QAPI: A Steep Learning Curve for Many

Compliance Conceptual MeterI am becoming increasingly concerned that many, if not most, post-acute/long-term care organizations are poorly prepared to embrace the requirements of the looming Quality Assessment Performance Improvement (QAPI) reporting requirements mandated by the Affordable Care Act. I base that conviction on how much I have learned over the past few years working with my colleague, Nathan Ives, of Strategy Driven Enterprises, LLC.

A graduate of the United States Naval Academy, for over two decades Nathan has been immersed in the world of quality assessment, performance improvement and regulatory compliance as each has applied to the nuclear power industry. He has held several influential positions at the Institute of Nuclear Power Operations (INPO) and has led teams of nuclear operations professionals in the performance evaluation of over 24 nuclear electric generating stations from 20 utilities in the United States, Canada, and Japan. He also led the nuclear industry’s effort to redefine performance standards in the areas of organizational alignment, managerial decision-making, plant operations, and risk management.

For the past two years, Nathan has been working with my Artower colleague, Terri Williams, RN, on developing EviQual™, a turnkey regulatory compliance solution that PA/LTC organizations can use to create a QAPI program. Terri has nearly 30 years of experience as a practitioner, educator and advocate for quality improvement and patient safety at PA/LTC facilities. Now, as a I have neither an operational engineering nor clinical background, for me it has been a fascinating learning experience. And what I have learned primarily is that QAPI – as understood from how it has been applied in other industries – is an entirely different approach to outcome quality and patient safety than what most PA/LTC organizations are currently familiar with.

Whereas historically those organizations have focused a great deal of attention on observing, recording and diagnosing the cause(s) of adverse events, the whole point of a quality assessment program is to proactively diagnose existing practices, policies and performance to create an environment in which such events don’t happen in the first place. It is a paradigm shift in thinking and approach that for most organizations must be accompanied by changes in organizational culture.

That’s why in creating EviQual™ we have sought to leverage the already existing knowledgebase of what has been proven effective in improving quality and safety in an industry that has many parallels with healthcare. In fact, Nathan and I collaborated on a white paper  some time ago on the applicability of lessons learned in the nuclear power industry to aligning healthcare organizations via quality and performance improvement.

The Centers for Medicare and Medicaid Services has made available QAPI at a Glance, a step-by-step guide focusing on 12 core elements ranging from organizational sponsorship and leadership to tactical  program implementation. A very well written accompaniment to that guide was just recently completed as a series of articles for Long-Term Care Magazine by Nell Griffin, LPN, EdM. Both are wonderful resources if you are new to understanding QAPI and the important ramifications it will have on PA/LTC organizations.

The first step in the 12-step process for implementing a QAPI program focuses on leadership, responsibility and accountability. What this requires is the active and committed sponsorship of the QAPI process by senior executives and board members. So when I hear leadership teams at PA/LTC organizations say they are confident their clinical teams are proactively addressing the QAPI requirements, I can’t help but fear those organizations have already stumbled out of the gate.

Cheers,
  ~ Sparky

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QAPI ~ Ready (or Not?)

2013-01-09_14251sI have been receiving a fair amount of anecdotal intelligence that many post-acute/long-term care providers are not at all prepared to implement the Affordable Care Act’s QAPI when (still waiting . . . ) those regulations ultimately get published. So I thought sharing this post again might be useful.

Section 6102(c) of the Affordable Care Act – Quality Assurance and Performance Improvement Program (or QAPI) requires the Secretary of Health and Human Services (as delegated to CMS) to, “establish and implement a quality assurance and performance improvement program …” and to, “…establish standards relating to quality assurance and performance improvement with respect to [nursing] facilities and provide technical assistance to facilities on the development of best practices in order to meet such standards.“

Last Friday CMS released a memorandum to state survey agency directors announcing the rollout of electronic assistance and compliance-oriented materials on the QAPI website. HHS/CMS has still not yet published the condition of participation regulation that will provide nursing facilities with compliance guidance (facilities were to have already been compliant in March of this year), but there already exists comparable regulations for other healthcare provider types that will serve as a template. Once that regulation is finally published nursing care providers will have one year to develop an acceptable QAPI plan.

QAPI compliance for nursing facilities is not entirely new. The nursing facility QAPI is based in part on existing Quality Assessment and Assurance (QA&A) regulations. However, the new planning and reporting provision significantly expands the level and scope of QAPI activities that nursing facilities must enact in order to ensure they continually identify and correct quality deficiencies as well as sustain performance improvement.

It is a tad ironic that in promoting a key differentiator between historic, traditional quality assurance – now being coupled with performance improvement – that while quality assurance is to be viewed as a requirement and reactive, performance improvement should be viewed as discretionary and proactive. Never mind that performance improvement is being mandated as part of the QAPI program. Sort of like being able to choose any whole number between zero and two, right?

Anyway, I really fear that for a lot of nursing facilities – particularly smaller and/or single site organizations – this requirement is going to sneak up on them. And the true impact of that reality will not just be the regulatory and economic consequences but the lost opportunity to utilize the QAPI process to drive better quality, higher safety and better outcomes – while lowering the overall cost of care.

There are two ways to view the new QAPI requirement: another onerous regulation designed to burden caregivers with unnecessary compliance requirements at additional cost; or an opportunity to sponsor and embrace a process that – if done strategically and conscientiously – should improve productivity and efficiency while strengthening market position based on quality and outcome characteristics.

So my counsel is don’t wait for the regulation to be promulgated. Start now to learn and understand the tools that have already been made available. CMS has stated that, once provided, the QAPI formal regulation will not contradict the materials that have already been developed and provided.

And for those organizations that are truly interested in taking a strategic approach to developing a continuous quality improvement system that has the complimentary advantage of combining regulatory compliance with value-driven financial performance, please review the white paper that I drafted with colleague Nathan Ives of StraegyDriven Consulting, Aligning Healthcare Organizations: Lessons in Improved Quality and Efficiency from the Nuclear Power Industry.

Cheers,
  Sparky

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