The “Feedback, Data Systems, and Monitoring” element of the Centers for Medicare and Medicaid Services (CMS) new “Quality Assurance and Performance Improvement” (QAPI) program is designed to put in place systems to monitor care and services, while drawing its data from multiple sources.
This forms the third element of the CMS’s QAPI program, which all long-term-care facilities must have in place by November 28, 2017.
The CMS’s official handout, titled “QAPI at a Glance,” says that this feedback system must “actively incorporate input from staff, residents, families, and others as appropriate.”
Included in this monitoring are “Performance Indicators” which will look at a “wide range of care processes and outcomes,” and which will review findings against predetermined benchmarks and targets.
The plan must also include the tracking, investigating, and monitoring of “Adverse Events,” each and every time that they occur, and the development of action plans to prevent those events from happening again.
Pointers setting up the QAPI “Feedback, Data Systems, and Monitoring” element:
- The development of “Performance Indicators” can be expedited by using the CMS’s Measure/Indicator Development Worksheet (https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/measindicatdevwksdebedits.pdf). This will allow for the setting of standards, thresholds, and benchmarks by which improvement can be measured.
- It is very helpful to identify all “data sources” before you begin. This is best done by physically creating a list of sources which can then be systematically worked through. This list can comprise, for example, staff, caregivers, residents, and families; or detailed reports from adverse events, reports on quality control, medication use, infection rates, hospitalization rates, and a myriad of other sources which already exist within a facility’s administrative section.
- Other valuable data sources which should not be overlooked include the survey findings and complaint records. A comparison of these reports from year to year will provide great insight into the institution’s functioning.
- It is also important to have a list of “Potentially Preventable Events” which can include adverse outcomes to medication, injuries sustained by residents due to care-related events, elopement, and infection rates.
- For the purposes of data collection, the QAPI team must ensure that the following categories are identified and catalogued:
• The measure/indicator to be studied.
• When and how often the measure will be studied.
• Where the data will come from.
• Who is responsible to track the measure.
• A performance goal or aim to be achieved.
• How data findings will be tracked.
• How data findings will be displayed. - For the purpose of setting goals, the CMS’s Goal Setting Worksheet (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/QAPIGoalSetting.pdf) can be used, and in particular, the “SMART” formula (S = Specific, M = Measurable, A = Attainable, R = Relevant, and T = Time-Bound).
The feedback cycle also needs to be spelled out. Issues which are likely to cause serious harm, impairment, or death must be reported and responded to immediately by the QAPI/QAA committee members, while other improvement plans must be assigned to a dedicated Performance Improvement Project (PIP) team.
Once collated, all the data must be analyzed against the set goals to determine successes or failures. The CMS’s Plan-Do-Study-Act (PDSA) Worksheet can be used in this regard.
Finally, this element will include a communication plan on how the information will be distributed to those who need to know: either through written reports, presentations, or other suitable methods.
