI)
    in Your Nursing Home
    Table of Contents
    Introduction: Why This Guide?����������������������������������������������������������������������������������������������������������1
    QAPI Builds on QA&A���������������������������������������������������������������������������������������������������������������������3
    QAPI Features����������������������������������������������������������������������������������������������������������������������������������4
    Illustrating QAPI in Action�����������������������������������������������������������������������������������������������������������������4
    Five Elements for Framing QAPI in Nursing Homes�����������������������������������������������������������������������������7
    Action Steps to QAPI������������������������������������������������������������������������������������������������������������������������9
    STEP 1: Leadership Responsibility and Accountability������������������������������������������������������������������������� 9
    STEP 2: Develop a Deliberate Approach to Teamwork��������������������������������������������������������������������� 10
    STEP 3: Take your QAPI “Pulse” with a Self-Assessment��������������������������������������������������������������������� 12
    STEP 4: Identify Your Organization’s Guiding Principles�������������������������������������������������������������������� 12
    STEP 5: Develop Your QAPI Plan�������������������������������������������������������������������������������������������������� 13
    STEP 6: Conduct a QAPI Awareness Campaign����������������������������������������������������������������������������� 13
    STEP 7: Develop a Strategy for Collecting and Using QAPI Data������������������������������������������������������� 15
    STEP 8: Identify Your Gaps and Opportunities�������������������������������������������������������������������������������� 16
    STEP 9: Prioritize Quality Opportunities and Charter PIPs������������������������������������������������������������������ 16
    STEP 10: Plan, Conduct and Document PIPs����������������������������������������������������������������������������������� 17
    STEP 11: Getting to the “Root” of the Problem�������������������������������������������������������������������������������� 18
    STEP 12: Take Systemic Action���������������������������������������������������������������������������������������������������� 19
    QAPI Principles Summarized�����������������������������������������������������������������������������������������������������������20
    How to Learn More������������������������������������������������������������������������������������������������������������������� 21
    QAPI Tools and Related Resources���������������������������������������������������������������������������������������������������22
    Appendix A: QAPI Tools�����������������������������������������������������������������������������������������������������������������25
    QAPI Self-Assessment Tool ���������������������������������������������������������������������������������������������������������� 26
    Guide for Developing Purpose, Guiding Principles, and Scope for QAPI��������������������������������������������� 31
    Guide for Developing a QAPI Plan����������������������������������������������������������������������������������������������� 34
    Goal Setting Worksheet ������������������������������������������������������������������������������������������������������������ 37
    Appendix B: QAPI Definitions���������������������������������������������������������������������������������������������������������39
    Disclaimer: Use of this guide or its tools is not mandated by CMS for regulatory compliance.
    Introduction: Why This Guide?
    As you use
    this guide, please
    take note of the
    following:
    •• The term
    “Caregiver”
    refers to
    individuals who
    provide care in
    nursing homes.
    •• The tool
    icon:
    indicates
    that there is
    a QAPI tool
    associated with
    that concept in
    Appendix A of
    this guide. Click
    the tool icon
    to access the
    corresponding
    QAPI tool.
    •• Words
    underlined
    in bold blue
    are defined
    in Appendix
    B. Click the
    underlined
    word icon to be
    automatically
    linked to the
    definitions listed
    in Appendix B.
    Effective Quality Assurance
    and Performance Improvement
    (QAPI) is critical to our national
    goals to improve care for individuals
    and improve health for populations,
    while reducing per capita costs in our
    healthcare delivery system. We have
    the opportunity to accomplish these
    goals in each local nursing home
    with the aid of QAPI tools and the
    establishment of an effective QAPI foundation. Nursing homes are in the best
    position to assess, evaluate, and improve their care and services because each
    home has first-hand knowledge of their own organizational systems, culture,
    and history. Effective QAPI leverages this knowledge to maximize the return
    on investments made in care improvement. This QAPI at a Glance guide is a
    resource for nursing homes striving to embed QAPI principles into their day to
    day work of providing quality care and services.
    Nursing homes in the United States will soon be required to develop QAPI
    plans. QAPI will take many nursing homes into a new realm in quality—a
    systematic, comprehensive, data-driven, proactive approach to performance
    management and improvement. This guide provides detailed information about
    the “nuts and bolts” of QAPI. We hope that QAPI at a Glance conveys a
    true sense of QAPI’s exciting possibilities. Once launched, an effective QAPI
    plan creates a self-sustaining approach to improving safety and quality while
    involving all nursing home caregivers in practical and creative problem solving.
    Your QAPI results are generated from your own experiences, priority-setting,
    and team spirit.
    The Affordable Care Act of 2010 requires nursing homes to have an
    acceptable QAPI plan within a year of the promulgation of a QAPI regulation.
    However, a more basic reason to build care systems based on a QAPI
    philosophy is to ensure a systematic, comprehensive, data-driven approach
    to care. When nursing home leaders promote such an approach, the results
    may prevent adverse events, promote safety and quality, and reduce risks
    to residents and caregivers. This effort is not only about meeting minimum
    standards—it is about continually aiming higher. Many nursing homes are
    already demonstrating leadership in developing and implementing effective
    QAPI plans.
    We encourage nursing home leaders to use QAPI at a Glance as a reference
    as they examine their own activities in the context of the goals and expectations
    for QAPI and sustainable improvement. You can also visit the QAPI website at
    http://go.cms.gov/Nhqapi, which we will update regularly as new materials
    and resources become available.
    QAPI at a Glance
    |
    1
    WHAT IS QAPI?
    QAPI is the merger of two complementary approaches to quality management, Quality Assurance (QA)
    and Performance Improvement (PI). Both involve using information, but differ in key ways:
    •• QA is a process of meeting quality standards and assuring that care reaches an acceptable level.
    Nursing homes typically set QA thresholds to comply with regulations. They may also create standards
    that go beyond regulations. QA is a reactive, retrospective effort to examine why a facility failed to
    meet certain standards. QA activities do improve quality, but efforts frequently end once the standard
    is met.
    •• PI (also called Quality Improvement – QI) is a pro-active and continuous study of processes with the
    intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing
    new approaches to fix underlying causes of persistent/systemic problems. PI in nursing homes aims
    to improve processes involved in health care delivery and resident quality of life. PI can make good
    quality even better.
    The chart below was adapted from the Health Resources and Services Administration (HRSA)1 and shows
    some key differences between QA and PI efforts.
    QUALITY ASSURANCE
    PERFORMANCE IMPROVEMENT
    Motivation
    Measuring compliance with
    standards
    Continuously improving processes to
    meet standards
    Means
    Inspection
    Prevention
    Attitude
    Required, reactive
    Chosen, proactive
    Focus
    Outliers: “bad apples”
    Individuals
    Processes or Systems
    Scope
    Medical provider
    Resident care
    Responsibility
    Few
    All
    QA + PI = QAPI
    QA and PI combine to form QAPI, a comprehensive approach to ensuring high quality care.
    QAPI is a data-driven, proactive approach to improving the quality of life, care, and services in nursing
    homes. The activities of QAPI involve members at all levels of the organization to: identify opportunities for
    improvement; address gaps in systems or processes; develop and implement an improvement or corrective
    plan; and continuously monitor effectiveness of interventions.
    1
    U.S. Department of Health and Human Services, Health Resources and Services Administration. Quality Improvement adapted from
    http://www.hrsa.gov/healthit/toolbox/HealthITAdoptiontoolbox/QualityImprovement/whatarediffbtwqinqa.html
    QAPI at a Glance
    |
    2
    WHY QAPI IS IMPORTANT
    Once QAPI is launched and sustained, many people report that it is a rewarding and even an enjoyable
    way of working. The rewards of QAPI include:
    •• Competencies that equip you to solve quality problems and prevent their recurrence;
    •• Competencies that allow you to seize opportunities to achieve new goals;
    •• Fulfillment for caregivers, as they become active partners in performance improvement; and
    •• Above all, better care and better quality of life for your residents.
    Being new at QAPI is like being a new driver…
    A new driver must coordinate so many actions and
    pay attention to so many cues that driving feels
    awkward, confusing, and almost impossible at first.
    Yet when it suddenly comes together, it becomes
    automatic and ushers in new horizons for that
    driver. In the same way, once you get some QAPI
    experience, it will come together, seem automatic,
    and will take you to new places in your quality
    management.
    NEW
    DRIVER ON
    BOARD
    In the following pages, we discuss QAPI and its inter-related components (QA and PI), and emphasize
    how it can readily fit into your nursing home. Launching QAPI is not necessarily easy or quick, but it has a
    compelling logic and it is feasible for all nursing homes, beginning wherever your nursing home is right now.
    QAPI Builds on QA&A
    QAPI is not entirely new. It uses the existing QA&A, or Quality Assessment and Assurance regulation
    and guidance as a foundation. Maybe you recognize some of the statements below as things you are
    already doing:
    •• You create systems to provide care and achieve
    compliance with nursing home regulations.
    •• You track, investigate, and try to prevent
    recurrence of adverse events.
    •• You compare the quality of your home to that
    of other homes in your state or company.
    •• You receive and investigate complaints.
    •• You seek feedback from residents and front-line
    caregivers.
    •• You set targets for quality.
    •• You strive to achieve improvement in specific
    goals related to pressure ulcers, falls, restraints,
    or permanent caregiver assignment; or other
    areas; (for example by joining the Advancing
    Excellence Campaign).
    •• You are committed to balancing a safe
    environment with resident choice.
    •• You strive for deficiency-free surveys.
    •• You assess residents’ strengths and needs to
    design, implement, and modify person-centered,
    measurable and interdisciplinary care plans.
    You are already partly there. All of this is part of QAPI.
    QAPI at a Glance
    |
    3
    QAPI Features
    “Not all change is
    improvement, but all
    QAPI includes components that may be new for many nursing homes. It
    emphasizes improvements that can not only elevate the care and experience of improvement is change.”
    all residents, but also improve the work environment for caregivers. With QAPI,
    your organization will use a systems approach to actively pursue quality, not
    just respond to external requirements. Look at the following list of QAPI features.
    How many are you already using?
    Donald Berwick, MD
    Former CMS Administrator
    •• Using data to not only identify your quality problems, but to also identify other opportunities for
    improvement, and then setting priorities for action
    •• Building on residents’ own goals for health, quality of life, and daily activities
    •• Bringing meaningful resident and family voices into setting goals and evaluating progress
    •• Incorporating caregivers broadly in a shared QAPI mission
    •• Developing Performance Improvement Project (PIP) teams with specific “charters”
    •• Performing a Root Cause Analysis to get to the heart of the reason for a problem
    •• Undertaking systemic change to eliminate problems at the source
    •• Developing a feedback and monitoring system to sustain continuous improvement
    Illustrating QAPI in Action
    The scenario below illustrates how a QAA committee might develop a plan of correction in response to
    deficiencies identified during an annual survey. The example shows how facilities often react to regulatory
    non-compliance with a “band-aid” approach. The activities described are representative of the types of
    plans of corrections that are often submitted to Survey Agencies and accepted. It addresses the immediate
    problem, and then takes steps assumed to prevent recurrence of the problem.
    Scenario 1
    The Issue: Your nursing home, Whistling Pines, received deficiencies during their annual survey
    because residents had unexplained weight loss, and weights and food intake were not accurately and
    consistently documented.
    What Whistling Pines did: The QA Committee developed a Plan of Correction, which contained the
    following components: Re-weighing all residents, and updating the weight records for the affected
    residents; in-servicing the Nursing Department on obtaining and documenting weights and intake. They
    stated they would conduct 3 monthly audits of weight and intake records, with results reported to the
    QA committee.
    This plan of correction was accepted by the State Survey Agency.
    The next case study shows a facility with effective QAPI systems in place to identify issues proactively,
    before trends become serious problems. A nursing home chooses a limited number of PIP projects in
    “high-risk, high volume, problem-prone” areas.
    QAPI at a Glance
    |
    4
    Scenario 2
    The Issue: During the monthly QAPI meeting at Whistling Pines, staff discovered a trend of unexplained
    weight loss among several residents over the last two months. During the discussion, a representative
    from dining services noted that there had been an increase in the amount of food left on plates, as well
    as an increase in the amount of supplements being ordered. Although other issues and opportunities
    for improvement were identified at the meeting, the QAPI Steering Committee decided to launch a
    Performance Improvement Project (PIP) on the weight loss trend because unexplained weight loss posed
    a high-risk problem for residents.
    What Whistling Pines did: The QAPI Steering Committee chartered a PIP team composed of a certified
    nursing assistant (CNA), charge nurse, social worker, dietary worker, registered dietitian, and a nurse
    practitioner. The team studied the issue, and then performed a root cause analysis (RCA) to help direct
    a plan of action. The RCA revealed several underlying factors, which included:
    •• No process existed for identifying and addressing risks for weight loss such as dental condition,
    diagnosis, or use of appetite suppressing medications;
    •• No system existed to ensure resident preferences are honored;
    •• Staff lacked an understanding of how to document food intake percentages; and
    •• Residents reported the food was not appetizing.
    Based on the identified underlying causes, the PIP team recommended the following interventions:
    •• Development of a protocol for identifying residents at risk for weight loss to be done on admission
    and with each care plan. This protocol included a review of medications (appetite suppressants),
    new diagnoses, and resident assessments, including dental issues;
    •• Development of standing orders for residents identified as “at risk” for weight loss. These would
    include bi-weekly weights, referral to attending physician and dietitian for assessment, and
    documentation of meal percentages;
    •• Development of a new program for CNAs to be “Food Plan Leads” for at risk residents. The
    program would include identification of food preferences and accurate documentation of meals laminated badge cards with pictures of meal percentages were distributed to all CNAs; and
    •• Revision of the menu to focus on favorite foods, adding finger foods and increasing choices
    outside of mealtimes.
    The interventions were implemented in one area of the building that was home to 25 residents. The PIP
    team collected data from dietary (food wasted and supplement use), CNAs (observation of resident
    satisfaction and meal percentages), residents (satisfaction surveys), and weights.
    After 3 months, they found that 5 residents gained weight,15 remained stable, and 5 lost weight, but
    the weight loss was not unexpected and consistent with their clinical condition. Food costs did not
    increase and supplement costs decreased by 12%.
    Whistling Pines decided to adopt and expand the changes to other areas of the facility. They received
    no deficiencies in the areas of nutrition on their annual survey. Using QAPI allowed them to identify and
    correct developing issues before they escalated to larger problems.
    QAPI at a Glance
    |
    5
    Many of the QAPI action steps discussed in this guide are found in the second scenario. Here are some of
    the key highlights:
    •• The facility had a structured Steering Committee for directing the QAPI activities (Step 1).
    •• The facility established performance measures and was conducting routine monitoring (Step 6).
    •• The facility used data to identify gaps or opportunities for improvement (Step 8).
    •• The QAPI Steering Committee used prioritization to decide when to conduct PIPs (Step 9).
    •• The QAPI Steering Committee created an interdisciplinary team, and as seen in this example, each
    discipline in the team brought a unique perspective that contributed to a balanced and comprehensive
    analysis (Step 2).
    •• The QAPI Steering Committee gave each team member real responsibility to study the issue, analyze
    the data, and recommend corrective actions (Step 2).
    •• The PIP team explored the issue, and designed interventions using a Plan-Do-Study-Act (PDSA) model
    (Steps 9 and 10).
    •• The PIP team’s investigation revealed several underlying systemic issues and made recommendations
    that addressed those systems, rather than focusing on individual behavior (Step 12).
    QAPI at a Glance
    |
    6
    Five Elements for Framing QAPI in Nursing Homes
    CMS has identified five strategic elements that are basic building blocks to effective QAPI.
    These provide a framework for QAPI development.
    Systematic Analysis and
    Systemic Action
    Performance
    Improvement Projects
    Feedback, Data Systems
    and Monitoring
    Governance and Leadership
    Design and Scope
    The 5 elements are your strategic framework for developing, implementing, and
    sustaining QAPI. In doing so, keep the following in mind:
    •• Your QAPI plan should address all five elements.
    •• The elements are all closely related. You are likely to be working on them all at once—they may all
    need attention at the same time because they will all apply to the improvement initiatives you choose.
    •• Your plan is based on your own center’s programs and services, the needs of your particular residents,
    and your assessment of your current quality challenges and opportunities.
    QAPI at a Glance
    |
    7
    THE FIVE ELEMENTS ARE:
    ■ 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 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.
    ■ Element 2: Governance and Leadership
    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 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 are comfortable identifying and reporting quality
    problems as well as opportunities for improvement.
    ■ 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)
    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.
    ■ 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.
    QAPI at a Glance
    |
    8
    Action Steps to QAPI
    The next few sections detail action steps that may help you on your road to implementing
    QAPI. They do not need to be achieved sequentially, but each step builds on other QAPI principles.
    The most important aspect of QAPI is effective implementation. Learning and understanding the principles is
    just the first step.
    STEP 1: Leadership Responsibility and Accountability
    Creating a culture to support QAPI efforts begins with leadership. Support from the top is essential, and
    that support should foster the active participation of every caregiver. The administrator and senior leaders
    must create an environment that promotes QAPI and involves all caregivers.
    Executive leadership sets the tone and provides resources. Their challenge is to help leadership flourish in
    each home.
    Put a Personal Face on Quality Issues
    Leadership should:
    •• give residents, family and staff the opportunity to meet board members and executive
    leaders to generate support for QAPI.
    •• tour the organization regularly, meeting with residents and caregivers where they live and
    work.
    •• choose the person or persons who will be the QAPI lead in conjunction with top
    management—QAPI needs champions.
    Here are some ways leadership can take action:
    •• Develop a steering committee, a team that will provide QAPI leadership:
    —— The steering committee has overall responsibility to develop and modify the plan, review
    information, and set priorities for PIPs. The steering committee charters teams to work on particular
    problems. It reviews results and determines the next steps. The steering committee must learn and
    use systems thinking—a nursing home has many competing interests and needs. Top leadership
    such as the Administrator and the Director of Nursing must be part of this structure.
    —— It is also important to have a medical director who is actively engaged in QAPI. It is possible to
    adapt your Quality Assurance committee to become your “Steering committee” to oversee QAPI.
    For this to work, the QA Committee may need to meet more often, include more people, and
    establish permanent and time-limited workgroups that report to it.
    •• Provide resources for QAPI—including equipment and training:
    —— Caregivers may need time to attend team meetings during working hours, requiring others to cover
    their clinical duties for a period of time.
    —— Equipment might include anything from additional computers, to low-cost supplies like posters to
    create story boards, or multiple copies of resource books or CDs.
    —— Leadership may want to consider sending one or more team members to a specialized training.
    QAPI at a Glance
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    9
    •• Establish a climate of open communication and respect. Leadership may wish to consider:
    —— Having an open-door policy to communicate with staff and caregivers.
    —— Emphasizing communication across shifts and between department heads.
    —— Creating an environment where caregivers feel free to bring quality concerns forward without fear
    of punishment.
    —— Understand your home’s current culture and how it will promote performance improvement:
    —— Create the expectation that everyone in your nursing home is working on improving care and
    services.
    —— Establish an environment where caregivers, residents, and families feel free to speak up to identify
    areas that need improvement.
    —— Expect and build effective teamwork among departments and caregivers.
    STEP 2: Develop a Deliberate Approach to Teamwork
    Teamwork is a core component of QAPI and too often it is taken for granted. You will hear and read
    that you should discuss a situation with “your team,” or that the opinion of “everyone on the team” is
    valued. The word “teamwork” may have different meanings. Many people work together without being a
    designated or formal “team.”
    TEAMWORK
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    Characteristics of an effective team include the following:
    •• Having a clear purpose
    •• Having defined roles for each team member to play
    •• Having commitment to active engagement from each member
    The roles of team workers may grow out of their original discipline (e.g., nurse, social
    worker, physical therapist) or their defined job responsibilities.
    QAPI relies on teamwork in several ways:
    •• Task-oriented teams may be specially formed to look into a particular problem and their work may be
    limited and focused.
    •• PIP teams are formed for longer-term work on an issue.
    •• When chartering a PIP, careful consideration must be given to the purpose of the PIP and type of
    members needed to achieve that purpose. Here are some examples:
    —— A PIP team with the goal of helping residents go outside more often decided that grounds
    personnel needed to be on that team so that procedures for snow removal, sun protection, and
    outdoor seating could be considered.
    —— Another PIP team working at simplifying medication regimens included a pharmacist, even though
    the time needed to be added to the consultant contract.
    —— After a PIP team began working on the problem of anxiety among residents, the members realized
    that many of the affected residents reported reassurance from the pastor and asked the QA
    committee to add him to the team that was planning the approach.
    —— A PIP team working on reducing falls asked that the housekeeping department be involved as
    it considered root causes of falls and realized that equipment in the corridors and clutter in the
    bathrooms contributed.
    Note: Generally, each team should be composed of interdisciplinary members.
    For example, a concern with medication administration should include nursing
    and pharmacy team members. However, even other disciplines or family
    members may bring a different perspective to understanding this issue and
    should be considered for this type of team.
    •• Family members and residents may be team members, though for confidentiality reasons, they may not
    review certain data or information that identifies individuals.
    •• PIP teams need to plan for sufficient communication—including face-to-face meetings to get to know
    each other and plan the work. The team should also plan for the way each team member will review
    information that emerges from the PIP.
    •• Leadership needs to convey that being on a PIP team is an important part of the job—not something
    to put aside if other things come up. They must also support this idea through action and resources to
    enable staff to complete daily assignments, provide clinical care and also participate on QAPI teams.
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    STEP 3: Take your QAPI “Pulse” with a Self-Assessment
    In order to establish QAPI in your organization, it is helpful to conduct a self-assessment in your
    organization. As you continue implementing the action steps outlined in this guide, you should periodically
    evaluate QAPI in your organization – see how far you’ve come.
    To get you started, we’ve developed a self-assessment tool to take your QAPI “pulse.” It will assist you in
    evaluating the extent to which components of QAPI are in place within your organization and identifying
    areas requiring further development. It will help you determine how you really know whether QAPI is taking
    hold.
    You may use the self-assessment tool as you begin work on QAPI and then for annual or semiannual
    evaluation of your organization’s progress. You should complete the tool with input from the entire QAPI
    team and organizational leadership. This is meant to be an honest reflection of your progress with QAPI.
    The results of this assessment will direct you to areas you need to work on in order to establish QAPI in
    your organization.
    Click here to go to the QAPI Self-Assessment Tool in Appendix A
    STEP 4: Identify Your Organization’s Guiding Principles
    It is important to lay a foundation that will help you think about what principles will guide your decision
    making and help you set priorities.
    Nursing homes are complex organizations, with numerous departments performing different functions that
    interact with and depend on each other. Establishing a purpose and guiding principles will unify the facility
    by tying the work being done to a fundamental purpose or philosophy. These principles will help guide
    your facility in determining programmatic priorities.
    Use the Guide for Developing Purpose, Guiding Principles, and Scope for QAPI to establish the principles
    that will give your organization direction. The team completing this assignment should include senior
    leadership. Taking time to articulate the purpose, develop guiding principles, and define the scope will
    help you to understand how QAPI will be used and integrated into your organization. This information will
    also help your organization to develop a written QAPI plan.
    Click here to go to the Guide for Developing Purpose, Guiding Principles, and
    Scope for QAPI in Appendix A
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    STEP 5: Develop Your QAPI Plan
    Your plan will assist you in achieving what you have identified as the purpose, guiding principles and
    scope for QAPI. This is a living document that you may revisit as your facility evolves.
    A written QAPI plan guides the nursing home’s quality efforts and serves as the main document to support
    implementation of QAPI. The plan describes guiding principles that will be used in QAPI as well as the
    scope QAPI will have based on the unique characteristics and services of the nursing home. The QAPI
    plan should be something that is actually used and not viewed as a task that must be completed. You
    should continually review and refine your QAPI plan.
    •• Tailor the plan to fit your nursing home including all units, programs, and resident groups (for example,
    your sub-acute care unit, your dementia care unit, or your palliative care program). Think also of the
    range of residents. Do you have some younger residents? You may need to consciously develop a
    distinct plan to create quality of life for those residents.
    •• Some large organizations or corporations may choose to develop a general plan for all nursing homes
    in the group—in fact many multi-home organizations already have a corporate quality plan. Flexibility
    must be built in because individual nursing homes must have a plan that works for them. Leaders at the
    facility level need flexibility to develop plans for the priorities that fit their needs.
    You may use the Guide for Developing a QAPI Plan to help you create a comprehensive plan that
    addresses the full range and scope of care and services provided by your organization.
    Click here to go to the Guide for Developing a QAPI Plan in Appendix A
    STEP 6: Conduct a QAPI Awareness Campaign
    COMMUNICATE WITH ALL CAREGIVERS
    •• Let everyone know about your QAPI plan—often and in multiple ways.
    •• Plan ongoing caregiver education beyond single exposures—the goal is widespread awareness of
    QAPI initiatives.
    •• Train through dialogue, examples, and exercises. Transform the material in this guide into smaller
    pieces and easily understood ideas. Use your home’s own experiences with certain caregivers or
    residents as part of the learning materials.
    •• Convey the message that QAPI is about systems of care, management practices, and business
    practices—systems should support quality and/or acceptable business practices, or they must change.
    Use examples to get the message across, and ask caregivers to think of examples of their own.
    •• Be sure consultants, contractors, and collaborating agencies are also aware of your QAPI approach.
    Maybe you have several hospice organizations coming in and out of your home. You may work with
    a podiatrist who visits regularly. They each have a role in your system.
    •• Convey the message that any and every caregiver is expected to raise quality concerns, that it is safe
    to do so, and that everyone is encouraged to think about systems.
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    13
    •• Discuss the hard questions—what is meant by a culture of safety here in our nursing home? How
    does the nursing home try to balance issues of safety and resident choice/autonomy? These types of
    questions often do not have easy answers but QAPI opens up these types of issues for discussion and
    deeper thinking.
    Try this:
    An exercise where groups that cross disciplines and roles brainstorm the various ways
    their work influences the work of others. For example, activities personnel may find that
    their events are cut short because no one is available to help residents to and from activity
    areas. Also seek examples where resident choice did not prevail. For instance, evening
    caregivers may say residents cannot be up and out of their rooms after 9:30 pm because
    no one will be able to help them to bed after 10:00 pm. Brainstorm how to solve problems
    like these, even if jobs and routines would change.
    If systems don’t exist, they may need to be developed. If systems impede quality, they
    must be changed.
    COMMUNICATE WITH RESIDENTS AND FAMILIES
    •• Make sure all residents and families know that their views are sought, valued, and considered in
    facility decision-making and process improvements by announcing and discussing QAPI in resident
    and family councils and other venues.
    •• Ask residents and family members to tell you about their quality concerns. Many facilities today are
    using some type of customer-satisfaction survey—results should be used to identify opportunities for
    improvement that will proactively have an impact on all residents and their families.
    •• Try to view concerns through residents’ eyes. For example, getting back to a resident in 10 minutes
    may seem responsive, but may feel like an eternity to the resident. How would that feel to a resident
    waiting an answer to a call light or for help to the bathroom?
    •• Consider including QAPI information in routine communications to families.
    Family and resident
    complaints are often
    underused, and yet they are
    a valuable way of identifying
    more general problems.
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    STEP 7: Develop a Strategy for Collecting and Using QAPI Data
    Your team will decide what data to monitor routinely. Areas to consider may include:
    •• Clinical care areas, e.g., pressure ulcers, falls, infections
    •• Medications, e.g., those that require close monitoring, antipsychotics, narcotics
    •• Complaints from residents and families
    •• Hospitalizations and other service use
    •• Resident satisfaction
    •• Caregiver satisfaction
    •• Care plans, including ensuring implementation and evaluation of measurable interventions
    •• State survey results and deficiencies
    •• Results from MDS resident assessments
    •• Business and administrative processes—for example, financial information, caregiver turnover,
    caregiver competencies, and staffing patterns, such as permanent caregiver assignment. Data related
    to caregivers who call out sick or are unable to report to work on short notice, caregiver injuries, and
    compensation claims may also be useful.
    This data will require systematic organization and interpretation in order to achieve meaningful reporting
    and action. Otherwise, it would only be a collection of unrelated, diverse data and may not be useful.
    Compare this to an individual resident’s health—you must connect many pieces of information to reach
    a diagnosis. You also need to connect many pieces of information to learn your nursing home’s quality
    baseline, goals, and capabilities.
    •• Your team should set targets for performance in the areas you are monitoring. A target is a goal,
    usually stated as a percentage. Your goal may be to reduce restraints to zero; if so, even one instance
    will be too many. In other cases, you may have both short and longer-term goals. For example, your
    immediate goal may be reducing unplanned rehospitalizations by 15 percent, and then subsequently
    by an additional 10 percent. Think of your facility or organization as an athlete who keeps beating his
    or her own record.
    •• Identifying benchmarks for performance is an essential component of using data effectively with QAPI.
    A benchmark is a standard of comparison. You may wish to look at your performance compared
    to nursing homes in your state and nationally using Nursing Home Compare (www.medicare.gov/
    nhcompare); some states also have state report cards. You may compare your nursing home to other
    facilities in your corporation, if applicable. But generally, because every facility is unique, the most
    important benchmarks are often based on your own performance. For example, seeking to improve
    hand-washing compliance to 90 percent in 3 months based on a finding of 66 percent in the prior
    quarter. After achieving 90 percent for some period of time, the benchmark can be raised higher as
    part of ongoing, continuous improvement.
    •• It may be helpful to monitor what happens when residents leave the nursing home or come back,
    including discharges to the hospital or home. You may examine discharge rates from your post-acute
    care area, preventable hospitalizations (i.e., hospitalizations that can be avoided through good
    clinical care), and what happens after the resident returns from the hospital.
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    •• You’ll want to develop a plan for the data you collect. Determine who reviews certain data, and how
    often. Collecting information is not helpful unless it is actually used. Be purposeful about who should
    review certain data, and how often—and about the next steps in interpreting the information.
    STEP 8: Identify Your Gaps and Opportunities
    This step involves reviewing your sources of information to determine if gaps or patterns exist in your
    systems of care that could result in quality problems. Or, are there opportunities to make improvements?
    Potential areas to consider when reviewing your data:
    •• MDS data for problem patterns.
    •• Nursing Home Compare (provides quality information about every certified nursing home in the
    country).
    •• State survey results and plans of correction.
    •• Resident care plans for documented progress towards specified goals.
    •• Trends in complaints.
    •• Resident and family satisfaction for trends.
    •• Patterns of caregiver turnover or absences.
    •• Patterns of ER and/or hospital use.
    During this step, you may decide to spend more time discussing the quality themes you have identified
    with residents and caregivers. They may pick up patterns you have not yet identified, and they may have
    ideas about what is at the root of the problem. Consider hosting a series of small group meetings with your
    caregivers, and arrange to meet with your Resident Council. You may wish to provide refreshments and
    have an informal discussion.
    This step should lead to the next steps involving PIPs. Such projects are expected to be chosen to deal
    with “high risk, high volume, problem-prone areas” related to quality of care or quality of life. Take time to
    notice the things you are doing well—that’s important too, and deserves recognition.
    But while you are celebrating accomplishments, you can also begin to set priorities for improvement
    around issues that the team identifies.
    STEP 9: Prioritize Quality Opportunities and Charter PIPs
    Prioritizing opportunities for improvement is a key step in the process of translating data into action.
    As you continue to implement QAPI, you and your team will:
    •• Prioritize opportunities for more intensive improvement work. Problems versus opportunities are a matter
    of perspective and often require discussion.
    •• Choose problems or issues that you consider important (consider if the issue is high risk, high
    frequency, and/or problem prone). Remember that problems affecting psychosocial well-being and the
    ability of residents to exercise choice should also be considered as they may lead to resident suffering.
    •• Consider which problems will become the focus for a PIP.
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    —— All identified problems need attention—and usually from more than one person, but they do not all
    require PIPs.
    —— Begin some PIPs with problems you think you can solve relatively easily. A quick win is worthwhile.
    Charter PIP teams:
    We use the word “charter” on purpose. A PIP is more than a casual effort – it entails a specific written
    mission to look into a problem area. The PIP team should include people in a position to explore the
    problem (usually direct caregivers, such as nursing assistants, are needed). If the problem being addressed
    involves, for example, dietary choices, then someone from the dietary department should also be on the
    PIP team.
    Chartering implies that the team has been entrusted with a mission, and that it reports back to the Steering
    Committee at intervals. Being part of a formally chartered PIP team must be interpreted as an important
    assignment that team members and their supervisors must take seriously. The development of a charter adds
    strength, importance, and formality to the PIP process. The team typically has a leader—either chosen in
    the charter or by the team itself. Soon after it begins its work, the PIP should develop a proposed time line,
    and indicate the budget that is needed.
    Use the Goal Setting Worksheet to help your PIP team establish appropriate goals for organizational
    quality measures, informal improvement initiatives, and PIPs.
    Click here to go to the Goal Setting Worksheet in Appendix A
    STEP 10: Plan, Conduct and Document PIPs
    Careful planning of PIPs includes identifying areas to work on through your comprehensive data review
    which are meaningful and important to your residents. It is important to focus your PIPs by defining the
    scope, so they do not become overwhelming.
    You and your team may:
    •• consider each PIP a learning process.
    •• determine what information you need for the
    PIP.
    ACT
    • What changes are
    to be made?
    • Objective
    • Next Cycle?
    • Plan to carry out the
    cycle (who, what,
    where, when)
    •• determine a timeline and communicate it to the
    Steering Committee.
    •• identify and request any needed supplies or
    equipment.
    •• select or create measurement tools as needed;
    •• prepare and present results.
    •• use a problem solving model like PDSA
    (Plan-Do-Study-Act).
    •• report results to the Steering Committee.
    PLAN
    • Predictions
    • Plan for data collection
    STUDY
    DO
    • Analyze data
    • Carry out the plan
    • Compare results to
    predictions
    • Document observations
    • Record data
    • Summarize what was
    learned
    PDSA MODEL
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    PLAN-DO-STUDY-ACT (PDSA) CYCLE
    During a PIP you will try out some changes and then see whether or not they made a difference in the area
    you were trying to improve. In the PLAN stage, the team learns more about the problem, plans for how
    improvement would be measured, and plans for any changes that might be implemented. In the DO stage,
    the plan is carried out, including the measures that are selected. In the STUDY phase, the team summarizes
    what was learned. In the ACT phase, the team and leadership determine what should be done next. The
    change can be adapted (and re-studied), adopted (perhaps expanded to other areas), or abandoned.
    That decision determines the next steps in the cycle.
    STEP 11: Getting to the “Root” of the Problem
    A major challenge in process improvement is getting to the heart of the problem or opportunity.
    There is danger in starting with a solution without
    thoroughly exploring the problem. Multiple factors
    may have contributed, and/or the problem may be a
    symptom of a larger issue. What seems like a simple
    issue may involve a number of departments.
    Root Cause Analysis (RCA) is a term used to describe a systematic process for identifying contributing
    causal factors that underlie variations in performance. This structured method of analysis is designed to get
    to the underlying cause of a problem –which then leads to identification of effective interventions that can
    be implemented in order to make improvements.
    RCA helps teams understand that the most immediate or seemingly obvious reason for the problem or an
    event may not be the real reason that an event occurred. The RCA process leads to digging deeper and
    deeper—looking for the reasons behind the reasons. This process will generally lead to the identification
    of more than one root cause. The root cause(s) and any contributing factors can then be sorted into
    categories to facilitate the identification of various actions that can be taken to make improvements.
    RCA focuses primarily on systems and processes, not individual performance.
    The RCA process takes practice, but can be a valuable tool for performance improvement. In order to get
    familiar with RCA you and your team may consider:
    •• studying case examples of RCA.
    •• applying RCA to an adverse event and discussing this technique with the team.
    •• building RCA examples into training opportunities.
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    STEP 12: Take Systemic Action
    Identifying root causes is only the first step in improving performance. Next you will want to implement
    changes or corrective actions that will result in improvement or reduce the chance of the event recurring.
    This is often the most challenging step in the process. Common solutions such as providing more training/
    education or asking clinicians to “be more careful” do not change the process or system. These proposed
    solutions are based on two assumptions: lack of knowledge contributed to the event, and if a person is
    educated or trained, the mistake won’t happen again.
    Choosing actions that are tightly linked to the root causes and that lead to a system or process change are
    considered to have a higher likelihood of being effective. Actions that simply support the current process
    are considered “weaker” and should not be selected as the sole intervention. The goal is to make changes
    that will result in lasting improvement. Avoiding quick fixes and weak actions is vital to achieving that goal.
    To be effective, interventions or corrective actions should target the elimination of root causes, offer long
    term solutions to the problem, and have a greater positive than negative impact on other processes. In
    addition, interventions must be achievable, objective, and measurable.
    Pilot Test:
    Think about testing or “piloting” changes in one area of your facility before
    launching throughout. Some changes have unintended consequences.
    The Department of Veterans Affairs National Center for Patient Safety’s Hierarchy of Actions2 classifies
    corrective actions as:
    Weak: Actions that depend on staff to remember their training or what is written in the policy. Weak
    actions enhance or enforce existing processes.
    Examples of weak actions:
    •• double checks
    •• warnings/labels
    •• new policies/procedures/memoranda
    •• training/education
    •• additional study
    Intermediate: Actions are somewhat dependent on staff remembering to do the right thing, but they
    provide tools to help staff to remember or to promote clear communication. Intermediate actions modify
    existing processes.
    Examples of intermediate actions:
    •• decrease workload
    •• eliminate look alike and sound alike
    •• software enhancements/modifications
    •• read back
    •• eliminate/reduce distraction
    •• enhanced documentation/communication
    •• checklists/cognitive aids/triggers/prompts
    •• build in redundancy
    U.S. Department of Veterans Affairs. National Center for Patient Safety Root Cause Analysis Tools. Retrieved from http://www.patientsafety.gov/
    CogAids/RCA/index.html#page+page-1.
    2
    QAPI at a Glance
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    19
    Strong: Actions that do not depend on staff to remember to do the right thing. The action may not totally
    eliminate the vulnerability but provides strong controls. Strong actions change or re-design the process.
    They help detect and warn so there is an opportunity to correct before the error reaches the patient. They
    may involve hard stops which won’t allow the process to continue unless something is corrected or gives
    the chance to intervene to prevent significant harm.
    Examples of strong actions:
    •• physical changes: grab bars, non slip strips on tubs/showers
    •• forcing functions or constraints: design of gas lines so that only oxygen can be connected to oxygen
    lines; electronic medical records – cannot continue charting unless all fields are filled in
    •• simplifying: unit dose
    Prevent future problems by developing and testing strong actions.
    QAPI Principles Summarized
    •• All of QAPI may not be new to your facility. You already have a Quality Assessment and Assurance
    program—consider beginning by evaluating or re-evaluating that program and then conducting a self
    evaluation using the QAPI Self Assessment Tool.
    •• QAPI leadership starts at the top with executive management and the Board of Directors, Owners, or
    Trustees, and includes top management in each home.
    •• Three important principles of QAPI are Systems, Systems, and Systems. Start using systems thinking
    as you assess your own QAPI efforts, and develop a QAPI plan moving forward. Think of your entire
    center or community as you plan for monitoring, as you conduct PIPs, and particularly as you think
    about the way problems might be caused and how care is organized.
    •• Involve the people directly working in a process in order to improve that process. These are the people
    who really know what happens at any point in the process. It is crucial to focus on organization-wide
    inclusion, not for the sake of inclusion, but to truly understand what is going on in any given process.
    •• Communication about QAPI should be continuous throughout the whole organization. QAPI principles
    and ongoing training should be built into a facility-wide educational effort that involves all caregivers,
    residents, and families.
    •• Residents’ perspectives need to be considered in setting QAPI priorities. Solicit residents’ viewpoints
    and talk to residents and families about quality as they experience it.
    •• Two important components of your QAPI plan will be setting priorities and chartering PIP teams.
    Everyone should have an opportunity to participate in these activities.
    •• Create a record of QAPI activities. Consider using past experience as a resource as you move ahead.
    Keeping an ongoing record of QAPI achievements may help to sustain the improvements regardless of
    crises or changes in leadership. Build it into your plan.
    •• Celebrate and reward successes.
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    How to Learn More
    Our QAPI website: http://go.cms.gov/Nhqapi
    An excellent resource on QAPI in Nursing Homes is CMS’ QAPI website. It contains a number of tools and
    resources including:
    •• Learning modules complete with videos, QAPI Process Tools and how to use them, case study
    examples, best practices information, sections to help engage consumers, and much more
    •• Downloadable QAPI process tools with instructions for their use
    •• Best practice examples organized by topic
    •• QAPI tools for specific topics and purposes with links to many related resources
    •• Special resources for you in your particular practice role in the “Communities of Practice” section
    •• News Briefs on QAPI implementation
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    QAPI Tools and Related Resources
    QAPI PROCESS TOOLS
    These are tools that help make QAPI processes work. They may include:
    •• checklists
    •• reporting forms or outlines
    •• templates
    •• worksheets
    •• flow charts
    QAPI process tools are important to:
    •• organize multiple tasks.
    •• help generate ideas and reach decisions.
    •• enhance communication within and across
    teams.
    •• keep information organized and accessible.
    •• track successes and challenges using data.
    QAPI is largely about well-functioning and tightly coordinated systems that can identify, solve, and prevent
    problems effectively. Using QAPI can improve diverse aspects of care and services as well as resident,
    family, caregiver, and staff experience and satisfaction. TOOLS CAN HELP.
    QAPI TOPIC TOOLS
    QAPI Topic Tools are used to study and improve particular topic areas. Many tools are available to assess
    care processes and outcomes and to allow you to follow progress in areas you want to track and/or
    improve. Topic tools can take many forms, ranging from simple to complex, and they use multiple sources
    of information.
    •• Checklists or audits completed by caregivers and practitioners. Checklists can be used to review
    records of various kinds to determine that all steps have been taken. For example, an admission or fall
    prevention checklist.
    •• Rating forms completed by caregivers. For example,residents’ mood states are rated when residents
    cannot respond to direct questions.
    •• Structured observation (e.g., observations of interactions among residents and caregivers or of
    physical environments). Observations are objective and made at specific times and places; later they
    may be summarized into a score.
    •• Direct interviews with residents and family. Such tools, sometimes called resident self-report tools, may
    be related to single areas of functioning.
    •• Protocols to guide caregivers’ behavior to improve quality in a particular area. Such protocols may
    include procedures and forms meant to shape caregiver behavior around pressure ulcer prevention,
    respecting residents’ rights, etc. This comprehensive set of tools could be considered a QAPI process
    toolkit as well.
    Nursing homes may wish to select established tools that have been tested and use them consistently.
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    QAPI RESOURCES FOR PROVIDERS
    Each state is served by a Quality Improvement Organization that offers resources and tools for
    nursing homes. To find your Quality Improvement Organization, visit http://www.qualitynet.org/dcs/
    ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1144767874793
    RESOURCES AND TOOLS AVAILABLE THROUGH QIOS
    Oklahoma Foundation for Medical Quality
    Provides tools and resources for nursing homes.
    http://www.ofmq.com/nhtoolsandresources Improvement basics for nursing homes, Change
    management, and Facilitating group agreement.
    Stratis Health
    The following recorded webinars cover some basic principles of QI and can be used for caregiver
    education: http://www.stratishealth.org/events/recorded.html
    WEBSITES ON SELECTED QUALITY TOPICS
    Advancing Excellence in America’s Nursing Homes
    Supported by CMS, the Commonwealth Fund, and others, The Advancing Excellence Campaign provides
    tools and resources to improve nursing home care in clinical and organizational areas.
    http://www.nhqualitycampaign.org/
    Agency for Healthcare Research and Quality
    The Department of Defense and the Agency for Healthcare Research and Quality developed the Team
    STEPPS program to optimize performance among teams of healthcare professionals and improve
    collaboration and communication. The Long-Term Care version addresses issues specific to nursing homes:
    http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/ltc/index.html.
    Department of Veterans Affairs
    National Center for Patient Safety supports and leads the patient safety activities for all VA medical centers
    and has developed tools including Root Cause Analysis investigations: http://www.patientsafety.gov/
    CogAids/RCA/.
    Getting Better All the Time: Working Together for Continuous Improvement
    The Isabella Geriatric Center and Cobble Hill Health Center have developed a web manual on quality
    improvement approaches as a guide for nursing home caregivers. This is a particularly practical and lively
    resource that explains and illustrates performance monitoring and improvement approaches in ways that
    are understandable to most nursing home caregivers. Getting Better All the Time was written by Ann
    Wyatt, a social worker and nursing home administrator; it aims to present a model of quality improvement
    that integrates quality of care and quality life.
    http://www.susanwehrymd.com/files/gettingbetterall-the-time.pdf
    Interact II
    An example of a more extensive set of tools, INTERACT II is a system of tools to improve how nursing
    home caregivers communicate around change in resident condition. This comprehensive set of tools could
    be considered a QAPI process toolkit as well. www.interact2.net
    QAPI at a Glance
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    23
    Institute for Health Care Improvement (IHI)
    IHI uses the Model for Improvement as the framework to guide improvement work. The Model for
    Improvement, developed by Associates in Process Improvement, is a simple, yet powerful tool for
    accelerating improvement. Learn about the fundamentals of the Model for Improvement and testing
    changes on a small scale using Plan-Do-Study-Act (PDSA) cycles.
    http://www.ihi.org/knowledge/Pages/HowtoImprove/default.aspx
    WEBSITES ON PERSON-CENTERED CARE
    Implementing Change in Long-Term Care: A Practical Guide to Transformation
    This resource was prepared by Barbara Bowers and others with a grant from the Commonwealth Fund to
    the Pioneer Network. Although it deals with implementing culture change (not QAPI), it is a good resource
    on the change process.
    http://www.pioneernetwork.net/Data/Documents/Implementation_Manual_
    ChangeInLongTermCare%5B1%5D.pdf
    Picker Institute Publications
    These include a Long-Term Care Improvement Guide, commissioned in 2010 and a Patient-Centered
    Care Improvement Guide, commissioned in 2008, both by Susan Frampton and others. The website also
    carries information on current books related to person centered care that Picker Institute recommends.
    http://pickerinstitute.org/publications-and-resources/
    QAPI at a Glance
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    24
    Appendix A: QAPI Tools
    Disclaimer: Use of these tools is not mandated by CMS for regulatory compliance
    nor does their completion ensure regulatory compliance.
    QAPI at a Glance Appendix A |
    25
    QAPI Self-Assessment Tool
    Directions: Use this tool as you begin work on QAPI and then for annual or semiannual evaluation of your organization’s progress with QAPI.
    This tool should be completed with input from the entire QAPI team and organizational leadership. This is meant to be an honest reflection of your
    progress with QAPI. The results of this assessment will direct you to areas you need to work on in order to establish QAPI in your organization. You
    may find it helpful to add notes under each item as to why you rated yourself a certain way.
    Date of Review:
    Next review scheduled for:
    Rate how closely each statement fits your organization
    Not
    started
    Just
    starting
    On our
    way
    Almost
    there
    Doing
    great
    Our organization has developed principles guiding how QAPI will be incorporated into our culture and built into how we do our work. For
    example, we can say that QAPI is a method for approaching decision making and problem solving rather than considered as a separate
    program.
    QAPI SELF-ASSESSMENT TOOL
    Notes:
    Our organization has identified how all service lines and departments will utilize and be engaged in QAPI to plan and do their work. For
    example, we can say that all service lines and departments use data to make decisions and drive improvements, and use measurement to
    determine if improvement efforts were successful.
    Notes:
    Our organization has developed a written QAPI plan that contains the steps that the organization takes to identify, implement and sustain
    continuous improvements in all departments; and is revised on an ongoing basis. For example, a written plan that is done purely for
    compliance and not referenced would not meet the intent of a QAPI plan.
    Notes:
    Our board of directors and trustees (if applicable) are engaged in and supportive of the performance improvement work being done in our
    organization. For example, it would be evident from meeting minutes of the board or other leadership meetings that they are informed of
    what is being learned from the data, and they provide input on what initiatives should be considered. Other examples would be having
    leadership (board or executive leadership) representation on performance improvement projects or teams, and providing resources to support
    QAPI.
    Notes:
    Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor does its completion
    ensure regulatory compliance.
    QAPI at a Glance Apendix A
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    Rate how closely each statement fits your organization
    Not
    started
    Just
    starting
    On our
    way
    Almost
    there
    Doing
    great
    QAPI is considered a priority in our organization. For example, there is a process for covering caregivers who are asked to
    spend time on improvement teams.
    Notes:
    QAPI is an integral component of new caregiver orientation and training. For example, new caregivers understand and can
    describe their role in identifying opportunities for improvement. Another example is that new caregivers expect that they will be
    active participants on improvement teams.
    Notes:
    QAPI SELF-ASSESSMENT TOOL
    Training is available to all caregivers on performance improvement strategies and tools.
    Notes:
    When conducting performance improvement projects, we make a small change and measure the effect of that change before
    implementing more broadly. An example of a small change is pilot testing and measuring with one nurse, one resident, on one
    day, or one unit, and then expanding the testing based on the results.
    Notes:
    When addressing performance improvement opportunities, our organization focuses on making changes to systems and
    processes rather than focusing on addressing individual behaviors. For example, we avoid assuming that education or training
    of an individual is the problem, instead, we focus on what was going on at the time that allowed a problem to occur and look
    for opportunities to change the process in order to minimize the chance of the problem recurring.
    Notes:
    Our organization has established a culture in which caregivers are held accountable for their performance, but not punished
    for errors and do not fear retaliation for reporting quality concerns. For example, we have a process in place to distinguish
    between unintentional errors and intentional reckless behavior and only the latter is addressed through disciplinary actions.
    Notes:
    Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor does its completion
    ensure regulatory compliance.
    QAPI at a Glance Apendix A
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    Rate how closely each statement fits your organization
    Not
    started
    Just
    starting
    On our
    way
    Almost
    there
    Doing
    great
    Leadership can clearly describe, to someone unfamiliar with the organization, our approach to QAPI and give accurate
    and up-to-date examples of how the facility is using QAPI to improve quality and safety of resident care. For example, the
    administrator can clearly describe the current performance improvement initiatives, or projects, and how the work is guided by
    caregivers involved in the topic as well as input from residents and families.
    Notes:
    Our organization has identified all of our sources of data and information relevant to our organization to use for QAPI. This
    includes data that reflects measures of clinical care; input from caregivers, residents, families, and stakeholders, and other
    data that reflects the services provided by our organization. For example, we have listed all available measures, indicators or
    sources of data and carefully selected those that are relevant to our organization that we will use for decision making. Likewise,
    we have excluded measures that are not currently relevant and that we are not actively using in our decision making process.
    QAPI SELF-ASSESSMENT TOOL
    Notes:
    For the relevant sources of data we identify, our organization sets targets or goals for desired performance, as well as
    thresholds for minimum performance. For example, our goal for resident ratings for recommending our facility to family and
    friends is 100% and our threshold is 85% (meaning we will revise the strategy we are using to reach our goal if we fall below
    this level).
    Notes:
    We have a system to effectively collect, analyze, and display our data to identify opportunities for our organization to make
    improvements. This includes comparing the results of the data to benchmarks or to our internal performance targets or goals.
    For example, performance improvement projects or initiatives are selected based on facility performance as compared to
    national benchmarks, identified best practice, or applicable clinical guidelines.
    Notes:
    Our organization has, or supports the development of, employees who have skill in analyzing and interpreting data to assess
    our performance and support our improvement initiatives. For example, our organization provides opportunities for training and
    education on data collection and measurement methodology to caregivers involved in QAPI.
    Notes:
    Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor does its completion
    ensure regulatory compliance.
    QAPI at a Glance Apendix A
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    Rate how closely each statement fits your organization
    Not
    started
    Just
    starting
    On our
    way
    Almost
    there
    Doing
    great
    From our identified opportunities for improvement, we have a systematic and objective way to prioritize the opportunities in
    order to determine what we will work on. This process takes into consideration input from multiple disciplines, residents and
    families. This process identifies problems that pose a high risk to residents or caregivers, is frequent in nature, or otherwise
    impact the safety and quality of life of the residents.
    Notes:
    When a performance improvement opportunity is identified as a priority, we have a process in place to charter a project. This
    charter describes the scope and objectives of the project so the team working on it has a clear understanding of what they are
    being asked to accomplish.
    QAPI SELF-ASSESSMENT TOOL
    Notes:
    For our Performance Improvement Projects, we have a process in place for documenting what we have done, including
    highlights, progress, and lessons learned. For example, we have project documentation templates that are consistently used
    and filed electronically in a standardized fashion for future reference.
    Notes:
    For every Performance Improvement Project, we use measurement to determine if changes to systems and process have been
    effective. We utilize both process measures and outcome measures to assess impact on resident care and quality of life. For
    example, if making a change, we measure whether the change has actually occurred and also whether it has had the desired
    impact on the residents.
    Notes:
    Our organization uses a structured process for identifying underlying causes of problems, such as Root Cause Analysis.
    Notes:
    Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor does its completion
    ensure regulatory compliance.
    QAPI at a Glance Apendix A
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    Rate how closely each statement fits your organization
    Not
    started
    Just
    starting
    On our
    way
    Almost
    there
    Doing
    great
    When using Root Cause Analysis to investigate an event or problem, our organization identifies system and process
    breakdowns and avoids focus on individual performance. For example, if an error occurs, we focus on the process and look
    for what allowed the error to occur in order to prevent the same situation from happening with another caregiver and another
    resident.
    Notes:
    QAPI SELF-ASSESSMENT TOOL
    When systems and process breakdowns have been identified, we consistently link corrective actions with the system and
    process breakdown, rather than having our default action focus on training education, or asking caregivers to be more careful,
    or remember a step. We look for ways to assure that change can be sustained. For example, if a policy or procedure was not
    followed due to distraction or lack of caregivers, the corrective action focuses on eliminating distraction or making changes to
    staffing levels.
    Notes:
    When corrective actions have been identified, our organization puts both process and outcome measures in place in order to
    determine if the change is happening as expected and that the change has resulted in the desired impact to resident care. For
    example, when making a change to care practices around fall prevention there is a measure looking at whether the change is
    being carried out and a measure looking at the impact on fall rate.
    Notes:
    When an intervention has been put in place and determined to be successful, our organization measures whether the change
    has been sustained. For example, if a change is made to the process of medication administration, there is a plan to measure
    both whether the change is in place, and having the desired impact (this is commonly done at 6 or 12 months).
    Notes:
    Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor does its completion
    ensure regulatory compliance.
    QAPI at a Glance Apendix A
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    Guide for Developing Purpose, Guiding Principles, and Scope for QAPI
    Directions: Use this tool to establish the purpose, guiding principles and scope for QAPI in your
    organization. The team completing this worksheet should include senior leadership. Taking time to
    articulate the purpose, develop guiding principles, and define the scope will help you to understand how
    QAPI will be used and integrated into your organization. This information will also help your organization
    to develop a written QAPI plan. Use these step-by-step instructions to create a separate document that may
    be used as a preamble to your QAPI plan.
    STEP 1. LOCATE OR DEVELOP YOUR ORGANIZATION’S VISION STATEMENT
    A vision statement is sometimes called a picture of your organization in the future; it is your inspiration
    and the framework for your strategic planning. Consider involving staff in the development of your vision
    statement. Post it for everyone to view.
    For example, the vision of the Good Samaritan Society is to create an environment where people are
    loved, valued and at peace.
    STEP 2. LOCATE OR DEVELOP YOUR ORGANIZATION’S MISSION STATEMENT
    A mission statement describes the purpose of your organization. The mission statement should guide
    the actions of the organization, spell out its overall goal, provide a path, and guide decision-making. It
    provides the framework or context within which the company’s strategies are formulated. As above, get
    caregivers involved in establishing your organizations mission.
    For example, Meadowlark Hills is each resident’s home. We are committed to enhancing quality of life by
    nurturing individuality and independence. We are growing a value-driven community while leading the
    way in honoring inherent senior rights and building strong and meaningful relationships with all whose lives
    we touch.
    STEP 3. DEVELOP A PURPOSE STATEMENT FOR QAPI
    A purpose statement describes how QAPI will support the overall vision and mission of the organization.
    If your organization does not have a vision or mission statement, the purpose statement can still be written
    and would state what your organization intends to accomplish through QAPI.
    For example, the purpose of QAPI in our organization is to take a proactive approach to continually
    improving the way we care for and engage with our residents, caregivers and other partners so that
    we may realize our vision to [reference aspects of vision statement here]. To do this, all employees will
    participate in ongoing QAPI efforts which support our mission by [reference aspects of mission statement
    here].
    Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor
    does its completion ensure regulatory compliance.
    QAPI at a Glance Apendix A
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    STEP 4. ESTABLISH GUIDING PRINCIPLES
    Guiding Principles describe the organization’s beliefs and philosophy pertaining to quality assurance and
    performance improvement. The principles should guide what the organization does, why it does it and
    how.
    For example:
    •• Guiding Principle #1: QAPI has a prominent role in our management and Board functions, on par
    with monitoring reimbursement and maximizing revenue.
    •• Guiding Principle #2: Our organization uses quality assurance and performance improvement to
    make decisions and guide our day-to-day operations.
    •• Guiding Principle #4: In our organization, QAPI includes all employees, all departments and all
    services provided.
    •• Guiding Principle #5: QAPI focuses on systems and processes, rather than individuals. The emphasis
    is on identifying system gaps rather than on blaming individuals.
    •• Guiding Principle #6: Our organization makes decisions based on data, which includes the input
    and experience of caregivers, residents, health care practitioners, families, and other stakeholders.
    •• Guiding Principle #7: Our organization sets goals for performance and measures progress toward
    those goals.
    •• Guiding Principle #8: Our organization supports performance improvement by encouraging our
    employees to support each other as well as be accountable for their own professional performance
    and practice.
    •• Guiding Principle #9: Our organization has a culture that encourages, rather than punishes,
    employees who identify errors or system breakdowns.
    Add any additional Guiding Principles that may be important to your nursing home. Review the five QAPI
    elements to ensure you identify and capture guiding principles for your organization.
    Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor
    does its completion ensure regulatory compliance.
    QAPI at a Glance Apendix A
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    Guide to Develop Purpose, Guiding Principles, and Scope for QAPI
    •• Guiding Principle #3: The outcome of QAPI in our organization is the quality of care and the quality
    of life of our residents.
    STEP 5. DEFINE THE SCOPE OF QAPI IN YOUR ORGANIZATION
    The Scope outlines what types of care and services are provided by the organization that impact clinical
    care, quality of life, resident choice, and care transitions. Be sure to incorporate the care and services
    delivered by all departments.
    For example:
    Post-acute care
    Dementia care and services
    Dietary
    Dining
    STEP 6. ASSEMBLE DOCUMENT
    Once you’ve completed steps 1-5, assemble the vision and mission statements, guiding principles, and
    scope of QAPI into a separate document that may be used as a preamble to your QAPI plan. This
    document will help you articulate the goals and objectives of your organization; QAPI will help you get
    there. Consider posting for all to see.
    The next step is to develop a written QAPI plan that will meet your purpose, guiding principles and
    comprehensive scope described above. See “Guide for Developing a QAPI Plan.”
    Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor
    does its completion ensure regulatory compliance.
    QAPI at a Glance Apendix A
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    Guide to Develop Purpose, Guiding Principles, and Scope for QAPI
    Once the list of care and service area has been identified, you can determine how each will use QAPI to
    assess, monitor and improve performance on an ongoing basis.
    Guide for Developing a QAPI Plan
    DIRECTIONS:
    The QAPI plan will guide your organization’s performance improvement efforts. Prior to developing your
    plan, complete the Guide to Develop Purpose, Guiding Principles, and Scope for QAPI. Your QAPI
    plan is intended to assist you in achieving what you have identified as the purpose, guiding principles
    and scope for QAPI, therefore this information is needed before you begin working on your plan. This is a
    living document that you will continue to refine and revisit. Use these step-by-step instructions to create your
    QAPI plan. This plan should reflect input from caregivers representing all roles and disciplines within your
    organization.
    I.
    QAPI Goals
    Based on the Guide to Develop Purpose, Guiding Principles, and Scope for QAPI, indicate the
    QAPI goals that your plan will strive to meet. Goals should be specific, measurable, actionable,
    relevant, and have a time line for completion. (See Goal Setting Worksheet).
    II.
    Scope
    a. Describe how QAPI is integrated into all care and service areas of your organization.
    b. Describe how the QAPI plan will address:
    i. Clinical care
    ii. Quality of life
    iii. Resident choice (i.e., individualized goals for care)
    c. Describe how QAPI will aim for safety and high quality with all clinical interventions while
    emphasizing autonomy and choice in daily life for residents (or resident’s agents).
    d. Describe how QAPI will utilize the best available evidence (e.g., data, national benchmarks,
    published best practices, clinical guidelines) to define and measure goals.
    III. Guidelines for Governance and Leadership
    a. Describe how QAPI is integrated into the responsibilities and accountabilities of top-level
    management and the Board of Directors (if applicable).
    b. Describe how QAPI will be adequately resourced.
    i. Designate one or more persons to be accountable for QAPI leadership and for coordination.
    ii. Indicate the plan for developing leadership and facility-wide training on QAPI.
    iii. Describe the plan to provide caregivers time, equipment, and technical training as needed for
    QAPI.
    iv. Indicate how you will determine if resources are adequate for QAPI.
    v. Describe how your caregivers will become and remain proficient with process improvement
    tools and techniques. How will you assess their level of proficiency?
    Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor
    does its completion ensure regulatory compliance.
    QAPI at a Glance Apendix A
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    c. QAPI Leadership
    i. While everyone in the organization is involved in QAPI, you will likely have a small group of
    individuals who will provide the backbone or structure for QAPI in your organization. Who will
    be part of this group? Many of these individuals may be on your current QAA committee.
    ii. Describe how this group of people will work together, communicate, and coordinate QAPI
    activities. This could include but is not limited to:
    •• Establishing a format and frequency for meetings
    •• Establishing a method for communication between meetings
    •• Establishing a designated way to document and track plans and discussions addressing
    QAPI.
    iii. Describe how the QAPI activities will be reported to the governing body; i.e., Board of
    Directors, owner.
    IV. Feedback, Data Systems, and Monitoring
    a. Describe the overall system that will be put in place to monitor care and services, drawing data
    from multiple sources.
    i. Input from caregivers, residents, families, and others
    ii. Adverse events
    iii. Performance indicators
    iv. Survey findings
    v. Complaints
    c. Describe the process for collecting the above information.
    d. Describe the process for analyzing the above information, including how findings will be reviewed
    against benchmarks and/or targets established by the facility.
    e. Describe the process to communicate the above information. What types of reports will be used?
    One way to accomplish this is to use a dashboard or dashboards for individual performance
    improvement projects.
    f. Identify who will receive this information (i.e., executive leadership, QAPI leadership, resident/
    family council, and a center’s caregivers), in what format, and how frequently information will be
    disseminated.
    V.
    Guidelines for Performance Improvement Projects (PIPs)
    a. Describe the overall plan for conducting PIPs to improve care or services.
    i. Indicate how potential topics for PIPs will be identified.
    ii. Describe criteria for prioritizing and selecting PIPs: areas important and meaningful for the
    specific type and scope of services unique to the facility, requires a concentrated effort on a
    particular problem in one area of the facility or facility wide.
    iii. Indicate how and when PIP charters will be developed.
    iv. Describe the process for reporting the results of PIPs. Identify who will receive this information
    (i.e., quality committee, resident/family council, and a center’s caregivers), in what format, and
    how frequently information will be disseminated.
    Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor
    does its completion ensure regulatory compliance.
    QAPI at a Glance Apendix A
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    Guide for Developing a QAPI Plan
    b. Identify the sources of data that you will monitor through QAPI
    b. Describe how to designate PIP teams and establish and describe a process for assembling teams to
    work on specific PIPs.
    c. Define the required characteristics for any PIP team. This may include that the team be
    interdisciplinary (i.e., representing each of the job roles affected by the project), that it include
    resident representation (as appropriate), and that a qualified team leader is selected (i.e., ability to
    coordinate, organize and direct all activities of the project team). Describe how PIP teams should
    document and report their work.
    d. Describe your process for documenting PIPs, including highlights, progress, and lessons learned. For
    example, what project documentation templates will you use consistently and file electronically in a
    standardized fashion for future reference.
    VI. Systematic Analysis and Systemic Action
    a. Any change that is made has the potential to have broader impact than intended. If you are trying
    to make a change to a specific system or process, it is important to recognize any “unintended”
    consequences of your actions. Describe how your organization will identify these consequences
    which may be either positive or negative.
    b. Describe the process you will use to ensure you are getting at the underlying causes of issues, rather
    than applying quick fixes that address symptoms only.
    VII. Communications
    Outline the audiences for QAPI communications and the frequency and format of these
    communications.
    VIII. Evaluation
    a. Describe the process for assessing QAPI in your organization on an ongoing basis. (See QAPI SelfAssessment Tool.)
    b. Describe the purpose of this evaluation – to help your organization to expand your skills in QAPI
    and increase the impact of QAPI in your organization.
    IX. Establishment of Plan
    a. Date your plan.
    b. Determine when you will revisit the plan (i.e., at least annually).
    c. Determine how you will track revisions or updates to the plan.
    Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor
    does its completion ensure regulatory compliance.
    QAPI at a Glance Apendix A
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    Guide for Developing a QAPI Plan
    c. Describe how you will monitor to ensure that interventions or actions are implemented and effective
    in making and sustaining improvements.
    Goal Setting Worksheet
    Directions: Goal setting is important for any measurement related to performance improvement. This
    worksheet is intended to help QAPI teams establish appropriate goals for individual measures and also for
    performance improvement projects. Goals should be clearly stated and describe what the organization
    or team intends to accomplish. Use this worksheet to establish a goal by following the SMART formula
    outlined below. Note that setting a goal does not involve describing what steps will be taken to achieve
    the goal.
    Describe the business problem to be solved:
    Use the SMART formula to develop a goal:
    SPECIFIC
    Describe the goal in terms of 3 ‘W’ questions:
    What do we want to accomplish?
    Who will be involved/affected?
    Where will it take place?
    MEASURABLE
    Describe how you will know if the goal is reached:
    What is the measure you will use?
    What is the current data figure (i.e., count, percent, rate) for that measure?
    What do you want to increase/decrease that number to?
    Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor
    does its completion ensure regulatory compliance.
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    ATTAINABLE
    Defend the rationale for setting the goal measure above:
    Did you base the measure or figure you want to attain on a particular best practice/average score/
    benchmark?
    Is the goal measure set too low that it is not challenging enough?
    Does the goal measure require a stretch without being too unreasonable?
    RELEVANT
    Briefly describe how the goal will address the business problem stated above.
    TIME-BOUND
    What is the target date for achieving this goal?
    Write a goal statement, based on the SMART elements above. The goal should be descriptive, yet concise
    enough that it can be easily communicated and remembered.
    [Example: Increase the number of long-term residents with a vaccination against both influenza and
    pneumococcal disease documented in their medical record from 61 percent to 90 percent by
    December 31, 2011.]
    Tip: It’s a good idea to post the written goal somewhere visible and regularly communicate the goal during
    meetings in order to stay focused and remind caregivers that everyone is working toward the same aim.
    Disclaimer: Use of this tool is not mandated by CMS for regulatory compliance nor
    does its completion ensure regulatory compliance.
    QAPI at a Glance Apendix A
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    Goal Setting Worksheet
    Define the timeline for achieving the goal:
    Appendix B: QAPI Definitions
    Performance Improvement (PI)
    PI (also called Quality Improvement – QI) is a pro-active and continuous study of processes with the intent
    to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new
    approaches to fix underlying causes of persistent/systemic problems. PI in nursing homes aims to improve
    processes involved in health care delivery and resident quality of life. PI can make good quality even
    better.
    Performance Improvement Project (PIP)
    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.
    Quality Assurance and Performance Improvement (QAPI)
    QAPI is a data-driven, proactive approach to improving the quality of life, care, and services in nursing
    homes. The activities of QAPI involve members at all levels of the organization to: identify opportunities for
    improvement; address gaps in systems or processes; develop and implement an improvement or corrective
    plan; and continuously monitor effectiveness of interventions.
    Quality Assurance (QA)
    QA is a process of meeting quality standards and assuring that care reaches an acceptable level. Nursing
    homes typically set QA thresholds to comply with regulations. They may also create standards that go
    beyond regulations. QA is a reactive, retrospective effort to examine why a facility failed to meet certain
    standards. QA activities do improve quality, but efforts frequently end once the standard is met.
    Root Cause Analysis (RCA)
    Root cause analysis is a term to describe a systematic process to get to the underlying cause of a problem.
    Systems Thinking
    Systems thinking is a perspective that considers how things influence one another as a whole, rather than
    individual elements, or static “snapshots.”
    QAPI at a Glance Apendix B
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    QAPI Leadership Rounding Guide for AIT Students:
    Skilled Nursing Facility Template
    AIT Student Name:
    Date:
    CMS Compare Website Link
    Section 1: Basic Facility Information
    Complete Section 1 using the CMS 2567 Report and the information found on the CMS Compare website.
    General Facility Information – Section 1
    Provide a response to each item listed below and adjust spacing as needed for your responses.
    SNF Provider Name:
    City and State of the SNF:
    Number of Certified Beds:
    Ownership Type:
    Health Inspection Details from CMS Compare Website -Section 1
    Provide a response using the View Inspection Results, View Staffing Levels, and View Quality
    Measures information from the CMS Compare Website. Adjust spacing as needed for your responses.
    Date of Most Recent Inspection:
    Total Number of Health Citations:
    Number of Complaint from the Past 3 Years:
    Average Number of Residents per Day:
    Total Number of Licensed Nurse Staff Hours per Resident per Day:
    Registered Nurse Hours per Resident per Day:
    Physical Therapist Staff Hours per Resident per Day:
    Select 1 Detail that You Found the Most Interesting about this SNF on the CMS Compare
    Website and Provide the Information Below:
    CMS 5-Star Ratings
    Overall Rating
    Health Inspection
    Staffing
    Quality of Resident Care
    Note: Use the Section 1 information, along with any other relevant details, from the CMS
    Compare Site on your selected facility to complete the rounding questions in Section 3.
    Section 2: SNF F-Tags Citation Information
    Complete Section 2 using the CMS 2567 Report and the information found on the CMS Compare website.
    CMS 1567 Report: F-Tag Selection Information– Section 2
    Provide a response to each item listed below and adjust spacing as needed for your responses.
    F-Tag Citation 1 Information
    F-Tag Number and Tag Title:
    Code of Federal Regulations (Regulatory Reference):
    Level of Harm (as stated on 2567):
    Residents Affected (as stated on 2567):
    QAPI Leadership Rounding Guide for AIT Students:
    Skilled Nursing Facility Template
    F-Tag Citation 2 Information
    F-Tag Number and Tag Title:
    Code of Federal Regulations (Regulatory Reference):
    Level of Harm (as stated on 2567):
    Residents Affected (as stated on 2567):
    Example of SNF Citation (F-Tag) Information:
    (Information can be located under ID Prefix Tag on the 2567 and by using the CMS SNF F Tags List within the
    assignment prompt.)
    F-Tag Number and Tag Title: F572 -Notice of Rights and Rules
    Code of Federal Regulations (Regulatory Reference): 483.10 Resident Rights
    Level of Harm (as stated on 2567): Minimal harm or potential for actual harm
    Residents Affected (as stated on 2567): Few


    Compare Your Selected SNF to 2 Other SNFs: Submit as Part of the Assignment
    Remember to Select 2 Comparable SNFs to your selected SNF (3 SNFs in total), up to a 200mile radius, using the compare function on the CMS Compare Site.
    You can use the Print function on the CMS Compare website and save the information in PDF
    format to include the information in your submission. See example PDF in assignment prompt.
    Section 3: SNF QAPI Leadership Rounds
    1. Respond to each question below as though you are physically rounding in your SNF with
    some of your leadership team members.
    2. Complete Section 3 Using:
    a. Your selected SNF CMS 2567 Report from the assignment prompt.
    b. The information found on the CMS Compare website.
    c. The facility and/or organization’s website, if applicable.
    d. Include any research you found to assist you in your responses for question
    presented below.
    3. Support your information, comments, and recommendations with scholarly external
    evidence.
    4. All scholarly references must be from the last five years, you may use prior references
    provided within the report.
    5. Include a minimum of three APA 7th Edition formatted references with correlating intext citations for …

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