QAPI From the Front Lines

This is the PolicyPub’s first post by a contributing author. I have recently written on the upcoming QAPI mandate included in the Affordable Care Act and the impact that will have on nursing homes – particularly those unprepared (which I am coming to realize appears to be the majority).

I am thrilled to have my Artower colleague, Terri Durkin Williams, R.N., L.N.H.A., share her practical experiences with QAPI.

The Nursing Home industry is being challenged to develop quality programs that consistently maintain regulatory compliance. This shift in continuous improvement will require organizations to self-assess their operational performance. In turn, this will move organizations from the established routine of monitoring systems to self-assessments.

The federal government has mandated a Quality Assurance and Performance Improvement QAPI standard under the Affordable Care Act. This mandate was to be established and implemented in nursing facilities by December 31, 2011. As yet, regulations implementing the QAPI program have not been released by CMS.

The purpose of the QAPI program is to develop best practice in providing services and care to nursing home residents. This should be the mission of all health care providers. Waiting for the government to lead us in our business is jeopardizing organization survival both financially and in the delivery of services and care.

QAPI is not a new concept: it has been widely used in healthcare organizations for quite some time. The nuclear power industry has embraced this process to assure quality controls, safety, maintain regulatory requirements, increase efficiency and enhance the reputation of individual power plants. Achieving these goals requires a significant commitment of organizational time and personnel.

Given the tremendous cost pressures and narrowing reimbursement, however, management often judges such commitment as an unaffordable expense. The tendency is to not proceed with an in-depth evaluation of organizational functions. This is too often unfortunate short-sightedness of executive management. It leads to undesired consequences such as, poor care resulting in litigation, staffing turn-over, declining census, fines due to regulatory deficiencies, dissatisfied customers and increase in regulatory over-sight to just mention a few potential outcomes.

A common current practice in quality assurance programs is to monitor a task that is being performed by personnel. The evaluator observes the personnel and uses a check list to determine if the standard being monitored is compliant. The pitfalls of this approach include:

• Observers not being trained in a manner that results in the consistent application of standards used to perform the evaluation; i.e., the evaluation is based on the observer’s personal biases;
• Personnel performing to the standard while being observed;
• Personnel documenting what is required, but not assuring that care was delivered according to the established standard;
• Monitoring as a snapshot observation; it does not tell the entire story;
• Organizations using limited information that is gathered in the monitoring process to determine compliancy – this can give a false sense of success and prevent the exploration of best practices

Monitoring that  does not guide the organization to the root cause(s) of problems, does not allow for personnel to explain their performance and fails to obtain what knowledge the personnel have of the standard being monitored:

• limits the beneficial involvement of all personnel in the process;
• is often viewed by personnel as a punitive measure; and
• creates a disconnect in communication throughout the entire organization.

Poor preforming organizations tend not to take time to complete a comprehensive assessment of their operational issues and challenges. They may feel that they do not have time for a comprehensive assessment. This causes them to guess at what the problem is and just perpetuates a poor practice.

Example Case
I was recently involved working with an 84-bed nursing home that had seven (7) “immediate jeopardy’s” for a period of six and a half months. Their approach to quality assurance was to have nursing managers spend several hours a day monitoring and documenting problems. But there was no understanding of the root cause(s) of those problems. They received fines from CMS of over a half million dollars. This organization would have benefited from a self-assessment program.

The alternative to this chaos is planning for cultural change that will lead to best practices. The embracement of the self-assessments program exemplifies this and is characterized by the following:

• Supported by organizational leadership;
• Involvement of personnel at all levels within the organization to promote professional growth;
• Effective and efficient communication – a team working together and respecting each other;
• Focus on evaluating the most important aspects of the people, process, and technology;
• Comprehensive understanding based upon a collection of observations, record reviews, personnel interviews, benchmarking data, and other ongoing assessment information measured against specific criteria;
• Identification of performance deficiencies and potential causes, organizational strengths and weaknesses and opportunities for improvement
• Evaluates performance against established best practices;
• Provides opportunities to change the culture of the organization;
• Stabilizes daily operations, by consist expectations, policies and procedures and
• Establishes a culture whereby organizations control their business activities based on mission and purpose.

Key components of a successful self-assessment program include:

• Executive management and board leadership’s passion for excellence;
• Identification of an individual that is supported by leadership as the Team Leader in championing the Art of Quality.
• Entire self-assessment team educated on the organization’s mission and leadership’s expectations – and they are accountable for their actions;
• Defined sequence of the self-assessment process;
• Evidence based standards;
• Requisite IT support that facilitates the collection of relevant data, analyzes information and provides benchmarking; and
• An ability to have fun, learn and celebrate successes.

To explore how your organization can implement Artower’s EviQual™ Self-Assessment Program using evidence based practice contact me at twilliams@artoweradvisory.com or 216.244.2923.

  ~ Terri