QAPI: Quality Assurance/Performance Improvement

Yet another acronym; we say "kwa-pee." 

This program was introduced by the Centers for Medicare and Medicaid (CMS) to give skilled nursing facilities (nursing homes) the tools necessary to address the limitations, problems, or on-going concerns of each facility. Various tools are available to detail and guide management teams through the QAPI process, either from healthcare consultants or from CMS.

QAPI is a federally regulated mandate managed by CMS and is one of several pieces of the long term care (LTC) reimbursement puzzle. Other parts are Quality Measures and the Minimum Data Set (MDS).

Read more about the Five QAPI Elements

QAPI: Quality Assurance/Performance Improvement in Skilled Nursing Facilities - Nursing Homes - Fall Prevention

For example, QAPI tools would be implemented by a facility that has had a sudden uptick in patient falls over the past 30 days. Injuries sustained from a fall are more likely to be life-threatening or mobility-hindering for people who are already frail or partially debilitated. 

Therefore, when a fall occurs, management teams conduct an investigation and gather statements from individuals present at the time of any given incident. They use formulas to determine the rate of increase in incidences, followed by performing a root cause analysis to determine the process breakdowns that are leading to more falls. 

Several consistent themes surface throughout the investigations into these falls.

Commonalities between surveys include: 

  • New staff
  • Behavioral management
  • Mealtimes
  • Short staffing
  • Agency nurses or CNA's filling in
  • New medications
  • Environmental factors (e.g., a patient with cognitive decline spills his drink on the floor, creating a slippery surface)
  • Noisy or overwhelming surroundings 

Any of these factors would increase the number of resident falls. Root cause analysis points to these specifics, such as a noisy dining area at dinnertime with too few staff. In this scenario, there may not be enough help for a patient with dementia who a team member would typically feed one-on-one, and the confusion causes him to drop and spill food and drinks. No housekeeping services are available at that time; the skilled nursing staff is trying to disperse food and medications while feeding and supervising the residents. 

Because some residents eat in their rooms, one more staff person may become unavailable to oversee the dining room if one such patient requires assistance. The kitchen is also short-staffed, and several people received the wrong meals or wanted something different. As a result, yet another member of the nursing team may spend resident mealtimes running back and forth to the kitchen to communicate errors. 

The 35% increase in patient falls, on analysis, seems to be caused by a perfect storm of adverse conditions:

  • High-acuity patients
  • Poor staffing ratios in both the kitchen and the nursing unit 
  • Lack of environmental management services
  • Medication changes (usually examined when the same person falls)
  • The facility's disrepair 
  • Clutter on the floor

It could be new or temporary staff, but none had been on duty at dinnertime when the falls mainly occurred. The investigation and root cause analysis together help teams narrow down and address possible causes.

Enter the Performance Improvement Project (PIP) to develop and execute intervention strategies to reduce resident falls. A PIP may focus on a single department or unit, or it can encompass the whole facility. Interventions will include nursing home facility staff becoming educated about and involved in the PIP process and assessing the PIP's efficacy to confirm a desirable outcome or the need for a new strategy. 

QAPI and the Survey Process

The term "F-tag" refers to the occurrence of a facility receiving a deficiency for a QAPI that is not data-driven, is ineffective, or does not address previously noted flaws.

The big idea that comes with performance improvement is that it is always a work in progress. Interventions and strategies will change, as will residents, staff, families, and circumstances. Click here to access a detailed discussion of QAPI and some excellent tools to start a program at your facility.

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