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3/26/2014
QAPI
How To Do It
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Objectives
• List steps to take to become QAPI focused
• Explain how RCA and PDSA fit into QAPI
• Define system change
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Polling Question #1
• We believe we are doing QAPI in our
Nursing Home.
– Yes
– No
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QAPI at a Glance contents
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Definition of QAPI
Sample scenarios
Five Elements of QAPI
Action Steps
QAPI Principles
Tools:
– QAPI Self-Assessment
– Guide for Developing Purpose, Guiding Principles, and
Scope for QAPI
– Guide for Developing a QAPI Plan
– Goal Setting Worksheet
– QAPI Definitions
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Change Package contents
• Seven Strategies for change with related action
items
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Lead with a sense of purpose
Recruit and retain quality staff
Connect with residents in a celebration of their lives
Nourish teamwork and communication
Be a continuous learning organization
Provide exceptional compassionate clinical care that
treats the whole person
– Construct solid business practices that support your
purpose
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Other Tools
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QAPI News Brief – Volume 1
QAPI Leadership Rounding Tool
Examples of Performance Objectives for Job Descriptions and
Performance Reviews
Measure/Indicator Development Worksheet
Measure/Indicator Collection and Monitoring Plan
Instructions to Develop a Dashboard
Prioritization Worksheet for Performance Improvement Projects
Worksheet to Create a PIP Charter
PIP Launch Checklist
Plan-D-Study-Act Cycle Template
PIP Inventory
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Other Tools cont’d
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Sustainability Decision Guide
Brainstorming, Affinity Grouping, and Multi-Voting Tool
Communications Plan Worksheet
Storyboard Guide for PIPs
Improvement Success Story Template
Guidance for Failure Mode and Effect Analysis
Guidance for Root Cause Analysis
Flowcharting
Five Whys
Fishbone Diagram
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The Five Elements of QAPI
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CMS Video: Nursing Home QAPI –
What’s in it for you?
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QAPI Process Tool Framework
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Element 1 Scope and Design
• Learn the basics of QAPI
– Review the QAPI five elements
– Understand how QAPI coordinates with QAA
– Assess QAPI in your organization
– Create a structure and plan to support QAPI
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Polling Question #2
• Does your current QA committee contain all
the members just mentioned (ADM, DON,
MD, all department heads or their
representative)?
– Yes
– No
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Polling Question #3
• How often does your current QA committee
meet?
– A. weekly
– B. monthly
– C. quarterly
– D. other
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QAPI SelfAssessment
Tool
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Guide for
Developing
Purpose,
Guiding
Principles, &
Scope for
QAPI
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Steps
• 1. Locate or develop your organization’s
vision statement
• 2. Locate or develop your organization’s
mission statement
• 3. Develop a purpose statement for QAPI
• 4. Establish guiding principles
• 5. Define the scope of QAPI in your
organization
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Steps
• 1. Locate or develop your organization’s
vision statement
• 2. Locate or develop your organization’s
mission statement
• 3. Develop a purpose statement for QAPI
• 4. Establish guiding principles
• 5. Define the scope of QAPI in your
organization
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Guide for
Developing a
QAPI Plan
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Guide for
Developing a
QAPI Plan
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• Goal Setting
Worksheet
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Goal Setting Worksheet
• Describe the business problem to be solved.
– The incidence of facility acquired pressure
ulcers has increased gradually over the past
year.
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Be Specific
• What do we want to accomplish?
– Stop the development of pressure ulcers of
residents.
• Who will be involved/affected?
– All staff, residents and families.
• Where will it take place?
– Start on south unit and spread house-wide.
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Be Measurable
• What is the measure you will use?
• What is the current data figure for that
measure?
• What do you want to increase/decrease
that number to?
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Be Attainable
• Did you base the measure or figure you
want to attain on a particular best
practice/average score/benchmark?
• Is the goal measure set too low that it is not
challenging enough?
• Does the goal measure require a stretch
without being too unreasonable?
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Make it Relevant
• How will the goal address the business
problem stated at the beginning of the form
• Establish a reasonable target date
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Element 2 Governance and Leadership
• Understand the QAPI business case
– See remainder of CMS video: Nursing Home QAPI – What’s
in it for you?
• Promote a fair and open culture where staff are
comfortable identifying quality problems and
opportunities
• Create a culture that embraces the principles of QAPI
• Promote engagement and commitment of staff,
residents and families in QAPI
• Involve residents and families
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• QAPI Leadership
Rounding Guide
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• Examples of
Performance
Objectives for Job
Descriptions and
Performance
Reviews
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Element 3 Feedback, Data Systems
and Monitoring
• Use and make data meaningful
– Where is your data coming from?
– What is it telling you?
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• Measure
/Indicator
Development
Worksheet
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• Measure
/Indicator
Collection and
Monitoring Plan
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• Instructions to
Develop a
Dashboard
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Prioritization Worksheet for
Performance Improvement Projects
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Element 4 Performance
Improvement Projects (PIPs)
• Implement performance improvement
projects
• Enhance QAPI communications
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• Worksheet to
Create a
Performance
Improvement
Project Charter
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• Performance
Improvement
Project Launch
Checklist
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• PDSA Cycle
Template
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• Performance
Improvement
Project
Inventory
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• Sustainability
Decision Guide
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• Brainstorming,
Affinity
Grouping, and
Multi-Voting
Tool
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Communications Plan Worksheet
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• Storyboard
Guide for
PIPs
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• Improvement
Success Story
Template
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Element 5 Systematic Analysis and
Systemic Action
• Understand and focus on organizational
processes and systems
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• Guidance for
Performing
Failure Mode
and Effects
Analysis with
Performance
Improvement
Projects
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• Guidance for
Performing
Root Cause
Analysis(RCA)
with
Performance
Improvement
Projects (PIPs)
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• How to use the
Fishbone Tool for
Root Cause
Analysis
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Fishbone Diagram
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Fishbone Diagram
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Fishbone Diagram for Falls
Goal: __Decrease the number of falls among residents in our facility to____ per month by ______________
Equipment
Staff
Environment
Adequate and
good lighting
No clutter in hallways
Walker in good repair
Staff aware of
resident’s fall adequate # of staff
risk status
No Alarms going off
Consistent Assignment
Staff adequately
trained in fall
High number of falls
prevention
in home resulting
No clutter in room
w/c in good repair
in poor quality of
life for the resident
Fall Risk Assessment
Completed on Admission Fall Huddle p a fall
Falls are Tracked
Identified Intrinsic Identified Extrinsic
Risk Factors*
Risk Factors+
Problem in Process
Referral to PT/OT
Falls are trended
Methods/ Processes
Resident Issues
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• Five Whys Tool
for Root Cause
Analysis
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• Flowchart
Guide
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Action Steps to QAPI
1. Leadership responsibility and accountability
2. Develop a deliberate approach to teamwork
3. Take your QAPI “pulse” with a SelfAssessment
4. Identify your organization’s guiding
principles
5. Develop your QAPI plan
6. Conduct a QAPI awareness campaign
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Action Steps to QAPI cont’d
7. Develop a strategy for collecting and using
QAPI tools
8. Identify your gaps and opportunities
9. Prioritize quality opportunities and charter
PIPs
10. Plan, conduct and document PIPs
11. Getting to the “Root” of the problem
12. Take systemic action
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For More Information Contact
Darlene Smikahl, BSN, MSN, RN
Kansas Foundation for Medical Care, Inc.
2947 SW Wanamaker Drive
Topeka, Kansas 66614
dsmikahl@hcqis.org or 800-432-0770 ext 365
This material was prepared by the Kansas Foundation for Medical Care, Inc. (KFMC), the Medicare Quality Improvement Organization for Kansas, under
contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Servic es. The contents
presented do not necessarily reflect CMS policy. 10SOW-KS-NH_LAN_14_20
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