By now, your QAPI efforts should be well on the road even though we don’t have a final enforcement rule as of yet. The current conversation is that the regulation surrounding QAPI will be finalized in September along with the massive updates that CMS is planning – but those updates are a topic for another day!
As of a couple years ago, facilities were expected to be in compliance with QAPI even though there was no final rule yet. We have always had QAA programs, but as we know, QAPI is taking this process to a new level.
Which of these areas does my facility fall into?
This is a good time to pause and ask yourself: “Which of these areas does my facility fall into?”
- I don’t really have what could be called a compliance program
- I have a compliance program – well sort of
- My compliance program is an integral part of our organization
- My compliance program not only looks at issues but has ongoing plans for improvement and involves all aspects and departments of our organization and includes representatives from all departments
If you currently align with either of the first two, you have some catching up to do. If you align with the third one, you are on the right track, but will need to expand what you are currently doing. If you align with the last one, you are in pretty good shape – but you should still do a review of where you are and if you can expand further.
Remember the five elements? They are:
- Design and Scope
- Governance and Leadership
- Feedback, Data Systems and Monitoring
- Performance Improvement Projects
- Systematic Analysis and Systemic Action
In a nutshell, these elements require you to define your program based on the values and mission of your organization and that the functions of the program support these and develop policy and procedures for the program. One of the requirements is that you have a “robust” program in place that uses data and current best practices to define and measure goals. You will need to determine how you will collect and use the data, and if you are going to pursue an issue or not. Just like the MDS and working with the CAAs, if you determine to not proceed on a seemingly problematic area, documentation needs to exist to explain the rationale behind your decision.
Spotting the differences
One of the significant differences between QAPI and the current interpretive guidelines under F520 is that QAPI requires you to look at and evaluate all of your systems and processes, not just clinical and not just those where there has been a problem identified during a survey. The goal of QAPI is to lean heavily on the Performance Improvement aspect and always be looking to continue to make everything you do better and better.
Are there going to be things you do that are as good as they can be for now? Of course! However, the expectation is that you check in on them at time periods you determine to ensure it remains that way, or if there can indeed be an improvement.
A word of caution – as much as you want to be comprehensive in your program, if you determined you were in either group 1 or 2 above, you want to start slowly. Don’t try to boil the ocean! If you try to do too many things at one time, you will not have an effective program. Pick one area of the facility or a few of your known issues and grow from there.
Another aspect of QAPI that is different is the use of PIPs – Performance Improvement Projects. These are smaller groups of people working on a specific project. These teams should be cross departmental as this initiative is facility wide. The PIP team will look at the assigned issue, gather data and make recommendations as to how they think the issue can be resolved.
So take another look at what you are doing with your QAPI efforts. If you need help or don’t have the tools in place to be successful, CMS has provided information for you to use for each of the five elements and tools to go with each of them. Click here to access those tools.
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