1. QAPI Governance and Leadership

2. 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

3. 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.

4. 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

5. 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.

6. 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

7. 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

8. 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

9. 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.

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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