QAPI From the Front Lines

One person lifts the word Compliant and others are crushed by non-compliance, as the winner follows 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

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