Compliance Minute

Quality Improvement: most organizations have a process to identify areas to improve in. The nursing home industry is no different! Our process is known as Quality Assessment and Performance Improvement (QAPI) in the healthcare industry, but what exactly does that mean? QAPI is two things: Quality Assessment just means we are monitoring different things in our facilities for quality – such as census, care, staffing, environment, etc. Performance Improvement means we then take that information and work toward improving through a systematic approach.

An effective QAPI program has 5 elements:
1. Design and Scope: the program addresses all systems of care and life in the facility.
2. Governance and Leadership: the governing body provides general oversight for QAPI activities, and ensures resources and tools are available to conduct these activities (stay tuned for next
month’s article when we dive into governing body information!).
3. Feedback, Data Systems, and Monitoring: each facility has systems in place to monitor care and services and pulls data from various systems (such as PCC, survey reports, logs, audits, etc.). The program monitors this data for trends and identifies areas of opportunity based on the data.
4. Performance Improvement Projects (PIPs): this is an action plan developed using a root cause analysis to list out steps to achieving improvement or implementing change.
5. Systematic Analysis and 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 change.

Hypercare and its associated managed facilities have a very robust and comprehensive QAPI Program and Plan. Each facility has a committee (ask to join if you are interested in learning more!) that meets monthly. At this meeting, data is reviewed, benchmarks are set, and action plans are developed for areas needing improvement. Staff members, residents and families are encouraged to engage facility leadership with ideas and feedback on ways to enhance the quality of life, quality of care, and safety for everyone. Your input is valued and is at the core of a successful QAPI program. More information on QAPI, including policies and procedures, tools and resources, etc. can be found on SharePoint or by speaking with your facility administrator.

Contact Information:

Emery Dumas, LNHA, CHC
[email protected]
248-940-5390
“We Care” Hotline: 616-975-5335 (may remain anonymous)