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Part III Standards for Compliance

Based on the identified underlying causes and identified potential for unintended weight loss, the PIP team recommended the following interventions: ●

BOX 22.5 Key Points of Scenario 2 Identified

development of a protocol (with criteria) for identifying residents at risk for unintended weight loss to be done on admit and with ongoing, timely identification when the resi- dent’s change of condition meets the criteria along with consideration for a weekly weight variance meeting (with representation from nursing and dietary leadership) for high-risk res- idents to document evaluation, interventions, and revised care planning goals to stop the weight loss and/or recover the weight loss to usual body weight or per resident’s preference;

●

development of standing orders or Weight Variance Committee considerations for interven- tions for residents “at risk,” such as weekly weights, notification of physician, dietitian’s ongoing assessment and recommendations for interventions that individualize and empower residents;

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development of specific performance expecta- tions and criteria as established in the facility’s approved policy and procedures under Nutrition Care and to meet national standards of care;

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development of clinical chart audits (by peers/ administration) of high-risk residents to monitor performance and corrective actions when perfor- mance does not meet established criteria (These may include auditing for timeliness of notification to dietitian of identified risks such as nutrition [weight] decline; timeliness of dietitian’s ongoing assessments; care planning revised to match IDT’s and dietitian’s assessment and goals; time- liness of implementing interventions recom- mended by dietitian [physician’s notification and documentation if not in agreement]; effectiveness of interventions/changing interventions.);

● development of new program; and revision of menu.

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Before they escalated to larger problems, survey- ors recognized the “good faith effort” made when resi- dents were identified with unintended weight loss. The key points in Scenario 2 are listed in Box 22.5.

SUMMARY Effective programs to measure and ensure quality are of utmost importance. Blending QA initiatives and PI efforts can result in significant improvements in out- comes including few resident adverse clinical efforts,

Many of the QAPI action steps discussed in this guide are found in the second scenario. Here are some of the key highlights: ●

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The facility had a structured steering com- mittee for directing the QAPI activities (Step 1).

The facility established performance meas- ures and was conducting routine monitoring (Step 6).

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The facility used data to identify gaps or opportunities for improvement (Step 8).

The QAPI steering committee used prioritiza- tion to decide when to conduct performance improvement projects (PIPs) (Step 9).

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The QAPI steering committee created an interdisciplinary team. As seen in this example, each discipline in the team brought a unique perspective that contributed to a balanced and comprehensive analysis (Step 2).

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The QAPI steering committee gave each team member real responsibility to study the issue, analyze the data, and recommend corrective actions (Step 2).

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The PIP team explored the issue and designed interventions using a Plan-Do-Study-Act model (Steps 9 and 10).

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The PIP team’s investigation revealed several underlying systemic issues and made recom- mendations that addressed those systems, rather than focusing on individual behavior (Step 12).

Source: Department of Health & Human Services, Centers for Medicare & Medicaid Services, Center for Clinical Standards and Quality/Survey and Certification Group. Preview of Nursing Home Quality Assurance & Performance Improve- ment (QAPI) Guide—QAPI at a glance. December 14, 2012:6. Ref: S&C: 13-05-NH. www.cms.gov/Medicare/Provider-En- rollment-and-Certification/SurveyCertificationGenInfo /Downloads/Survey-and-Cert-Letter-13-05.pdf. Accessed September 10, 2015.

improved satisfaction ratings, more engaged staff, and improved operational performance.

REFERENCES 1. Centers for Medicare & Medicaid Services. QAPI description and background. www.cms.gov/Medicare/ Provider-Enrollment-and-Certification/QAPI/qapidefi- nition.html. Accessed December 30, 2015.