While most skilled nursing facility (SNF) leaders are aware of QAPI and have executed a QAPI plan, many view QAPI itself as nebulous, abstract, or vague. This lack of clarity complicates QAPI execution. This, in turn, encumbers QAPI’s potential to prompt continuous improvement. In the environment of value-based care, SNFs need every advantage to remain competitive. Moreover, staff need to know they are part of a team that provides the best care possible to their residents. QAPI is a vehicle to reinforce these aims. This article will answer three questions SNF leaders commonly raise to help decipher QAPI and harness its full benefits.
What is QAPI?
The Centers for Medicare and Medicaid Services (CMS) defines QAPI in Appendix PP of the State Operations Manual as the:
Coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving.
CMS continues by differentiating between quality assurance (QA) and performance improvement (PI):
Quality Assurance (QA): QA is the specification of standards for quality of care, service and outcomes, and systems throughout the facility for assuring that care is maintained at acceptable levels in relation to those standards. QA is on-going and both anticipatory and retrospective in its efforts to identify how the organization is performing, including where and why facility performance is at risk or has failed to meet standards.
Performance Improvement (PI): PI (also called Quality Improvement – QI) is the continuous study and improvement of processes with the intent to improve services or outcomes, and prevent or decrease the likelihood of problems, by identifying opportunities for improvement and testing new approaches to fix underlying causes of persistent/systemic problems or barriers to improvement.
In summary, QAPI is a data-driven approach to improve the quality of care and services provided by a facility, which entails both proactive and reactive activities. Comprehending these definitions and explanations from CMS are necessary to remain compliant with the regulations governing QAPI, yet it’s helpful to consider QAPI in terms of what it looks like in action. Steps facilities often take as part of a QAPI plan include:
- Setting facility and departmental goals that support the mission and vision of the facility
- Establishing key performance indicators (KPIs) that measure progress toward the goals
- Involving the staff who are closest to the work that is to be improved upon in the design of the new work process
- Monitoring performance data and then translating it into information to understand what creates the outcomes the data shows
- Seeking ways to be more effective and more efficient and then using different methods to achieve the improvement
- Fostering an environment in which everyone is encouraged to learn and challenge the status quo
- Conducting root cause analysis (RCA) to discover the root causes of a problem
- Planning, pilot testing, implementing, and evaluating changes to processes to reduce the risk of harm to residents and staff and improve outcomes
These actions are broad but encapsulate many of the daily reactive and proactive things SNF staff do. Not only are these actions necessary to provide residents quality care and services, but they also fall under QAPI.
What is RCA?
Root cause analysis (RCA) receives significant attention, as it drives QAPI yet simultaneously is almost impossible to do. It is important to dispel both notions. Eliminating misconceptions surrounding RCA helps to remove barriers to using it.
RCA is a broad term encompassing a variety of techniques, tools, and methods to discover the root causes of a problem. RCA is appropriate when there is deviation or non-conformity from what was supposed to occur; if there’s a problem, performing RCA helps to show what caused it. As a reactionary response to a problem, RCA is within the scope of QAPI actions, but QAPI isn’t limited to reactionary approaches. QAPI also includes proactive approaches to improve quality. This doesn’t diminish the importance of RCA as a vital aspect of QAPI, but SNF leaders should remember that RCA is only one of many activities that constitute QAPI.
Every SNF leader has experience with RCA and likely has more skills and ability than they give themselves credit for. RCA can be a very simple problem-solving exercise one thinks through in a matter of minutes. For example, a person is cooking a meal when the electricity turns off. The person cooking starts to work through the question “why did the power turn off?” They want to know the answer so they can continue cooking the meal, but they also want to prevent any further problems an electrical outage could cause, like disruption in the home’s temperature or spoiled food. The person looks at the neighbor’s houses and sees they have electricity, which rules out a problem with the electric company and narrows the possibilities to something related to a delinquent bill or a problem with the electric circuits in the house. The person first considers the bill not being paid and realizes they forgot to update the auto pay settings at the electric company with their new debit card number.
The thought processes the person used in this simple example to discover the root cause of why the electricity turned off mirror how a SNF leader must approach problems in the SNF. However, more complex problems may require a combination of different methods, techniques, and tools to conduct the RCA. Some of these include:
- Five whys
- Events and causal factor analysis (timeline creation)
- Fault tree
- Failure Mode Effects Analysis (FMEA)
- Pareto chart
- Fishbone diagram
- Process mapping
- Interviews and observations
The root causes of a problem discovered during the RCA almost always relate to a breakdown in one or more processes, a gap in the steps of a process, or the lack of a process. This leads to the next question.
What is a Process and Why Does it Matter?
The term “process” is often used interchangeably with the term system, but each term has a distinct definition. A system is the combination of interrelated components or processes that forms a complex whole. A process is a series of repeatable steps or a sequence of activities that are completed to produce a specific result.
Think of an umbrella as a system. Each metal cross member represents a process and gives shape to the system. If you remove one of the metal cross pieces from the umbrella, the umbrella would sag or lose the ability to weather the storm. In the center holding the umbrella are people; they push each cross member out to open the umbrella, allowing it to take shape. The team also holds the umbrella up, keeping it in position.
Understanding the function and purpose of a process enables SNF leaders and staff to narrow the RCA to determine which process isn’t producing the desired results. In addition, this understanding enables SNF leaders to focus on developing processes that are missing in the system.
For more information about what QAPI is and how leaders can use it to guide quality improvement efforts, AAPACN offers a webinar titled QAPI Is More Than A Meeting: Part 1, an article with the same title, and a package of QAPI Meeting Tools.
To learn more about how to conduct a RCA, AAPACN offers the QAPI Certified Professional (QCP) courses and the webinars Root Cause Analysis: A Six Step Approach and How to Use CASPER Reports: Tools Every DNS Needs to Be Successful. AAPACN also offers Guides to Resident Safety, which contain an RCA tool.
For more information on processes, systems, and how they relate to RCA, AAPACN also offers a webinar, QAPI Is More Than a Meeting: Part 2.
Centers for Medicare & Medicaid Services. (2017). State Operations Manual, Appendix PP, “Guidance to surveyors for long-term care facilities” (11-22-17). https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
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