Chapter 22 Quality Assurance and Performance Improvement

CENTER FOR MEDICARE & MEDICAID SERVICES FRAMEWORK FOR QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT

IMPLEMENTATION: FIVE ELEMENTS CMS developed a general framework for implementing a QAPI program in nursing facilities, based on five key elements of effective quality management, as shown in Figure 22.1.

When implementing a QAPI program, keep in mind that the plan should address all five elements; the elements are all closely related and are likely to be worked on at the same time. These elements may all need attention at the same time because they apply to the improvement initiatives chosen. The plan is based on the facility’s programs and services, the needs of the residents, and the assessment of current quality chal- lenges and opportunities The five elements of QAPI are detailed in Box 22.3 (see page 334).

QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT AND THE REGISTERED DIETITIAN NUTRITIONIST: STANDARDS OF

PROFESSIONAL PERFORMANCE As stated in the Academy’s Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Extended Care Settings (3), “an RDN in ECS [extended care settings] must answer to individuals, employers, boards of dietetics licensure, and the legal system if care is compromised. Therefore, RDNs must monitor nutrition and food safety outcomes associated with work done by NDTRs and support personnel as defined in rules, regulations, occupational codes, com- pliance laws, state licensure, certification, and/or reg- istration statutes” (3,4–6).

Standard 5: Quality in Practice states that “the [RDN] systematically evaluates the quality of services and improves practice based on evaluation results” (3). The Rationale: Quality practice requires regular perfor- mance evaluation and continuous improvement.

Examples of Outcomes for Standard 5: Quality in Practice

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Performance indicators are measured and evaluated.

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Aggregate outcomes results meet pre established criteria (goals/objectives).

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Results of quality improvement activities direct refinement of practice.

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PI for RDNs is a critical component of the Standards of Practice and Standards of Professional Performance in extended care settings.

QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT AND

THE QUALITY INDICATOR SURVEY The Quality Indicator Survey (QIS) method can be an important link to implementing QAPI. The first element of a QAPI plan includes being comprehen- sive and dealing with the facility’s full range of ser- vices. “The six QIS assessments in combination evaluate virtually all aspects of health, quality of life, and daily activities included in QAPI and also identi- fied as being of concern to residents.” If the facility uses the QIS forms to identify areas where the regula- tions are not being met, then those issues can be used to develop a QAPI project. These QIS assessments both meet regulations and provide a comprehensive basis for a practical QAPI program (7). The QAPI program also utilizes feedback and monitoring systems to sustain continuous improve- ment. This continuous process can be accomplished by conducting the full Stage I QIS assessment on a valid random sample of residents, alternating each quarter with the conduct of PI activities for identified problems (7).

“Coverage in monitoring quality of care in a QAPI program requires measuring quality on a sample of res- idents that is sufficiently large and provides a valid rep- resentation of care in the facility.” Performance indicators are required as part of Element 3 to monitor a wide range of care processes and review findings against benchmarks and/or targets the facility has established for performance. The original QIS showed that a sample of 40 residents is the minimum necessary for a valid quality snapshot (unless a facility has fewer than 40 residents and then all residents should be included) (7).

The corrective components of the QAPI plan involve root cause analysis (RCA) based on QIS Stage I and Stage 2 data to identify the source of the quality problems. The facility staff can then be cre- ative about how to address such problems, testing their approach through the use of a PIP. Once correc- tive action is implemented, then the facility will need to measure the impact, provide feedback, and make changes as needed in the facility’s policies and pro- cedures (7).

QIS forms are available online (www.cms.gov/ Medicare/Provider-Enrollment-and-Certification/ SurveyCertificationGenInfo/QIS-Survey-Forms .html).