QAPI Design and Scope

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 regulatory requirements for QAPI Recognize and be able to perform a QAPI self assessment Develop a QAPI plan that includes a mission, vision and guiding principles

Introduction QAPI : coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving. QA : is the specification of standards for quality of service and outcomes, and a process throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards. QA is on-going, both anticipatory and retrospective in its efforts to identify how the organization is performing, including where and why facility performance is at risk or has failed to meet standards.

Introduction PI : (also called Quality Improvement - QI) is the continuous study and improvement of processes with the intent to better services or outcomes, and prevent or decrease the likelihood of problems, by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems or barriers to improvement. 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. As a result, QAPI amounts to much more than a provision in Federal statute or regulation; it represents an ongoing, organized method of doing business to achieve optimum results, involving all levels of an organization.

Regulatory 483.75 Each long term care facility, including a facility that is a part of a multichain: Must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life Must maintain documentation and demonstrate evidence of ongoing QAPI programing Present its QAPI plan to State Survey Agency/Federal surveyor at each annual recertification survey and upon request during any other survey

Program Design and Scope Must be ongoing, comprehensive and address the full range of care and services provided by the facility Include all systems of care and management practices Include clinical care, quality of life and resident choice Utilize best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents Reflect the complexities, unique care, and services that the facility provides

Elements of QAPI These are your strategic framework for developing, implementing and sustaining QAPI QAPI plan should address all five elements Elements are closely related; likely working with all of them at once Plan is based on your own centers programs and services; needs of your particular residents and your assessment of your current quality challenges and opportunities

Element 1: Design and Scope

Tools for Success QAPI Self Assessment Tool-tool used as you begin work on QAPI and then for annual or semiannual evaluation of your organizations progress with QAPI Guide for Developing a QAPI Plan – intended to assist you in achieving what you have identified as the purpose, guiding principles and scope for QAPI. Living document that you will continue to refine and revisit Guide for Developing Purpose, Guiding Principles and Scope for QAPI – use this tool to establish purpose and guiding principles. Should include senior leadership on team completing this worksheet.

Tools for Success QAPI News Brief QAPI at a Glance Utilize these tools to begin your QAPI process