The “Governance and Leadership” element of the Centers for Medicare and Medicaid Services (CMS) new “Quality Assurance and Performance Improvement” (QAPI) program must “develop a culture that involves leadership seeking input from facility staff, residents, and their families.”
The CMS’s official handout, titled “QAPI at a Glance,” says that the development of this culture is the responsibility of a facility’s administrative heads—and that all long-term-care facilities must have the QAPI plan in place by November 28, 2017.
The facility administration must, the CMS continues, ensure that “adequate resources” are committed to conducting QAPI efforts, and this includes “designating one or more persons to be accountable for QAPI.”
This dedicated person or persons must coordinate the development of “leadership and facility-wide training on QAPI,” and ensure provision is made for “staff time, equipment, and technical training as needed.”
Importantly, the administration must “foster a culture where QAPI is a priority by ensuring that policies are developed to sustain QAPI despite changes in personnel and turnover.”
These responsibilities include setting expectations around safety, quality, rights, choice, and respect by balancing safety with resident-centered rights and choice.
Equally critical, the administration must ensure that there is a channel open to ensure staff accountability, “while creating an atmosphere where staff are comfortable identifying and reporting quality problems as well as opportunities for improvement.”
Here are some pointers for setting up this “Governance and Leadership” element:
1. Identify exactly who is responsible for the program and its implementation, and specifically name a “QAPI Champion” who will have full responsibility for all aspects of the plan.
2. Stipulate in writing the format, frequency, reporting activities, and outcome tracking processes involved in the program. Don’t forget to specify how duties will be handed over in the event of any personnel changes.
3. Specify which audit tools are going to used, and in what format the data analysis is going to be presented. An analysis report should also specify how any changes or improvements are going to be achieved and monitored.
In this regard, the facility can utilize the CMS’s recommended “QAPI Leadership Rounding” to monitor concerns and evidence of improvement (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/QAPILeadershipRoundingTool.pdf).
4. The QAPI Champion must ensure that there are sufficient opportunities for residents, families, and staff to interact with the program and participate in QAPI activities.
5. The QAPI Champion will also ensure that all new hires are given full QAPI training, and will ensure that administrators will monitor the engagement and level of understanding of their team members, arranging for additional training when a need is identified.
6. The QAPI team must ensure that all job and role descriptions include language that measures commitment to quality assurance and performance improvement efforts.
Sample job description content can be found in the CMS’s “Examples of Performance Objectives for Job Descriptions” tool (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/ExPerformanceObjectivesJobDesc.pdf).
7. The QAPI plan must be updated on an annual basis at the very least, and the effectiveness of all action plans must be monitored and evaluated on an ongoing basis.
