Tim Rowan recently published an article about QAP preparation by our senior consultant, Lorie Owens. You can find the article below for tips on designing a successful program. If you find you could use a little bit of help, we here!
The phase in compliance date for QAPI is TODAY!
There has been a lot of education around defining Quality Assurance and Performance Improvement (QAPI), the five elements of QAPI and QAPI background. Much to many providers' dismay, little information has been presented on where to start with your new QAPI process. We're here to help.
This article is intended to provide you with some helpful pointers on where to begin if you haven't started yet, and what to review if you've already completed your QAPI program. Further, this article is intended for everyone from the receptionist to the CEO. Like W. Edwards Deming said, "Quality is everyone's responsibility."
Set your foundation. To develop a solid program, I urge you to first take a step back and make sure you have a solid foundation. Do you know what your organization is all about and what you're trying to achieve? What's your organization's vision and mission statement? Once you pinpoint these cornerstones and feel emboldened by them, make sure your team rallies behind them. Review your vision and mission regularly. Post it everywhere! These are the guiding principles that dictate how you do business and make decisions every day.
Craft a purpose statement for your QAPI program. This statement should support your vision and mission and define what you want to accomplish.
Determine the philosophy. This is the why. Without understanding your why in anything you do, you won't be successful.
Design your program. This is the how. This is the part of QAPI we all think about. Because it's the big part we're all on the hook for establishing and maintaining, here are nine guidelines to design a successful program.
Ensure your management and board have a prominent role. QAPI activities are directed by your governing body. They should strive to incorporate culture-building projects and provide resources, expectations and accountability for the program.
Encourage a QAPI-focused organization. Develop a QAPI leadership team to promote a “QAPI Awareness Campaign” and quality-focused culture. Your leadership team should include an administrator, department heads and clinical managers who all engage with employees and patients in a process called, rounding. In this process the leadership team can ask open-ended questions regarding quality like:
What is going well with your care (patient/family) or changes implemented for the PIP (employees)?
What additional tools/resources/equipment do you need?
What barriers have you experienced in implementing? Was the barrier resolved?
After the information is collected, the QAPI leadership team needs to ensure they close the feedback loop and act on the feedback.
Ensure the program is focused on quality care and quality of life. Enough said. That's what QAPI is all about after all.
Get everyone involved. A successful program must include ALL departments, team members and services. The QAPI team will need designated leader(s) and representation from each discipline of services you provide. Consider additional resources from other departments including someone with working knowledge of your EMR.
Maintains focus on systems and processes. When you look at what in the process is failing rather than blaming an individual, that's when you can make major and lasting improvements. Every time you locate a failed step in your process, jumpstart your root-cause analysis by asking “Why?” five times.
Center your program around data. Data is not exclusive to Star ratings, Home Health Compare and other reports. You can only manage what you can measure. You must know your data and understand where that data is coming from. Make sure everyone is invested understanding and presenting data to improve quality care.
Time and measure your steps. Specific goals should have timelines. The progress toward those goals needs to be measured. Also, consider how progress will be communicated, how often and between whom?
Build in peer accountability. Individual accountability reinforced with performance metrics and included in evaluations. Team members should be encouraged to support and elevate each other regularly. Organizational culture encourages rather than penalize those who identify a gap or error.
Celebrate and reward! It doesn’t have to be big or monetary, but make sure you celebrate your wins as a team. An ice cream party or morning coffee social are always appreciated.
Now that you've built your program, review it for the following: Compliance, efficiency, effectiveness and potential barriers.
Define your scope. The scope is based on your individual population and the services you provide that impact care, quality of life, patient choice and transitions of care.
Assemble all of these into your “Preamble to QAPI." Share with all staff.
Implement a “QAPI Awareness Campaign." Educate on the goals and objectives of your program and how it should impact the day to day. Include everyone in your training including consultants, contractors and collaborating agencies. Train often and in multiple ways including in writing, email blasts, posters, role play, training videos and more. Get creative.
There are several resources available to help you get started or support you on the CMS site and HHQI. They include basic QAPI tools, educational videos for clinicians, PIP packages with Best Practice Intervention supported by CMS. Most importantly -- be patient. QAPI is a series of modifications over time (multiple PDSA cycles) that are specific to your agency's results. Keep your plan simple to keep your momentum!
Last thing, ask for help if you need it. Me (email me here) or anyone on the Maxwell Healthcare Associates' team is happy to help.
Lorie D. Owens, COS-C
Maxwell Healthcare Associates, LLC
Although these tools were established for Nursing facilities the fundamental elements remain relevant to both Home Health and Hospice QAPI programs.