QAPI Governance and Leadership

Overview Affordable Care Act of 2010 requires nursing homes to have an acceptable QAPI plan Building care systems based on QAPI philosophy ensures a systemic, comprehensive, data-driven approach to care This effort is about continually aiming higher

Disclaimer Developed as an educational program and for reference, and not as a standard or practice. Content cannot be considered absolute and universal, as guidance and interpretations will be forthcoming. As always, individual organizations are responsible for compliance with applicable regulations.

Objectives Identify and explain leadership responsibility related to QAPI Describe how to develop a leadership team and components required Express components needed when coordinating QAPI resources

Introduction Each nursing center needs to have a governing body for QAPI Governing body and/or administration of the nursing center develops a culture that involves leadership seeking input from facility staff, residents, and their families and/or representatives.

Governing Body The governing body assures adequate resources exist to conduct QAPI efforts. This includes, but not limited to: Designating one or more persons to be accountable for QAPI Developing leadership and facility wide training on QAPI Ensuring staff time, equipment, and technical training as needed

Governing Body Responsibilities Foster a culture where QAPI is a priority by ensuring policies are developed to sustain QAPI despite changes in personnel Setting expectations around safety, quality, rights, choice and respect by balancing accountability Creating an atmosphere where staff are comfortable identifying and reporting quality problems as well as opportunities for improvement

Governing Body QAPI Regulation s Required to ensure QAPI program is defined, implemented and maintained and address identified priorities QAPI program sustained during staff transition Corrective actions address gaps in systems and are evaluated for effectiveness QAA committee must report to governing body about its activities

Governing Body and Leadership Team Governing body could be a owner, board director, etc. Leadership Team would more than likely be those at the facility level: Administrator, Director of Nursing, Quality Leader, QAPI Coordinator, etc.

Leadership Team Considerations: Give residents, family and staff opportunities to meet governing body and/or executive leadership Tour the organization, regularly meeting with residents and caregivers where they live and work Choose person(s) who will be the QAPI leads in conjunction with top management (QAPI Champion) Conduct QAPI roll out meeting with residents, families and staff

Leadership Team Responsibility for Developing and modifying the QAPI plan Reviewing relevant information for priorities for PIPs Drawing in employees from all levels of organization Utilize QAPI Leadership Rounding Guide from CMS

Choosing your Leadership QAPI Team Consider member characteristics Positive attitude Capable of critical thinking Commitment to QAPI program and believes in process System thinking Calm and confident Commitment to organization Transparency Passion for residents and co-workers at the facility

Choosing your Leadership QAPI Team There are many different leadership styles A person may have one leadership style or several styles Using a blend of styles, which may change depending on the situation, is most effective as there are many different scenarios that the QAPI team will have to address Utilize QAPI at a Glance-provided by CMS to identify and build your Leadership QAPI/steering committee

QAPI Performance Objectives for Job Descriptions All job descriptions should be oriented to support QAPI efforts Administrator, Director of Nursing, Quality Leader, Rehab, Dietary, Social Services, Nursing, General Staff, Medical Director Utilize Examples of Performance Objectives for Job Descriptions and Performance Reviews Tool from CMS

QAPI Resources Employees at all levels need to attend meetings and work on projects/PIPs How will their assignment be covered in their absence Have to be creative in meeting staffing requirements and still allowing employees to participate Schedule meetings at least busy times of day Do short huddles, vs timed and long meetings Ask your staff best way to manage this

QAPI Resources Some potential items that may be needed: Resource manuals Computers Printer and supplies Flip charts “marketing budget: flyers, invitations, interactive tools, etc. Consider allocating budget line for QAPI Resources

Conduct a QAPI Awareness Campaign Strategies to convey the QAPI message: Provide ongoing QAPI education to staff, resident and family Communicate QAPI approach with consultants, contractors, and other collaborating agencies Convey the message that any and every caregiver is expected to raise quality concerns Convey the message to residents and families that their vies are valued and desires Share QAPI information at resident council and in communication with families Campaign slogan buttons, posters, newsletters, storyboards