It’s been more than four years in the making, but starting next year—March 30, 2021, to be exact—critical access hospitals will be required by the Centers for Medicare and Medicaid Services to meet new quality assessment and performance improvement (QAPI) requirements as a condition of their participation in Medicare.
Although quality assurance (QA) is addressed in current CMS CAH Conditions of Participation, the new requirements expand upon existing CAH requirements and may present compliance challenges if not carefully assessed and a plan for full implementation is not developed and implemented, says Mella Grainger, MSN, MBA, MT, RN, CNL, HACP, vice president of Healthcare Strategies Inc.
“If a CAH has a robust program, it may just be a matter of tweaking a few things to become more in line with the new requirements,” she says. “For others that have less robust programs, it will be much more challenging.”
Even more challenging is the fact that the Interpretive Guidelines and Survey Procedures for the new CAH QAPI requirements are not yet published. In the meantime, Grainger recommends getting up to speed on the requirements and the pitfalls to avoid.
Among the QAPI-related missteps Grainger sees healthcare organizations make, one of the bigger missteps is also the easiest to make. Grainger references a quote from the Institute of Healthcare Quality (IHI), “‘Quality is not a department,’” when describing this misstep. “This quote is one of my favorites because it so true” she says.
Specifically, the quote comes from Robert Lloyd, executive director of performance improvement at the IHI, which he spells out in this Improvement Tip:
“Quality is not a program or a project; it isn’t the responsibility of one individual or even those assigned to the Quality Department. The Quality Director is basically the coach, facilitator and cheerleader. His or her job is to instill principles of quality at all levels, helping everyone in your organization—every employee, executive, caregiver, and consultant—feel driven to achieve excellence.”
So often, though, it’s the quality director who is seen as having the responsibility for the QAPI program.
“The IHI description of how a quality director and a quality department is perceived as having all the responsibility for the QAPI program is unfortunately a frequent misconception,” Grainger says. “QAPI is not a department. Instead, it is everyone in the organization, from bedside to board room and back. QAPI encompasses everyone, including those who support bedside processes such as housekeeping, materials management, pharmacy, IT and so on.”
Achieving such a pervasive focus on quality requires a multipronged approach, starting with an organization’s board that is tuned into QAPI requirements, including their ultimate responsibility for it.
Here are some other missteps Grainger sees organizations make as they implement QAPI programs:
Drowning in data with no clearly defined priorities: When priorities are not established; are established without consideration given to the organization’s mission, vision and strategic plan; do not adequately address patient safety and health outcomes; or are established without associated clearly defined goals, the QAPI focus can become muddled.
Drowning in data and taking action with minimal or no analysis of the data. When the focus is on data /metric collection, all you have is more data/metrics. Failure to focus on analysis of the data—the “why” behind performance of the metric—and how to harness the root causes to identify the actions most likely to result in improvement is a frequent misstep.
Lack of a fully integrated QAPI Program: Failure to assess the full organizational structure, ensuring each department and service, including contractors are part of the QAPI program. To be successful, you must integrate all departments and services (it’s part of the final rule).
Mitigating indifference. A culture that lacks passion for embracing improvement changes and sustaining improvements results in a self-limiting QAPI program. “Your organization will only make meaningful and sustainable quality improvements when people at every level feel a shared desire to make processes and outcomes better every day, in bold and even imperceptible ways,” IHI’s Lloyd says.
Losing momentum. As with any initiative, it’s easy to lose momentum once the shiny and new wear off. Fend off this urge by assigning accountability, setting timelines for actions and scheduling regular check-ins.
Join Grainger on Friday, March 6 at noon CST for the webinar “Implementing an Effective QAPI Program—A Cheerleader’s Guide” to learn the essential components of a successful QAPI program and how to implement and sustain one. Although the new requirement is specific to CAHs, the webinar is applicable to any healthcare organization that is interested in implementing a QAPI program or strengthening their current program. Reserve your spot today.