Five Practicalities You Need to Know About Your QAPI Program

Quality Assurance and Performance Improvement (QAPI) is a two-in-one approach that can either boost or harm your facility, going beyond just a rule in Federal statute. QA requires facilities to develop and implement appropriate plans of action to correct identified deficiencies. PI aims to improve processes in health care delivery and resident quality of life.

QAPI regulatory language is mentioned 125 times in the State Operations Manual and insufficiencies involve four FTags.

• F865 Quality Assurance Performance Improvement - Design and Scope, Leadership and Governance
• F866 Program Feedback, Data Systems and Monitoring - Performance Improvement Projects or PIPs
• F867 Systematic Analysis and Systemic Action - Root Cause Analysis
• F868 Quality Assessment and Assurance (QAA)

While we all agree that QAPI, by definition, has the best of intentions, we must also recognize the realities and challenges of the ongoing magnitude of managing the program.  The turnover of personnel creates issues of gaining traction to keep the momentum going.  Facility Administrators have likened management turnover to two steps forward and three steps backward.  When a key player leaves, the comprehension and background of identified issues start at square one.  Of course, surveyors don’t see it that way and expect fluidity and cohesiveness in all projects, regardless of the faces appointed to provide oversight. Ask yourself “How can I ensure the process continues even when the face of the responsible person changes?”

Let’s explore 5 ways you can stay ahead of the game during crisis management, complaint surveys, resident and family obligations, and day-to-day process surveillance.

1. Avoid appointing one person as the task leader. Instead, appoint a team of two or three from each department as ‘managers’ specializing in problem-solving.  Does this mean 15-20 people will attend your QAPI meeting?  Perhaps. Appointing a team rather than an individual cements the action process and will serve you best in the long run.
2. Meet monthly.  Disregard the Federal quarterly requirement.  Too much time is lost in waiting 90 days to review an issue. Have an agenda.  Stick to one hour.  As the Administrator, it is recommended you rotate and appoint someone who will lead the monthly meeting.  Involve others! Who will forward the agenda to those attending PRIOR to the meeting?  And who will summarize action steps from the last meeting to identify what is completed and what remains as a focus?  QAPI is not a one-man show, even though managers and staff see it that way. The Administrator is part of the QAPI framework. They are NOT the entire QAPI framework. We disengage ourselves from meetings in which we do not have any responsibility or ‘assignment’.
3. Expect attendance and expect engagement.  Everyone around the QAPI table has valuable input and suggestions. No one gets a pass to attend the meeting and says nothing.  Energy creates energy and refueling each other’s passions and expectations is key to resolving issues and developing unique ideas.
4. Ask the five whys.  Why. Why. Why. Why. Why. Drilling down to the why after the fifth time generally reveals the real problem and often presents its own solution.  For example, missing clothing or misplaced clothing is one concern commonly noted on grievance logs.  Often the solution is to make sure clothing is marked upon admission.  Think about how many unanswered questions there are with this issue and the standard resolution to ‘make sure clothing is marked’.  Who gathers the clothing from the resident, the family, or the EMT’s when the resident arrives at the facility?  Is the nurse responsible?  The CNA?  The laundry employee?  The Housekeeping/Laundry Supervisor?  What about on the weekends?  How can clothing be marked if it’s left in the closet at the time of admission?  Is there a designated bin for unmarked clothing in the laundry area with the rule that no clothing leaves the unmarked area until a name is inserted?  Does your facility have a label maker to identify clothing?  Who knows how to use it?  Do you use black markers to write in names?  Is there an ample supply of those?  How is the name addressed?  Initials only?  First initial, last name?  Is the name written on the back of the shirt at the neck area or on a side tag?  A review of this whole process could prevent missing clothing and resident/family frustration.
5. Share the issues.  Air your dirty laundry to your employees but in a professional and private manner.  Employees are part of the solution. If the night shift CNA isn’t aware of what is being discussed at the QAPI meeting, consider your communication inadequate.  Some facilities play BINGO with team members and use PIPs and desired outcomes as columns/spaces.  Get creative.  Have fun.  Celebrate even the smallest win. As managers, we may feel embarrassed or uneasy to share detailed information about what’s happening at the facility. Realistically, no one wants to admit their own inadequacies.  But remember, when employees are asked questions by surveyors, you want them to be confident and knowledgeable, rather than making up an answer that generates more questions for the surveyor, not less.

The QAPI process is built on the framework: “Do Better." To achieve this, team members must be clued in as to what can be celebrated and what needs improvement. Engaged employees who align with the company's mission and values are more likely to provide valuable and candid feedback. Understanding the pulse of a facility can be achieved by simply being present in the breakroom and attentively listening to the staff. They can either serve as the catalyst for strengthening your QAPI efforts or become the obstacle hindering progress.

Polaris Consultants are trained and knowledgeable about QAPI elements, QAPI struggles, and QAPI successes and are ready to assist your team in developing a time-stamped, measurable QAPI program.

For further information on how to reach out for guidance and support, contact us today!

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