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What the NAC Brings to Quality Assurance and Performance Improvement (QAPI)

Nursing homes work hard to create the most effective Quality Assurance and Performance Improvement (QAPI) programs that help support the provision of quality services for residents, but translating voluminous data into meaningful information can be a challenge. Nurse assessment coordinators (NACs) play a vital role in the QAPI process and can bring valuable information and insight to the QAPI meeting.

In this article, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, AAPACN vice president of education and certification strategy and Jane Belt, MS, RN, QCP, RAC-MT, RAC-MTA, AANAC curriculum development specialist will elaborate on what NACs can bring to the QAPI meeting, how they can best evaluate the data and reports available, how they can help the QAPI team to make informed decisions about the need for a performance improvement plan (PIP), and how their efforts improve outcomes.

Overview of the Regulations

According to §483.75 of the State Operations Manual, Appendix PP, under Definitions at §483.75(g)(2)(ii):

Nursing home QAPI is 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.

  • 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. PI in nursing homes aims to improve facility processes involved in care delivery and enhanced resident quality of life. PI can make good quality even better.

Why Is QAPI important?

“The whole reason that QAPI came about is that Quality Assurance only collected data and answered the question ‘Do we meet the standard or not?’” says Belt. “If the standard was not met, there was no real action plan as to what to do next. Often, this led to just doing the same audits over and over with no real changes following. You never got to the root cause. Quality Assessment and Assurance (QAA) is all about the numbers. Quality Assurance and Performance Improvement (QAPI) is all about analyzing those numbers and developing appropriate next steps.”

Embracing this emphasis on improvement can improve facilities’ survey results. Belt explains, “Surveyors are now looking at what facilities did in the QAPI meeting to see if the facility is following the data, taking steps to identify the root cause, and developing an action plan to create a system of improvement that can be sustained. The reason for the QAA/QAPI meetings is to have the team identify problems and decide how to proceed to a solution. Is it a relatively easy problem that a department head could work on? Or, is the problem more complicated and something that will take additional members of the team to develop an action plan? Always, the goal is to improve the quality of care and quality of life for residents, while also considering how this will help the staff. But if a facility can work on issues before a surveyor finds the problem, the probability of a severe penalty is lessened. Unfortunately, with any survey problem, whether it’s a dietary issue or an MDS issue, if it’s a problem you have not identified and you wait for the surveyor to find it, you are going to receive a citation. Citations can have financial penalties, and they impact your health inspection score in the Five-Star rating—both of which affect the facility’s coffers,” warns Belt.

The NAC’s role in QAPI

“The NAC monitors and provides data that should be reviewed during QAPI meetings,” says Stewart. “For example, they monitor Quality Measure data and are often responsible for bringing this data to the QAPI meeting. But the NAC’s role extends beyond just bringing data to the meetings. He or she also needs to translate the data into meaningful information so the committee can identify real or potential issues and determine if a PIP is needed based on the information.”

The Reports Available to NACs

“The NAC is often the one who generates the CASPER reports and identifies that there is a problem,” says Belt. “For example, in the MDS 3.0 Facility-Level Quality Measure Report, the CASPER system puts an asterisk next to the percentage if the facility exceeds the threshold of 75 percent. The asterisk indicates that if the facility performed for a measure above 75%, that’s a concern about performance or quality of care. Surveyors are bound by regulation to investigate those measures that have an asterisk. So, NACs can provide great information as to what the surveyors will look at when they come in.” Belt suggests that, if the NAC can provide that information to the director of nursing services (DNS) or the person in charge of the QAPI process, the facility can develop plans to address those issues before surveyors examine them.

There are several reports that the NAC may be assigned to keep track of and review, including:

  • MDS assessments
  • Certification and Survey Provider Enhanced Reports (CASPER) reports

o   MDS 3.0 Quality Measure (QM) Reports

§  MDS 3.0 Facility Characteristics Report

§  MDS 3.0 Facility-Level Quality Measure Report

§  MDS 3.0 Resident-Level Quality Measure Report

o   Skilled Nursing Facility Quality Reporting Program (SNF QRP) Reports

§  SNF Facility-Level Quality Measure Report

§  SNF Resident-Level Quality Measure Report

§  SNF Provider Threshold Report

§  SNF Review and Correct Report

o   MDS 3.0 Nursing Home Provider Reports

§  MDS 0003D/0004D Package Report Provider History Profile/Provider Full Profile

§  MDS 3.0 Admission/Reentry

§  MDS 3.0 Discharges

§  MDS 3.0 Missing Assessment

o   MDS 3.0 Nursing Home Final Validation Report

For more details about each of these CASPER reports and questions to help analyze them, check out AANAC’s Guide to Key MDS-Related CASPER Reports for the Nurse Assessment Coordinator (NAC) Tool.

NACs reviewing these reports can identify issues, errors, or trends that can lead to opportunities for performance improvement. For example, the provider profile reports allow NACs to review survey history. NACs can check to see what the facility has been cited for in the last three years, including any issues with the MDS, such as for Significant Change Assessments. Surveyors often examine these past citations to see if these issues were fixed. “The data that you have on your CASPER reports or the data that you can get on your software reports can be used to be proactive,” says Belt.

Turning Data into Information and Analysis

“The problem today is that everyone has a lot of data, but they’ve got to put it together,” says Belt. “Looking at a lot of numbers doesn’t necessarily mean anything. If the NAC is looking at the MDS 3.0 QM reports, he or she may know how many residents have a pressure ulcer, or a fall, or have lost some of their ADL function. The NAC has a number. But what is that number telling us?”

Stewart adds, “It is important to remember that data alone doesn’t tell us what the problem is. For example, a high number of urinary tract infections doesn’t tell us what is causing them. To determine the problem, we must analyze, synthesize, and evaluate the data.”

The below steps outline how the NAC can translate data into information with an example regarding falls.

  • Review the data – The NAC gets the falls report and determines X is the facility’s number of falls for the month.
  • Look at the same data over time – The NAC not only looks at the data for that month, but also previous months, the average for the year, and the target number of falls for the facility.
  • Identify irregularities, errors, or negative trends over time The NAC then looks for any changes in the data. Even slight changes may indicate there is a problem. If investigated when the data shifts slightly, the facility may be able to prevent future falls and thus lower the number. The NAC knows falls have been an issue in the facility and sees that even with the measures the facility adopted over the last few months, the numbers aren’t getting better.
  • Evaluate the severity and accuracy of the data Since falls affect resident well-being and Quality Measures, the NAC determines it is important to address this issue. The falls data reported on the MDS is accurate, so the problem isn’t simply a coding issue; it is a system or process issue that needs further investigation.

Questions the NAC should raise in a QAA/QAPI meeting

Once the NAC has reviewed the data and evaluated it, the NAC can provide some suggestions in the QAA/QAPI meeting.

The NAC should bring the following information to the meeting:

  • Areas that need improvement
  • Why these areas need to be improved
  • The data to back up the numbers
  • Whether these issues are high risk, high frequency, or problem-prone
  • Information to evaluate whether these issues rise to the level of needing a PIP—such as if there is a need for expert involvement or resource allocation, and a simple fix won’t resolve or improve the issue
  • Suggestions for possible action plans

“In the QAPI meeting,” says Belt, “the NAC should be able to say ‘I looked at this data and I did some analysis, and I think that maybe our problem with falls is getting worse. We are having more and more falls. We’ve put in some measures and tried some steps through Quality Assurance. The problem wasn’t fixed, so I suggest we consider working on a Performance Improvement Project (PIP). We need to take a deeper dive into the issue, really look at the numbers and analyze them. Did the falls occur at certain times—did the falls occur during shift change? Did they occur on a certain shift? With certain staff? On a certain day of the week? What would cause a fall at two o’clock in the afternoon?’ Those questions lead to more specific data points which then can narrow down the problem. Perhaps it is determined that more of the falls are occurring in the bathrooms. That’s part of the PIP project. You don’t know what the root cause is for an issue, so you go on to find the root cause in the PIP. Once the root cause is determined, then an action plan can be developed to address that root cause specifically.”

Next Steps for Corrective Action and Ongoing Improvement

In §483.75(d)(1) of Appendix PP, CMS states, “The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.”

The PIP committee, which the NAC might be a part of, should use an improvement model, like the Plan-Do-Study-Act (PDSA) model, 5 Whys, or Fishbone Diagram to seek improvement options. The PIP committee would then test improvements and evaluate if the intervention is effective. If not, then they must consider if their assessment needs to be changed. If the intervention is effective, they must monitor the issue to ensure success over time and weigh if further improvement trials might be needed.

“When trialing improvements, they should be tested on a small scale before rolling them out across the entire facility,” advises Stewart.

Facility Goals

“Everyone works so hard to make sure their nursing home provides the best quality of care and quality of life as possible for residents, and how do we do that? We want to continuously improve. We don’t want to just stay average. Instead of just inspecting, we work on improvement and prevention,” says Belt. “Also, even if we have good numbers, how are we going to keep them there? Sometimes things that were fixed become unfixed. In QAPI, there is a system to continually monitor those areas that you’ve worked on, and you’re going to keep watching them. Our goal is quality of care. We don’t want to be average; our residents deserve the best.”

Want to become the QAPI expert in your facility? For the best in QAPI education, enroll today in AADNS’s QAPI Certified Professional (QCP) Education and Certification Program.


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