Harmony Healthcare Blog

Five Elements of a Successful QAPI Program (Part 2)

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Tue, Feb 28, 2017

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Edited by Kris Mastrangelo

C.A.R.E.

Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency


5steps.jpgHarmony Healthcare International (HHI) recommends facilities investigate the current strength of the QAA committee to determine how well the team is poised for the transition to QAPI.  If the team is meeting only quarterly to meet the minimum requirements, the facility will have a more difficult transition and will want to allow plenty of time to develop initiatives, data-streams, perform root cause to identify internal trends and time for subcommittee development for initiative ownership. 

There are 5 elements to a successful QAPI program:

  1. Element 1:  Design and Scope
     The QAPI Program must be ongoing and comprehensive.  It must address all services provided by the facility and it extends to all departments in the facility.  QAPI addresses clinical care, quality of life issues, resident choice, and safe and effective care transitions.  It will utilize the best available evidence to define and measure goals.  Facilities will be required to develop a written QAPI plan that adheres to these principles. 
  2. Element 2:  Governance and Leadership:
    The QAPI Program must be developed with input and participation from facility staff, residents, and family members/patient representatives.  It will be the responsibility of the governing body to confirm the QAPI program is given the resources that it needs, including staff time for meetings, training of key staff as necessary, ongoing functioning of the program even in times of staffing turnover, and accountability to the changes that the QAPI program makes.  The governing body also safeguards that staff accountability is balanced with a culture in which staff are not punished for errors and do not fear retaliation for reporting quality concerns.
  3. Element 3:  Feedback, Data Systems, and Monitoring
     It is not enough to create change for the sake of change; change must be meaningful.  Various sources of data to monitor care and services must be utilized.  The facility may use staff or resident surveys, admission and discharge data, internal compliance monitoring tools, and feedback from Resident Council, for example.  Benchmarks for facility performance must be set and success (or failure) must be monitored.  It also includes tracking and investigating all Adverse Events that happen in the facility, and monitoring the action plan implemented to prevent recurrences.
    PEPPER Analysis
  4. Element 4:  Performance Improvement Projects (PIPs) 
    PIPs are established based on topics the facility identifies as areas of concern or areas that need increased staff focus.  All staff should be encouraged to participate in a PIP that interests them.  Similarly, staff should feel free to suggest an area where a PIP may offer improvement or fine-tune an area in which the facility already does well.  PIPs are selected in areas important and meaningful to the specific type and scope of services unique to each facility.
  5. Element 5:  Systematic Analysis and Systemic Action
    The facility will adopt a systematic approach to determine when an in-depth analysis is needed to fully understand the problem.  Facilities will be expected to demonstrate proficiency in the use of the Root Cause Analysis to identify the cause, prevent future events, and promote sustained improvement.  The facility will have the goal of continual learning to stay abreast of current evidence-based solutions and to continuously improve the facility.

Need additional training or a better understanding of QAPI?  Join us for our upcoming QAPI Certification Courses (CHHi-QAPI).  Click here to see the dates and locations.


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Tags: QAPI

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