This week’s “Ftag of the Week” is F867 QAPI/QAA Improvement Activities, which is the third Ftag in the Quality Assurance and Performance Improvement regulatory group. This regulation was partially effective in Phase 1 as it relates to the QAA , and then has two major components which become effective this November with Phase 3.
Quality Assessment and Assurance (QAA)
This section of the regulation became effective with Phase 1 of the RoPs, November 28, 2016 with the exception of the part related to implementation the QAPI program. This regulation requires that the facility’s QAA Committee reports to the Governing Body. The Committee is responsible for developing and implementing appropriate corrective action plans for identified quality deficiencies. The Committee must routinely review and analyze data, including data from Drug Regimen Reviews and act on that data to make improvements.
In Phase 3, the QA Committee must also report to the Governing Body regarding implementation of the QAPI program as it relates to the major requirements of this regulation – Program Systematic Analysis and Systemic Action and Program Activities. This includes using QAPI data for routine analysis and action.
Program Systematic Analysis and Systemic Action
F867 requires a facility to conduct performance improvement actions that are measured for success and track performance improvements to ensure they are realized and sustained. Nursing homes need to have policies in place that are the related “hows” for this process, including:
- How a systematic approach will be used to determine the underlying causes of problems that impact larger systems
- How corrective action plans will be developed to effect change at the systems level to prevent problems related to quality of care, quality of life or safety
- How performance improvement activities will be monitored for effectiveness
This part of the regulatory requirement is effective Phase 3.
The other part of F867 that will be effective with Phase 3 relates to the QAPI Program activities. The facility’s QAPI program needs to prioritize performance improvement activities that:
- Focus on high-risk, high-volume, problem-prone areas
- Consider the incidence, prevalence and severity of problems
- Include areas that impact quality of care, resident safety, health outcomes and resident autonomy and choice
Performance improvement activities must track medical errors and adverse resident events. The causes of these issues must be analyzed, and preventive actions put into place to prevent recurrence. This includes “feedback and learning throughout the facility” per the Interpretive Guidance (IG), so there is a staff education component included here as well.
Performance Improvement Projects (PIPs)
Performance Improvement Projects (PIPs) are one of the QAPI program’s features that has been emphasized since QAPI was initially announced. PIPS are focused performance improvement activities that the facility must conduct. There are two important requirements to note here:
- The number and frequency of PIPs must reflect the scope/complexity of the facility’s services and resources as per the Facility Assessment.
- One PIP, annually, must focus on a facility-identified high-risk or problem-prone area that has been identified through data collection and analysis.
As you can see from the regulatory requirements under this Ftag as well as the requirements at F865 and F866, there is a tremendous focus on the facility’s ability to capture and analyze data to identify potentially problematic issues before the surveyors do. The importance of ensuring that once an issue has been identified, that your facility understands the need to prioritize implementation of corrective actions to address the issues at a systems level to prevent recurrence cannot be stressed enough. The Facility Assessment continues to be a key element of compliance as well, since the care and services listed in the Facility Assessment will also be driving PIPs in Phase 3. Needless to say, the QAPI Committee meeting once on a quarterly basis is probably not going to be enough.