QAPI: Basic Building Blocks Governance & Leadership

QAPI: Basic Building Blocks
Governance & Leadership
Beth Hercher, CPHQ
June/July 2013
NH Quality Care Collaborative
Mission Statement:
The National NHQCC and its partners seek to ensure that every
nursing home resident receives the highest quality of care.
Specifically, the collaborative strives to:
Instill quality and performance improvement practices
Eliminate healthcare acquired conditions
Dramatically improve resident satisfaction by July 31, 2014
NHQCC: Local Initiative
Select group of Tennessee nursing homes, committed to this
national initiative, working together for 18 months to test
systems of change
Today’s Objectives
Understand the first 2 elements of QAPI: Design and
Scope and Governance and Leadership
Understand the difference between a vision statement
and a mission statement
How to align your vision and mission statement with a
Performance Improvement Project (PIP)
Apply QAPI elements 1 and 2 to your organizational
initiatives and culture
QAA Historical Perspective
OBRA 1987, established first quality of care legislation
and defined Quality Assessment and Assurance (QAA
F-520) as a:
Management process that is “ongoing, multi-level and
Framework for evaluating systems
Enforcement system for noncompliance
QAA Historical Perspective
2007 Kaiser Family Foundation Report recounts that the
Administration on Aging National Ombudsman System
Over 230,000 complaints in 2005 concerning nursing facility
residents’ quality of care, quality of life or residents’ rights
Citations for one or more deficiencies in 2006 for over 90% of
all certified facilities
One-fifth were cited for deficiencies that caused harm or
immediate jeopardy to its residents
QAA Historical Perspective
American Health Care Association (AHCA), released
2011 Annual Report:
New strides in quality of care reporting improvements in 9
out of 10 quality measures
Steady decline in health facility survey citations and
facilities cited for substandard quality of care
QAA Historical Perspective
“While things are moving in the right direction and people on
average are making improvements, not everyone is making
David Gifford, MD, MPH,
Senior VP of Quality and Regulatory Affairs
QAPI: Background
Requirement of the Affordable Care Act enacted in March
Legislation requires CMS to establish QAPI program
standards and provide technical assistance to nursing
Opportunity for CMS to develop and test QAPI
technical assistance tools and resources before the
rule promulgation
Transformational Change
CMS is challenging providers to create an environment
that promotes transformational change
This occurs through collaboration, partnership and
commitment to shift paradigms to a person-directed care
approach to quality improvement
QAPI: Framework
QAPI does not refer to a program; rather, it is the way
we do our work
The ability to think, make decisions and take action at
the system level is a prerequisite for QAPI success
5 Elements of QAPI
Design and Scope
Clinical care, quality of life, resident choice and care transitions
Governance and Leadership
Leadership working with staff, residents and families on QAPI
Feedback, Data Systems and Monitoring
Design, implementation, and monitoring of care and services
Performance Improvement Projects (PIPs)
Specialized projects of focus centered around a particular opportunity for
improvement or conducted facility-wide
Systematic Analysis and Systemic Action
A systematic approach to reviewing process and outcomes measures
5 Elements of QAPI
Design and Scope
Should address clinical care, quality of life, resident choice
and care transitions
Utilize the best available evidence to define and measure
Written QAPI plan adhering to these principles
5 Elements of QAPI
Governance and Leadership
Administration of the NH develops and leads a QAPI program
Administration supports working with and obtaining input from
facility staff, as well as from residents and families
Leadership should be responsible for sustaining QAPI, setting
expectations around resident’s safety, rights choice and
Staff are held accountable, but do not feel they will be
punished for errors so as to not fear reporting quality concerns
Building Blocks for QAPI - Facilitators
Beverly Patnaik
Charla Long
P. Elaine Griffin
Next Steps….
Breakthrough Collaboration:
will look
this plan
Breakthrough Collaboration: Learning
Sessions (LS)
All teach, all learn event
Highly interactive, engaging
Opportunity to learn from a set of strategies and change
Existing and fun educational experience
Breakthrough Collaboration: Action
Periods (AP)
The time between Learning Sessions
▪ Conduct tests of change
▪ Implement and spread improvements
– Inside and outside of facility
▪ Measure and report results
– Sharing calls
– Tracking tools
– Storyboard
Breakthrough Collaboration:
Outcomes Congress (OC)
Share lessons learned
Share sustainability concepts
Share spread concepts
Action Period 1 (July thru September)
July through September you and your QAPI team will be…
Participating on monthly coaching calls hosted by the
Qsource NH Team
Meeting with your QAPI team to review brief podcasts that
will assist you in achieving your goals and QAPI structure
Providing Qsource with a monthly progress report via Survey
Developing a storyboard (see handout for details)
Preparing for LS 2 scheduled for Fall 2013
12 Step Guide, QAPI and
Podcasts…oh my!
Say what…
The 12 Step Guide will be a companion to the CMS QAPI
At A Glance Toolkit
Podcasts will walk your team through the steps,
supporting tools and resources that will assist with the
next step
Will not replace QAPI toolkit; it will enhance it and align
with the CMS resources already developed
The 12 Step Guide and podcasts will be posted on the
NHQCC webpage beginning in late July
Podcast Topics:
How to conduct PDSA cycles
How to utilize the CMS Change Package for small tests of
change (PDSAs)
How to conduct an effective Root Cause Analysis
How to develop a “living” Storyboard
How to have a productive and effective QAPI team
How to use and track data for your Performance
Improvement Project
Qsource NHQCC Webpage Hot Topic
Tools & Resources:
Antipsychotic Reduction
Dementia Care/Person Centered Care
Consistent Assignment & Staff Stability
Mobility: Falls
TN NHQCC webpage
Beth Hercher, CPHQ
Quality Improvement Specialist
[email protected]
The presentation and related material was prepared by Qsource, the Medicare
Quality Improvement Organization (QIO) for Tennessee, under a contract with
the Centers for Medicare & Medicaid Services (CMS), a federal agency of the
Department of Health and Human Services (HHS). Contents do not necessarily
reflect CMS policy.
Nursing Home Team:
Beth Hercher, CPHQ
[email protected]
John Wright, SR, RN, BSN, WCC, BC
[email protected]
Julie Clark, LPTA
[email protected]
The presentation and related material was prepared by Qsource, the Medicare
Quality Improvement Organization (QIO) for Tennessee, under a contract with
the Centers for Medicare & Medicaid Services (CMS), a federal agency of the
Department of Health and Human Services (HHS). Contents do not necessarily
reflect CMS policy.

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