I was that weird little kid who decided to become a nursing home administrator in middle school, so it should come as no surprise that I believe the title of this article. My entry into the workforce was as a quality assurance coordinator in a failing standalone nonprofit community. I was the annoying quality assurance (QA) person, running from department to department begging for a few minutes of the busy managers’ time. I wanted to share my findings from the countless QA audits I had performed and discuss ideas on how we could improve the care we provided with my newly obtained knowledge of the process of quality assurance. Alas, it was not to be, and I soon moved on to my first administrator position.
Over the next 20 years, I saw quality assurance managed differently in several companies, but the common denominator was that we collected copious amounts of information. Usually, this information was discussed in a long meeting with a large team and an impatient medical director. There was no possible way to do anything meaningful with all that information, and the QA kid in me was dying.
Enter the Mega Rule of 2016 and Phase 1, 2 and 3 of required Quality Assurance and Performance Improvement, so lovingly referred to as QAPI. It quickly became a bad word in our field, but the QA kid in me saw the opportunity to bring the whole team along on my road to realizing my dreams of effective QA programs. In no time, our team implemented Phase 1, 2, and 3, before the Phase 1 deadline, and now I am living the QA dream! The requirements are overwhelming, but when given the proper attention and, more importantly, the right attitude, QAPI can be fun and rewarding. Here are a few tips to get you started.
QAPI Levels the Playing Field
In any organization, when one department is triple the size of the others, it garners the most attention and time from leadership. As providers, we tout the interdisciplinary approach and yet our ancillary departments do not always feel they are as important as the nursing department. QAPI levels the playing field when done right, because all team members now can brainstorm, identify weaknesses and develop plans for improvement.
The QAPI environment must be open and have no sacred cows. The committee chair, or another member, should be a skilled facilitator who can elicit input from the team as members become accustomed to this true interdisciplinary style. Our committee chair is our director of nursing because she has that skill set; yours may be someone different. Have some fun with it and use icebreakers or games to get the team warmed up. Remember that you are setting the atmosphere for dynamic improvements in your organization!
Use the Tools Developed by CMS
In long-term care, we often complain about cumbersome regulations, and how as a regulatory body, CMS finds fault but never gives solutions. This criticism is not valid in the case of QAPI. There are amazing tools, available for download, that will guide you in organizational self-assessment, prioritization of performance improvement projects, and step-by-step instructions on structuring your performance improvement plans (PIPs). Our team has found the prioritization forms to be extremely helpful, as we have a number of projects we would like to address but do not want to overwhelm the staff with too much, too fast. This is a tool you can show to let a surveyor know a concern is on your radar and in your QA pipeline, but you are working on other projects based on the criteria established by CMS itself. Game, set, match! Go to www.cms.gov and search QAPI.
Have a QAPI Party
I did promise fun, and this is how you deliver. In Phase 2, there is a requirement to educate all staff members on QAPI principles and plans. We shared this information with our staff by holding several mandatory parties. Yes, I said “mandatory” and “parties” in the same sentence. It has to be mandatory, or whatever language your community uses to describe “you have to come,” because it needs to be established that this is important, it matters to the organization and we are willing to invest our time and resources. There was music—iconic music like “We are the Champions” and “Don’t Stop Believin’.” Yes, I have a QAPI playlist (click here). There was food, lots of food, the kind of spread that says, this is a big deal. Our goal was to make this a mandatory party to remember!
We unveiled our performance improvement projects and solicited feedback and ideas from our staff at this event. We broke the large group into small groups and asked each group to give 3 ideas for our PIPs and post them anonymously on the board. We left the meetings with over 250 ideas.
Tackle the Hard Stuff and Score Some Easy Wins
Once you establish a safe place to begin to pick your organization apart, you will find opportunities for improvement everywhere you look. At Mohun Health Care Center, we have completed performance improvement projects on dining enhancement, falls, activities, pressure ulcers and discharge planning, just to name a few. Once our team got the process down we began to implement extensive plans with amazing outcomes. We reduced our pressure ulcer rate to zero, upgraded our dining program, reduced our falls with major injury from 9.5% to 1.5% (taking our percentile national rank from 96th to 28th), eliminated morning activities based on resident preferences, and overhauled our discharge process, all in less than a year.
We hold QA meetings monthly, while subcommittees meet as needed to give these plans the attention they deserve.
Recent reviews of our data showed that the number of our residents with cognitive impairment has doubled in the last 2 years; we are currently running a PIP to ensure we have the proper education and competency to address this development. A long-standing high-quality measure of incontinence had been previously attributed to our population’s median age of 88 and high population (96%) of women residents. A closer look has helped us to develop a PIP that includes PTNS (Posterior Tibial Nerve Stimulation), a procedure we had never considered until diving deeper.
Be a QAPI Champion: Support, Lead and Promote QAPI as an Organizational Value
Phase 3 requires that QAPI involves the leaders, board and corporate members of the organization. Don’t wait for that mandate (which is over a year away) because you will miss out on the opportunity to improve your team’s communication and improve the lives of your residents and staff. Most importantly, you will miss the chance to have some fun. The QA kid in you will thank you.
April Queener is administrator at Mohun Health Care Center, Columbus, OH.