QAPI for Dummies - Home Care Answers (2022)

QAPI for Dummies - Home Care Answers (1)

What is QAPI in Home Health?

Most of the time, when people hear the word QAPI, they usually roll their eyes, grumble under their breath, or go glassy eyed and remember therapy recently completed therapy sessions. QAPI is something in home health that people don't really like to do, but have to do it.

So, what is it? QAPI means Quality Assessment and Performance Improvement. QAPI is required for home health agencies as a condition of participation. It is listed as this in the link for conditions of participation.

484.65 Condition of participation: Quality assessment and performance improvement (QAPI). You can read all about reading theConditions of Participation. It is some light reading.

One of the biggest headaches we hear about is QAPI. It is the job no one really wants to do, has to get done, and is easily overwhelming.

What are the 5 Elements of QAPI?

(Video) QAPI for Home Health: Part 1

Here is the text of the introduction for QAPI from the CMS website. Develop, implement, evaluate, and maintain are just some of the words. Not only does it have to be on going, but it has to be data driven. Here is what it says:

"The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS." But wait, there's more:

Here are the 5 Standards of QAPI per the Conditions of Participation (COPs).

  • Program Scope
  • Program Data
  • Progam Activities
  • Performance Improvement Projects
  • Executive Responsibilities

We will briefly go over these 5 things, and then offer some suggestions on how we can help with some of these elements.

Program Scope

An Agency's QAPI program needs to show measurable indicators and that those indicators will improve outcomes, patient safety, and quality of care. Basically, it's saying that you have to measure something that is measurable and helpful to patients and the agency. Agencies then need to be able to track certain quality indicators "including adverse patient events" and other key indicators that shows that an agency is trying to and tracking improvement in outcomes and operations.

Program Data

(Video) PART 1 - Home Care QAPI | Develop and Implement Your Own Program.

Agencies need to use OASIS driven data, along with other relevent data, to track the indicators in designing the QAPI program. The agency then needs to actually do something with the data that can track and monitor the effectiveness of the QAPI program and identifies areas of improvement.

Program Activities

QAPI must focus on the high risk, high volume, or problem prone areas. Agencies need to be able to understand the what, where, how, how much and how often, and why of operational challenges that could impact patient health and safety. These activities need to track adverse patient events and then find out what and how those events happened, and then put corrective action plans in place so those things can be eliminated or avoided in the future. "The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained."

Performance Improvement Projects

Agencies must now do something about the areas of improvement that have been identified and track them. These projects need to reflect the complexity of the agency, document the projects undertaken, why they were undertaken, and the measurable progress achieved from the projects.

Executive Responsibilities

Home health leadership must be involved in the QAPI program and its oversite. Management needs to make sure that the program is defined, implemented, and maintained. It needs to be managed by managers! Further management needs to set priorities for QAPI and its efforts to improve the quality of care, patient safety, operational excellence, and that the improvement actions are evaluated. If any fraud or waste is discovered, then it needs to be immediately addressed and corrected.

(Video) Home Care QAPI - Part 2

What is a QAPI Plan?

Home Care Answers not only provides quality service through coding and OASIS review to ensure OASIS is correct, we also provide data analytics to help agencies improve. We provide you with your own data in a way that you can do something with it! Agencies need to use OASIS driven data for the QAPI program. Do agencies know and understand what OASIS questions are most frequently answered incorrectly? Do they know that by Clinician? Well, we can help! Below, you will see a chart that shows an agency that recently signed on to work with us. We provide data analytics for several groups of OASIS questions. Below, you can see what ADL questions we are suggesting changes on the most often.

ADL/PDGM OASIS Questions

M1860 Ambulation107 / 155 Changed 69.030%

M1830 Bathing86 / 155 Changed 55.480%

M1850 Transferring82 / 155 Changed 52.900%

M1810 Dress Upper Body61 / 155 Changed 39.350%

(Video) Home Care QAPI Deficiencies on the Rise Across the Country

M1820 Dress Lower Body53 / 155 Changed 34.190%

M1840 Toileting52 / 155 Changed 33.550%

As you can see, M1860 we are suggesting changes on this question 69% of the time. Bathing, 55% of the time. These questions certainly can impact quality outcomes patient safety. If a clinician scores a patient as independent, but the patient has advanced Parkinson's disease, dimentia, and other issues, the patient very likely is not independent and needs at least supervision for bathing an ambulating, if not more. Incorrect understanding and a knowledge gap on ADL questions can certainly impact patient safety and outcomes. Agencies can use this data to identify and track these two questions as they are relevant to the agency.

Below, an agency can track the improvement, or lack of improvement, through our reporting system. As an example below:

The agency uses our data to identify that there is a knowledge gap on M1860, M1830, and M1850 quarterly. The plan is to conduct training for all staff on these questions in January with follow up monthy and track the progress every quarter. Below is what the data shows the agency for a benchmark in the 1st Quarter ending 3/31/21.

QAPI for Dummies - Home Care Answers (2)

Let's say that there is a training specifically on these three M Questions on April 1. We can then track from April 1 until now to see what the progress is.

(Video) What's QAPI

QAPI for Dummies - Home Care Answers (3)

Notice, that we suggested changes on M1860, M1850, M1830 as follows: The agency went down to 65% from 70% in M1860, that's improvement! M1850 went up to 58% from 51%, a decrease. Bathing went from 58% to 49%, that's improvement also! So, the agency needs to focus and document training on M1850 to show improvement. These questions can certainly help with patient help and safety, we help with data driven analysis of the QAPI project, and it is absolutely in scope of the agency. QAPI accomplished!

We would love to help you with QAPI. It is a difficult job that never ends, is hard to remain relevant for staff, and can be cumbersome. Management can use the data to make sure that staff understands the importance of the project, give support to agency staff for QAPI, but can give a lot of the legwork to us, so that you can document and file the activities and projects to remain compliant with conditions of participation. Let us help you use data to tame QAPI! Click here to contact us for a free review of charts to identify problem areas for your staff.Claim your FREE 10 chart review!

FAQs

What are the 5 elements of QAPI? ›

  • Element 1: Design and Scope. ...
  • Element 2: Governance and Leadership. ...
  • Element 3: Feedback, Data Systems and Monitoring. ...
  • Element 4: Performance Improvement Projects (PIPs) ...
  • Element 5: Systematic Analysis and Systemic Action.

How many elements are there in QAPI? ›

QAPI is then further divided into five elements as defined by CMS below. Each of these five elements must be an integral part of your QAPI process in order to build a successful program.

Which element of QAPI addresses clinical care quality of life and resident choice? ›

Element 1: Design and Scope

When fully implemented, the QAPI program should address all systems of care and management practices, and should always include clinical care, quality of life, and resident choice.

What is the following principle of QAPI? ›

Guiding Principle #5: QAPI focuses on systems and processes, rather than individuals. The emphasis is on identifying system gaps rather than on blaming individuals.

How do I write a QAPI plan? ›

  1. Write the Purpose of Your Organization's QAPI Plan. ...
  2. List of Services You Provide to Residents. ...
  3. Describe How Your QAPI Plan Will Address Key Issues. ...
  4. Current Quality Assessment and Assurance Activities. ...
  5. Use of Best Available Evidence. ...
  6. Responsibility and Accountability. ...
  7. Describe How QAPI Will Be Adequately Sourced.

Is QAPI mandatory? ›

The Affordable Care Act of 2010 requires nursing homes to have an acceptable QAPI plan within a year of the promulgation of a QAPI regulation.

How often are QAPI meetings held? ›

The facility must maintain a Quality Assessment and Assurance (QA&A) committee consisting of the Director of Nursing, Physician, and three other members of the facility staff. The QA&A Committee must: Meet at least quarterly.

What is an example of a weak corrective action? ›

Examples of Weak Actions: Double checks. Warnings/labels. New policies/procedures/ memoranda.

What are QAPI activities? ›

Quality Assurance and Performance Improvement (QAPI) is a data driven and proactive approach to quality improvement. It combines two approaches - Quality Assurance (QA) and Performance Improvement (PI). QA is a process used to ensure services are meeting quality standards and assuring care reaches a certain level.

What is QAPI benchmark? ›

Benchmarking is the process of comparing a set of results to these best practices and performances. For example: ∎ A benchmark for physical restraints in nursing homes might be zero, as many homes have achieved this rate.

What is PIP in QAPI? ›

A Performance Improvement Project (PIP) is a concentrated effort on a particular problem in one area of the facility or facility wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements.

What is a QAPI report? ›

Quality Assurance and Performance Improvement (QAPI) is a data driven and proactive approach to quality improvement. All members of an organization are involved in continuously identifying opportunities for improvement.

How do you write a Performance Improvement plan Example? ›

How to write a performance improvement plan
  1. Determine acceptable performance. ...
  2. Create measurable objectives. ...
  3. Define what support the employee will receive. ...
  4. Draw up a schedule for check-Ins. ...
  5. State the consequences of a lack of improvement.
21 Dec 2021

What is discussed in QAPI meeting? ›

QAPI tackles identified problems, such as underperforming quality measures or high staff turnover, but it also proactively seeks out weaknesses in systems before problems occur and initiates improvements to prevent poor outcomes. QAPI is formed by merging reactive and proactive approaches.

What is QCP certification? ›

The QAPI Certified Professional (QCP) education and certification program is intended for members of the QAPI/QAA committee and covers all aspects of QAPI from theory to application-based strategies. Learn how to translate data into actionable information and drive performance improvement.

Why do we do QAPI? ›

QAPI takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving.

Who uses QAPI? ›

The QAPI rule requires that all nursing homes establish and implement effective, comprehensive, data-driven QAPI programs that focus on systems of care, including indicators of outcomes of care, quality of life, and resident and staff satisfaction.

What is the difference between quality assurance and performance improvement? ›

The first approach, quality assurance, is the process of meeting standards and assuring that care reaches an acceptable level. The second, performance improvement, is the pro-active, continuous study of processes with the intent to prevent or decrease the likelihood of problems.

What is a difference between corporate compliance and quality assurance and quality improvement QAPI programs? ›

The distinction is clear: QAPI is primarily designed to ensure standards of care and service, and the compliance and ethics program is designed to ensure legal compliance.

What is a PIP charter? ›

What is a project charter? A project charter clearly establishes the goals, scope, timing, milestones, and team roles and responsibilities for an Improvement Project (PIP).

What are the three corrective actions? ›

Corrective actions can include engineering controls, process changes, or personal protective equipment (PPE) and are usually initiated once root causes are identified.

What is a good corrective action? ›

An effective corrective action plan identifies the root cause of problems and prevents their recurrence with rigorous documentation. The CAP aims to resolve the root cause of the issue rather than just address the surface signs. A corrective action plan template can help mitigate similar issues in the future.

What are the two types of corrective action? ›

There are two types of corrective action: immediate and preventative.

How often must the QAPI Committee meet at minimum? ›

The QAA Committee must meet at least quarterly and be comprised of the Director of Nursing, the Medical Director (or designee) and three additional members of the facility.

Which element of QAPI includes identifying reporting analyzing? ›

Element 5: Systematic Analysis and Systemic Action

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.

What is quality improvement? ›

Quality improvement is the framework used to systematically improve care. Quality improvement seeks to standardize processes and structure to reduce variation, achieve predictable results, and improve outcomes for patients, healthcare systems, and organizations.

Does your QA&A Committee and QAPI steering committee must be two separate entities? ›

Your QA&A committee and QAPI steering committee must be two separate entities.

What is QAPI in dialysis? ›

Knowledge and active leadership with a hands-on approach in the quality assessment and performance improvement process (QAPI) is essential for the achievement of high-quality outcomes in dialysis centers.

What are some examples of quality improvement in healthcare? ›

What are Examples of Quality Improvement Initiatives in Healthcare?
  • Reduction in medication-related adverse events.
  • Optimization of sepsis care.
  • Decreased number of urinary catheter infections.
  • Reduced hospital readmissions.
  • Decreased medication administration errors.
  • Improved electronic medical record documentation.
28 Jan 2022

How do you improve performance of a project? ›

Five steps to an effective Performance Improvement Plan
  1. Identify any underlying issues. Before you start to put the plan together, make sure you are fully aware of any issues which may be behind poor performance. ...
  2. Involve the employee. ...
  3. Set clear objectives. ...
  4. Agree training and support. ...
  5. Review progress regularly.
28 Jan 2020

What does QAPI mean quizlet? ›

Quality Assurance and Performance Improvement.

What are QAPI activities? ›

Quality Assurance and Performance Improvement (QAPI) is a data driven and proactive approach to quality improvement. It combines two approaches - Quality Assurance (QA) and Performance Improvement (PI). QA is a process used to ensure services are meeting quality standards and assuring care reaches a certain level.

What does QA in QAPI stand for? ›

Quality Assurance &

Performance Improvement. Effective QAPI programs are critical to improving the quality of life, and quality of care and services delivered in nursing homes.

What is QAPI benchmark? ›

Benchmarking is the process of comparing a set of results to these best practices and performances. For example: ∎ A benchmark for physical restraints in nursing homes might be zero, as many homes have achieved this rate.

What is PIP in QAPI? ›

A Performance Improvement Project (PIP) is a concentrated effort on a particular problem in one area of the facility or facility wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements.

What is an example of a weak corrective action in QAPI? ›

Examples of Weak Actions: Decrease workload. Software enhancements/ modi cations. Checklists/cognitive aids/ triggers/prompts.

How often should QAPI meet? ›

The facility must maintain a Quality Assessment and Assurance (QA&A) committee consisting of the Director of Nursing, Physician, and three other members of the facility staff. The QA&A Committee must: Meet at least quarterly.

How often must the QAPI Committee meet at minimum? ›

The QAA Committee must meet at least quarterly and be comprised of the Director of Nursing, the Medical Director (or designee) and three additional members of the facility.

What is the difference between quality improvement and performance improvement? ›

Overview. Quality improvements focus on impacting the quality of healthcare directly. Performance improvements focus on the administrative systems performance. Both can be prospective or retrospective and aim at improving how things are done.

What is the purpose of Quality Assurance in healthcare? ›

It involves assessing or evaluating quality; identifying problems or issues with care delivery and designing quality improvement activities to overcome them; and follow-up monitoring to make sure the activities did what they were supposed to.

What is the difference between Quality Assurance and performance improvement? ›

The first approach, quality assurance, is the process of meeting standards and assuring that care reaches an acceptable level. The second, performance improvement, is the pro-active, continuous study of processes with the intent to prevent or decrease the likelihood of problems.

What is a threshold in quality improvement? ›

Thresholds: A minimum value assigned to 7 of the Quality Indicators which serves as a benchmark of performance and it linked to the data. These thresholds identify areas of performance which may warrant a further review of agency performance or situation.

Which element of QAPI includes identifying reporting analyzing? ›

Element 5: Systematic Analysis and Systemic Action

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.

What is quality improvement? ›

Quality improvement is the framework used to systematically improve care. Quality improvement seeks to standardize processes and structure to reduce variation, achieve predictable results, and improve outcomes for patients, healthcare systems, and organizations.

How do you write a performance improvement Plan Example? ›

How to write a performance improvement plan
  1. Determine acceptable performance. ...
  2. Create measurable objectives. ...
  3. Define what support the employee will receive. ...
  4. Draw up a schedule for check-Ins. ...
  5. State the consequences of a lack of improvement.
21 Dec 2021

What are some examples of quality improvement in healthcare? ›

What are Examples of Quality Improvement Initiatives in Healthcare?
  • Reduction in medication-related adverse events.
  • Optimization of sepsis care.
  • Decreased number of urinary catheter infections.
  • Reduced hospital readmissions.
  • Decreased medication administration errors.
  • Improved electronic medical record documentation.
28 Jan 2022

How do you approach a performance improvement plan? ›

Consider these 5 tips as you craft the performance improvement plan and prepare for your conversation:
  1. Be specific and objective. Clearly convey exactly why the employee's productivity and/or behavior isn't up to par. ...
  2. Align on a plan. ...
  3. Acknowledge all potential outcomes. ...
  4. Follow up regularly. ...
  5. Document the conversations.
17 Nov 2021

Videos

1. Nursing Home QAPI -- What's in it for You?
(CMSHHSgov)
2. Using QAPI in Nursing Homes Part 1 - Brainstorming (August 3, 2022 Webinar)
(Quality Insights Quality Innovation Network)
3. QAPI: Making a Difference
(Comagine Health)
4. Webinar | Leading Effective QAA/QAPI Meetings
(Lake Superior Quality Innovation Network (Lake Superior QIN))
5. Quality Assurance Performance Improvement (QAPI) Self-Assessment
(Lake Superior Quality Innovation Network (Lake Superior QIN))
6. Setting a Foundation for Your QAPI Program
(Mountain-Pacific Quality Health)

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