Possible one year delay of the SNF QAPI Program requirements

While CMS published a proposed rule to delay for one year the Phase 3 SNF QAPI Program requirements, providers have good reason to move forward in implementing a comprehensive QAPI Program with the original phase 3 target date of November 28, 2019. (1) The proposed rule remains “proposed” and has not been finalized. (2) QAPI programs help to solidify strong processes for identifying and prioritizing problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information.

5 Elements of QAPI

There are 5 elements that form the foundation of a QAPI program for nursing facilities:

  • Design & Scope
  • Governance & Leadership
  • Feedback, Data Systems, & Monitoring
  • Performance Improvement Projects (PIPs)
  • Systematic Analysis & Systemic Action

Facility leadership should use these elements to develop a QAPI program that is individualized to the facility’s specific characteristics, resident population, specialized services, and unique circumstances. With a QAPI program that is grounded in these five elements, you will be able to identify and strengthen areas of weakness and your areas of strength can be made even stronger.

Where do I begin to develop or refresh the QAPI Program in my facility?

1) Understand the five elements of QAPI that should be implemented and review the regulations and Interpretive Guidance on QAPI programs for nursing facilities.

2) Develop written QAPI plan, policies, and procedures and updated them periodically.

3) Designate a QAPI Program leader or Designee and establish a QAPI Committee.

4) Establish routine QAPI training. Communicate the goal of your facility’s culture of QAPI. QAPI training is generally recommended for new employees, contractors, and volunteers as relevant to their specific job roles as part of orientation and at least annually thereafter.

5) Develop a method of collecting and monitoring data. This should include methods for obtaining feedback from staff and residents on opportunities for improvement that exist.

6) Prioritize opportunities for improvement. Your QAPI PIP selection should be based on facility-specific risks that include identified situations, and processes that may cause harm to your organization. Determine priorities by conducting a facility risk assessment and prioritizing identified risks.

7) Develop a process for conducting Performance Improvement Projects that includes development of PIP sub-committees, conducting root-cause analysis to guide development of appropriate corrective actions, and the use of Plan, Do, Study, Act (PDSA) cycles to monitor effectiveness of PIP actions.

8) Periodic Review. A QAPI program is never finished; it should always be a work in progress. Periodic reviews for program effectiveness should be conducted to review strengths and weaknesses of the program.

Proactive has a SNF QAPI Program toolkit that contains the policies, tools, and resources you need to jump start your program without reinventing the wheel and on-demand training on Implementing an Effective QAPI program. Contact us today to develop a program or to request a review of an existing program to fill any gaps.

Learn more about Proactive’s Compliance Program Implementation Partnerships.

Moving Mountains Series Phase 3: Implementing an Effective QAPI Program

This 1.25 hour webinar focuses on the fundamentals of QAPI and incorporating the 5 QAPI elements into existing continuous quality improvement (CQI) facility quality programs. Self-assessment for goal setting, the QAPI written plan, policies and procedures, and leadership’s role in accountability for QAPI programs are emphasized. Click here to learn more about this product in our shop.

QAPI Toolkit

This toolkit is designed to assist facilities in meeting the Phase 3 Requirements of Participation related to QAPI, which require each facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Click here to learn more about this product in our shop.

Get more resources in our shop!

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Blog by Shelly Maffia MSN, MBA, RN, LNHA, QCP Director of Regulatory Services, Proactive Medical Review

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