QAPI Phase III: Data Collection and Monitoring
Jeannine LeCompte, Compliance Research Specialist
November 28, 2019 is the final deadline for implementation of the Centers for Medicare & Medicaid Services’ (CMS) Quality Assurance (QA) and Performance Improvement (PI) Rules of Participation (ROP) Phase III, which includes specific rules on data collection and monitoring.
These rules are spelled out in §483.75(c) of Title 42 (“Quality assurance and performance improvement”) and state that a facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring.
Title 42 goes on to state that these policies and procedures must include, at a minimum, written policies which will ensure that the facility maintains effective systems to obtain and use feedback and input from direct care staff, other staff, residents, and resident representatives. These must explain how such information will be used to identify problems that are “high risk,” “high volume,” or “problem-prone,” and detail opportunities for improvement in the areas of health outcomes, resident safety, resident autonomy, resident choice, and quality of care.
The first step in establishing an effective data monitoring, analysis, and feedback system is the collection of accurate data. This means that residents, their families or representatives, staff members, and all others have to be polled and surveyed on identified topics. In addition, the facility’s CMS quality measures, assessments, CASPER reports, fall incidence, and the results of a compliance hotline should be factored in. Another source of information should be derived from discharged resident surveys, family satisfaction surveys, and any information provided by physicians, contractors, or vendors.
Finally, statistical
data such as occupancy rates, pressure ulcer records, rehospitalization rates, staff
turnover, medication errors, medication reviews, infection rates, and all other
means of physical
measurement should be included. Once all this data is collected and analyzed, it
will quickly become apparent where problem areas are, and which aspects of the facility’s
service need to be addressed.
It is important to bear in mind the frequency at which data is collected. Data which remains constant over long periods of time (for example, occupancy rates) might only be collected monthly, whereas fall rate data might be collected weekly.
The task of analyzing the data must be given to specific staff members as part of their job description. It must also be specified to whom the results of this analysis should be presented—for example, to all board members, residents, etc., and how this data is transmitted (electronically, physical reports, on a noticeboard, etc.).
The person or persons entrusted with making the analysis must use predetermined benchmarks such as clinical guidelines, best practices, national data, state data, facility identified performance indicators, etc., in order to provide a rating by which the facility can measure its overall performance.
