Quality Assurance and Performance Improvement Plan Template (QAPI)
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TABLE OF CONTENTS
I.
Disclaimer
II.
Introduction to the Quality Assurance and Performance Improvement (QAPI) Plan Template
III.
QAPI Goals A. Introduction to QAPI B. Organizational Mission, Vision and Values C. Goals
IV.
Design and Scope A. Fundamentals of Performance Improvement 1 Key Elements 2 Key Focus Areas 3 Limits of the QAPI Plan 4 QAPI Effort\ B. Objectives of the QAPI Plan
V. VI. VII.
VIII.
IX. X. XI.
Governance and Leadership Feedback, Data Systems and Monitoring Performance Improvement Projects (PIPs) A. Identification of PIPs B. Prioritizing PIPs C. PIP Project Charter D. PIP Team E. PIP Team Reporting Process Systematic Analysis and Systemic Action A. Performance Improvement Process Cycle B. Root Cause Analysis (RCA) C. Benchmarking Communications Evaluation Establishment of Plan
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DISCLAIMER This Quality Assurance and Performance Improvement (QAPI) plan template is presented as a model only by way of illustration. It has not been reviewed by counsel. Before applying a form to a specific use within your organization, it should be reviewed by a counsel knowledgeable concerning applicable federal and state health care laws, rules and regulations. The QAPI plan template should not be used or relied upon in any way without consultation with and supervision by qualified physicians and other health care professionals who have full knowledge of each residentʼs case history and medical condition. The QAPI plan template is offered to nursing facilities as a guideline for developing QAPI plans and for informational and educational purposes only. The development process included a review of government regulations, literature review, expert opinions and consensus. The guidelines strive to be consistent with these principles: • Relative simplicity • Ease of implementation • Evidence-based criteria • Inclusion of suggested, appropriate forms • Application to various long term care settings • Consistent with statutory and regulatory requirements • Use of state and federal government terminology, definitions and data collection
Appropriate staff at each facility/program should develop specific policies, procedures and protocols to best assure the efficient, implementation of the QAPI principles.
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INTRODUCTION TO THE QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT (QAPI) PLAN TEMPLATE The QAPI plan template development process included a review of government regulations, relevant literature, various performance improvement programs, expert opinions and consensus. The QAPI plan template design is relatively easy to use and customize. Current, evidence-based criteria for defining, advancing and sustaining performance improvement strategies have been incorporated into the document, as well as suggested forms and analytical tools. The plan template may be used in nursing and skilled nursing facilities, and sub-acute care facilities to assist in developing a facilityspecific QAPI program and plan. Health Quality Innovators (HQI) recommends that each facility designate a team of knowledgeable senior leaders, day-to-day managers, key clinical care and service, directors/supervisors, front line staff, consumers, community leaders and consultants to carefully review this plan template. The team should make thoughtful, appropriate adjustments in the template to produce a comprehensive, organizationspecific QAPI plan. Then, the governing board and/or senior management should review the draft plan, make appropriate adjustments as needed, and approve the plan. The approved plan will be documented as appropriate. HQI suggests that each facility/program conduct a formal review and revision as needed of its QAPI plan at regular intervals, not to exceed every twelve (12) months.
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Quality Assurance and Performance Improvement (QAPI) Plan
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Guidance:
Template:
QAPI Goals:
I.
Based upon the “Guide to Develop Purpose, Guiding Principles, and Scope for QAPI,” provided in QAPI at a Glance, indicate the QAPI goals that your plan will strive to meet. Goals should align with overall organizational services and initiatives. For example: Memory care Disease management Specialized rehabilitation programs Transitions of care Quality workforce
Goals should be specific, measurable, actionable, relevant, and have a timeline for completion. (See QAPI at a Glance Goal Setting Worksheet.)
QAPI Goals A. Introduction to QAPI Effective QAPI originates from the organization's leaders to instill a desire in the hearts of all staff to find and embrace better ways to get the right things done, and done well. QAPI is more than a task, a program, a process or a committee; it is the essential bridge to a successful future. The term “QAPI” is intended to communicate an organization-wide philosophy and process to regularly identify and implement constructive, cost-effective strategies to improve performance. This facility-wide performance improvement process includes identifying and implementing opportunities to improve the quality of resident care and quality of life, as well as other measures of organizational performance.
B. Organizational Mission, Vision and Values
C. QAPI Purpose Statement
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D. QAPI Goals
Clinical Care: Address how the facility will implement and integrate QAPI to provide the necessary care and services to attain or maintain the residentsʼ highest practicable physical, mental and psychosocial well-being.
II. Design and Scope A. Fundamentals of Performance Improvement 1. Key elements Organizational performance that achieves and sustains high quality care and services is a complex, interdependent process. is committed to ensuring continuing resources for key elements of the success of this QAPI plan including the following:
Quality of Life: Address how the facility will implement and integrate QAPI into the care for residents in a manner and in an environment that maintains or enhances each residentʼs quality of life. Resident Choice: Address how the facility will implement and integrate QAPI to promote person-centered care and protect and honor each residentʼs rights. Care Transitions:
a) Leadership that is competent, committed and stable b) Reliable capital and operational funding sufficient to achieve the mission c) Human resources d) An inclusive process supported by all stakeholders e) Selective, focused performance improvement initiatives 2. Key areas of focus It is the goal of the facility to integrate QAPI into all care and service areas of the organization. The following will be key areas of focus of the facility: a) Clinical care
b) Quality of life 7
Address how the facility will implement and integrate QAPI into transitions across varying levels of care to promote resident safety and continuity of care.
c) Resident choice
d) Care transitions Describe how QAPI will aim for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents and/or a residentʼs agent.
3. QAPI efforts Effective performance improvement efforts will focus on the development, maintenance and periodic improvement of systems that influence organizational outcomes. Systems will be designed and modified to achieve reliable, efficient outcomes. Objectives of the QAPI plan: a) Improve the quality of care thereby enhancing the quality of life for residents and other key stakeholders b) Improve quality of work environment c) Achieve improved outcomes that exceed regulatory standards The objectives of the QAPI plan will be implemented, monitored and assessed using evidence-based best practices, clinical guidelines, data and benchmarking. The plan and the outcomes will be used to determine appropriate care and to define and measure goals. 4. Limits of the QAPI plan
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Like all plans, this plan is an expression of intent that outlines a philosophy and a process for self-improvement. As such, this plan is intended to be flexible and to accommodate timely and appropriate adjustments to address seen and unforeseen circumstances, while adhering to the fundamental mission, vision and values of this organization Board of directors/governing body may include but are not limited to:
Chief Executive Officer (CEO) Chief Financial Officer (CFO) Shareholder Consumer Representative Community Representative Professional Representative
III. Governance and Leadership The governing body and the facility leadership are responsible for the development and leadership of the facility QAPI program. The governing body will take a proactive role in working with facility leadership to gather input from facility staff, residents and families. The governing body is responsible for oversight and direction of the QAPI program. The governing body will be responsible for establishing and approving policies to sustain the facilityʼs QAPI program and will set expectations around resident safety, rights, choice and respect. The leadership of the building will ensure appropriate and adequate resources are available for facility staff to carry out the QAPI plan.
Facility leaders may include but are not limited to:
Executive Director Administrator Assistant Administrator Director of Nursing
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Assistant Director of Nursing Director of Environmental Services Director of Dietary Services Director of Rehabilitation Services Director of Social Services Director of Activities
Feedback systems may include but are not limited to:
Resident/family satisfaction surveys Staff satisfaction surveys Resident council meetings Family council meetings Staff meetings Community partnerships Regulatory surveys Grievance/compliment logs Hotlines Contract vendor reports
Clinical data elements may include but are not limited to:
IV. Feedback, Data Systems and Monitoring The facility has in place systems to monitor care and services through multiple data sources. The facility feedback systems incorporate information obtained from staff, residents, families and others as appropriate. The facility uses performance indicators to monitor a wide range of care processes and outcomes. Data findings are assessed against facility established benchmarks and/or targets for performance. The facility will use benchmarking to compare outcomes against those of other long-term care facilities. The results of benchmarking analysis will aid the facility in identifying opportunities for changes in processes and systems to improve outcomes. Facility monitoring systems include processes to monitor adverse events and investigation protocols to include actions plan to prevent reoccurrences. Feedback systems may include but are not limited to the following:
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Falls Medication errors Polypharmacy Pressure ulcers Infections Vaccination compliance Nutrition Physical/chemical restraints Unplanned hospitalizations Unexpected deaths Dementia care Abuse/neglect Decline in functional status
Data systems may include but are not limited to the following:
Organizational systems may include but are not limited to the following:
Monitoring systems include but are not limited to the following:
Organizational data elements may include but are not limited to:
Safety-related parameters Employee illnesses Functional status of alarms (door, fire, bed/chair, etc.) Staff retention Regulatory survey outcomes Laundry services 11
Dietary services Environmental services Recreational programming Staff education/training Employee Immunization Criminal background checks
Monitoring systems may include but are not limited to:
My InnerView Team TSI/PointRight Incident reports Workers compensation claims Safety rounds Environmental rounds Leadership rounds Clinical rounds Focused clinical review Clinical observation Competency validation Committees such as; risk committee, safety committee, standards of care committee Organizational reports
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Benchmarking may include but is not limited to:
My InnerView Team TSI/PointRight CMS Casper reports Nursing Home Compare Organizational scorecard
V. Performance Improvement Projects (PIPs) A. Identification of PIPs Based upon feedback, data systems and monitoring procedures the facility will identify opportunities for improvement. As a result, the facility develops action plans in the form of PIPs. B. Prioritizing PIPs PIPs are focused on preventing problems and improving current systems and services. The facility seeks to prioritize PIPs that are high risk, high frequency, and/or problem prone to include issues that may affect the psychosocial well-being and rights of residents. The PIPs will serve the greatest good or ensure better comes. C. PIP project charter 13
Once the facility identifies the area of opportunity for improvement, the leadership will appoint a steering committee and develop a PIP committee. The steering committee will ensure that the PIP committee understands their roles and mission and has the required time and resources to implement the PIP. The PIP committee will report findings to the steering committee on an agreed upon meeting time, i.e. weekly, biweekly or monthly as appropriate for PIP. D. PIP team The PIP team will involve those individuals closest to the issue which often includes staff and resident/family participation. Before making a change to the process, participants will need to understand the whole process from start to finish. The PIP team will be expected to examine the path of the process for weaknesses and potential problems. The team will need to work well together and apply communication technique such as brainstorming in the development of change. E. PIP team reporting processes 1. The PIP team will schedule routine meeting times. During the meeting the team will review assigned duties/tasks, results of assigned work, plan progress, lessons learned and a project timeline. A designated member of the team will be responsible for documenting the meeting minutes. A copy of these minutes will be provided to the steering committee. 2. The PIP report to the steering committee will include, at a minimum: 1. Team member roles/responsibilities 2. The aim statement 3. The measurement parameters to identify improvement 14
4. 5. 6. 7. 8. Methods used to assess outcomes may include but are not limited to:
PDSA - Plan, Do, Study, Act SMART - Strategic, Measurable, Achievable, Relevant, Timely PI Cycle - Data, Information, Knowledge, Plan, Act, Evaluate DMAIC - Design, Measure, Assess, Improve, Control
Data being collected Data collection system/process Interventions/changes Outcomes Next steps
VI. Systematic Analysis and Systemic Action The facility leadership will be responsible for assessing the outcome and impact of changes implemented. Leadership should ask questions such as “Have the revisions or changes had a positive impact on resident outcomes?” or “Have the revisions or changes improved the residentsʼ quality of life?”
The facility will use a variety of tools for analysis to ensure underlying causes of issues are identified.
The facility will use a variety of methods to monitor progress to ensure that interventions or actions implemented are effective and sustainable.
Tools used to assess underlying cause(s) may include but are not limited to:
RCA - Root Cause Analysis Fish bone 15
Failure mode and effects analysis Investigation tools (falls, wounds, abuse/neglect, unplanned adverse outcome, etc.)
Methods to monitor effectiveness and sustainability may include but are not limited to:
Documentation audits Observational audits Benchmarking Performance evaluations Competencies validation
General meetings and times may include but are not limited to:
Stand up (daily) Huddles (daily) Standards of care/at risk meeting (weekly) Medicare/utilization review (weekly) QAPI (monthly)
VII. Communication The facility leadership team will share performance improvement data as appropriate while complying with confidentiality requirements to the governing body, staff, residents, families and the community. The data and information that includes appropriate records and documents will be available to select individuals based upon a need to know basis. The ability of the facility to produce, analyze, and maintain some performance improvement records as “confidential” is vital to the self-improvement process.
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Staff meetings (monthly/quarterly) Resident council (monthly/quarterly) Family council (monthly/quarterly) Board meeting (quarterly/annually) Corporate meetings (quarterly/annually) Ad hoc
The communication plan includes the process of education and training on QAPI principles and techniques for the governing board, senior management, PIP team members, staff, residents, families and community members. Education and training will be offered during regularly scheduled meetings, new hire orientation, PIP development and as needed.
General reporting methods may include but are not limited to:
Formal and confidential reports Formal and public reports Minutes Verbal reports
Timeframe may be:
Quarterly Six months Annually Ad hoc
VIII.
Evaluation
The facility will identify an interdisciplinary QAPI team to review the processes and systems for performance improvement. The QAPI team will utilize the QAPI selfassessment tool provided in QAPI at a Glance a mechanism for analysis. The QAPI team will complete an evaluation every 17
IX. Establish Plan
This material was prepared by Health Quality Innovators (HQI), the Medicare Quality Innovation Network-Quality Improvement Organization for Maryland and Virginia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. HQI|11SOW|20170209-185240
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