Quality Assurance and Performance Improvement …

1 1 Quality Assurance and Performance Improvement plan Template (QAPI) 2 TABLE OF CONTENTS I. Disclaimer II. Introduction to the Quality Assurance and Performance Improvement (QAPI) plan Template III. QAPI Goals A. Introduction to QAPI B. Organizational Mission, Vision and Values C. Goals IV. Design and Scope A. Fundamentals of Performance Improvement 1 Key Elements 2 Key Focus Areas 3 Limits of the QAPI plan 4 QAPI Effort\ B. Objectives of the QAPI plan V. Governance and Leadership VI. Feedback, Data Systems and Monitoring VII. Performance Improvement Projects (PIPs) A. Identification of PIPs B. Prioritizing PIPs C. PIP Project Charter D. PIP Team E. PIP Team Reporting Process VIII. Systematic Analysis and Systemic Action A. Performance Improvement Process Cycle B. Root Cause Analysis (RCA) C. Benchmarking IX. Communications X. Evaluation XI.

2 Establishment of plan 3 DISCLAIMER This Quality Assurance and Performance Improvement (QAPI) plan template is presented as a model only by way of illustration. It has not been reviewed by counsel. Before applying a form to a specific use within your organization, it should be reviewed by a counsel knowledgeable concerning applicable federal and state health care laws, rules and regulations. The QAPI plan template should not be used or relied upon in any way without consultation with and supervision by qualified physicians and other health care professionals who have full knowledge of each resident s case history and medical condition. The QAPI plan template is offered to nursing facilities as a guideline for developing QAPI plans and for informational and educational purposes only. The development process included a review of government regulations, literature review, expert opinions and consensus.

3 The guidelines strive to be consistent with these principles: Relative simplicity Ease of implementation Evidence-based criteria Inclusion of suggested, appropriate forms Application to various long term care settings Consistent with statutory and regulatory requirements Use of state and federal government terminology, definitions and data collection Appropriate staff at each facility/program should develop specific policies, procedures and protocols to best assure the efficient, implementation of the QAPI principles. 4 INTRODUCTION TO THE Quality Assurance AND Performance Improvement (QAPI) plan TEMPLATE The QAPI plan template development process included a review of government regulations, relevant literature, various Performance Improvement programs, expert opinions and consensus. The QAPI plan template design is relatively easy to use and customize.

4 Current, evidence-based criteria for defining, advancing and sustaining Performance Improvement strategies have been incorporated into the document, as well as suggested forms and analytical tools. The plan template may be used in nursing and skilled nursing facilities, and sub-acute care facilities to assist in developing a facility-specific QAPI program and plan . Health Quality Innovators (HQI) recommends that each facility designate a team of knowledgeable senior leaders, day-to-day managers, key clinical care and service, directors/supervisors, front line staff, consumers, community leaders and consultants to carefully review this plan template. The team should make thoughtful, appropriate adjustments in the template to produce a comprehensive, organization-specific QAPI plan . Then, the governing board and/or senior management should review the draft plan , make appropriate adjustments as needed, and approve the plan .

5 The approved plan will be documented as appropriate. HQI suggests that each facility/program conduct a formal review and revision as needed of its QAPI plan at regular intervals, not to exceed every twelve (12) months. 5 Quality Assurance and Performance Improvement (QAPI) Plan6 Guidance: Template: QAPI Goals: Based upon the Guide to Develop Purpose, Guiding Principles, and Scope for QAPI, provided in QAPI at a Glance, indicate the QAPI goals that your plan will strive to meet. Goals should align with overall organizational services and initiatives. For example: Memory care Disease management Specializedrehabilitation programs Transitions of care Quality workforceGoals should be specific, measurable, actionable, relevant, and have a timeline for completion. (See QAPI at a Glance Goal Setting Worksheet.) I. QAPI GoalsA. Introduction to QAPIE ffective QAPI originates from the organization's leaders to instill a desire in the hearts of all staff to find and embrace better ways to get the right things done, and done well.

6 QAPI is more than a task, a program, a process or a committee; it is the essential bridge to a successful future. The term QAPI is intended to communicate an organization-wide philosophy and process to regularly identify and implement constructive, cost-effective strategies to improve Performance . This facility-wide Performance Improvement process includes identifying and implementing opportunities to improve the Quality of resident care and Quality of life, as well as other measures of organizational Performance . B. Organizational Mission, Vision and ValuesC. QAPI Purpose Statement7 D. QAPI GoalsClinical Care: Address how the facility will implement and integrate QAPI to provide the necessary care and services to attain or maintain the residents highest practicable physical, mental and psychosocial well-being. Quality of Life: Address how the facility will implement and integrate QAPI into the care for residents in a manner and in an environment that maintains or enhances each resident s Quality of life.

7 Resident Choice: Address how the facility will implement and integrate QAPI to promote person-centered care and protect and honor each resident s rights. Care Transitions: II. Design and ScopeA. Fundamentals of Performance Improvement1. Key elementsOrganizational Performance that achieves and sustains high Quality care and services is a complex, interdependent process. is committed to ensuring continuing resources for key elements of the success of this QAPI plan including the following: a) Leadership that is competent, committed and stableb) Reliable capital and operational funding sufficient to achieve the missionc) Human resourcesd) An inclusive process supported by all stakeholderse) Selective, focused Performance Improvement initiatives2. Key areas of focusIt is the goal of the facility to integrate QAPI into all care and service areas of the organization.

8 The following will be key areas of focus of the facility: a)Clinical careb) Quality of life8 Address how the facility will implement and integrate QAPI into transitions across varying levels of care to promote resident safety and continuity of care. Describe how QAPI will aim for safety and high Quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents and/or a resident s agent. c)Resident choiced)Care transitions3. QAPI effortsEffective Performance Improvement efforts will focus on the development, maintenance and periodic Improvement of systems that influence organizational outcomes. Systems will be designed and modified to achieve reliable, efficient outcomes. Objectives of the QAPI plan : a)Improve the Quality of care thereby enhancing the Quality of life for residentsand other key stakeholdersb)Improve Quality of work environmentc)Achieve improved outcomes that exceed regulatory standardsThe objectives of the QAPI plan will be implemented, monitored and assessed using evidence-based best practices, clinical guidelines, data and benchmarking.

9 The plan and the outcomes will be used to determine appropriate care and to define and measure goals. 4. Limits of the QAPI plan9 Like all plans, this plan is an expression of intent that outlines a philosophy and a process for self- Improvement . As such, this plan is intended to be flexible and to accommodate timely and appropriate adjustments to address seen and unforeseen circumstances, while adhering to the fundamental mission, vision and values of this organization Board of directors/governing body may include but are not limited to: Chief Executive Officer(CEO) Chief Financial Officer(CFO) Shareholder Consumer Representative CommunityRepresentative ProfessionalRepresentativeFacility leaders may include but are not limited to: Executive Director Administrator Assistant Administrator Director of NursingIII. Governance and LeadershipThe governing body and the facility leadership are responsible for the development and leadership of the facility QAPI program.

10 The governing body will take a proactive role in working with facility leadership to gather input from facility staff, residents and families. The governing body is responsible for oversight and direction of the QAPI program. The governing body will be responsible for establishing and approving policies to sustain the facility s QAPI program and will set expectations around resident safety, rights, choice and respect. The leadership of the building will ensure appropriate and adequate resources are available for facility staff to carry out the QAPI plan . 10 Assistant Director ofNursing Director of EnvironmentalServices Director of DietaryServices Director of RehabilitationServices Director of Social Services Director of ActivitiesFeedback systems may include but are not limited to: Resident/familysatisfaction surveys Staff satisfaction surveys Resident councilmeetings Family council meetings Staff meetings Community partnerships Regulatory surveys Grievance/complimentlogs Hotlines Contract vendor reportsClinical data elements may include but are not limited to: IV.