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QAPI Cheat Sheet (DRAFT) by [deleted]

Quality Assurance Performance Improvement

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Element 1: Design and Scope

A QAPI program must be ongoing and compre­hen­sive, dealing with the full range of services offered by the facility, including the full range of depart­ments. 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.
It aims for safety and high quality with all clinical interv­entions while emphas­izing autonomy and choice in daily life for residents (or resident’s agents). It utilizes the best available evidence to define and measure goals. Nursing homes will have in place a written QAPI plan adhering to these princi­ples.

Element 2: Governance and Leadership

The governing body and/or admini­str­ation of the nursing home develops a culture
that involves leadership seeking input from facility staff, residents, and their families and/or repres­ent­atives. The governing body assures adequate resources exist to conduct QAPI efforts. This includes design­ating one or more persons to be accoun­table for QAPI; developing leadership and facili­ty-wide training on QAPI; and ensuring staff time, equipment, and technical training as needed. The Governing Body should foster a culture where QAPI is a priority by ensuring that policies are developed to sustain QAPI despite changes in personnel and turnover. Their respon­sib­ilities include, setting expect­ations around safety, quality, rights, choice, and respect by balancing safety with reside­nt-­cen­tered rights and choice. The governing body ensures staff accoun­tab­ility, while creating an atmosphere where staff is comfor­table identi­fying and reporting quality problems as well as opport­unities for improv­ement.

Element 3: Feedback, Data Systems & Monitoring

The facility puts systems in place to monitor care and services, drawing data from multiple sources. Feedback systems actively incorp­orate input from staff, residents, families, and others as approp­riate. This element includes using Perfor­mance Indicators to monitor a wide range of care processes and outcomes, and reviewing findings against
benchmarks and/or targets the facility has establ­ished for perfor­mance. It also includes tracking, invest­iga­ting, and monitoring Adverse Events that must be invest­igated every time they occur, and action plans implem­ented to prevent recurr­ences.


Element 4: Perfor­mance Improv­ement Projects

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. The facility conducts PIPs to examine and improve care or services in areas that the facility identifies as needing attention. Areas that need attention will vary depending on the type of facility and the unique scope of servic­esthey provide.

Element 5: Systematic Analysis & Systemic Action

The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implic­ations of a change. The facility uses a thorough and highly organized/ structured approach to
determine whether and how identified problems may be caused or exacer­bated by the way care and services are organized or delivered. Additi­onally, facilities will be expected to develop policies and procedures and demons­trate profic­iency in the use of Root Cause Analysis. Systemic Actions look compre­hen­sively across all involved systems to prevent future events and promote sustained improv­ement. This element includes a focus on continual learning and continuous improv­ement.