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The Twelve Steps of QAPI Cheat Sheet (DRAFT) by [deleted]

Quality Assurance & Performance Improvements

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


In order for any QAPI process to be effective, it is recomm­ended that you use the twelve steps as developed by the Centers for Medicare and Medicaid Services (CMS). To begin the QAPI process in your building, you should begin with step one of the twelve step process from CMS, and work your way through to step twelve. It may take anywhere from six to twelve months to get your program up and running. Remember, this is a process that requires a team approach to work through. Below is the basic framework you will need to build a successful QAPI process in your facility process.

The Twelve Steps

1. Leadership Respon­sib­ility and Accoun­tab­ili­ty: Support must come from the top/ Provide resources for your staff.
2. Develop a Deliberate Approach to Teamwo­rk: Have a clear purpose/ have defined roles/ have a commitment to active engage­ment.
3. Take Your QAPI "­Pul­se" with Self-A­sse­ssm­ent: Use the CMS self-a­sse­ssment tool to determine areas you need to work on.
4. Identify Your Organi­zat­ion's Guiding Princi­ples: This will unify the facility by tying the work being done to a purpose or philos­ophy.
5. Develop Your QAPI Plan: Tailor your plan to fit your facility/ Scope will be based on the unique services you offer.
6. Conduct a QAPI Awareness Campai­gn: Inform everyone about QAPI and your organi­zat­ion’s QAPI plan.
7. Develop a Strategy for Collecting and Using QAPI Data: Effective use of data will ensure that decisions are made based on full inform­ation.
8. Identify Your Gaps and Opport­uni­ties: Use this time to observe for any areas where processes are breaking down.
9. Prioritize Quality Opport­unities and Charter PIP: Prioritize opport­unities for more intensive improv­ement work.
10. Plan, Conduct, and Document PIPS: PIP teams should use a standa­rdized process for making improv­ements.
11. Getting to the "­Roo­t" of the Problem: Determine all potential root cause(s) underlying the perfor­mance issue(s).
12. Take Systemic Action: Implement changes that will result in improv­ement of overall processes.