QAPI Phase III Deadline Approaches: Are You Ready?
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 is focused on the implementation of the entire QAPI system.
QA and PI combine to form QAPI, a comprehensive approach to ensuring high quality care. Both involve seeking and using information, but they differ in key ways: QA is a process of meeting quality standards and ensuring that care reaches an acceptable level. QA is a reactive, retrospective effort to examine why a facility failed to meet certain standards. QA activities do improve quality, but efforts frequently end once the standard is met. PI is a proactive and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems.
CMS’s QAPI requirements have been rolled out in three enforcement phases:
- Phase I (Implemented November 2016): the QAA/QAPI Committee;
- Phase II (November 2017): the QAPI Plan; and
- Phase III (November 28, 2019): The implementation of the QAPI Plan.
By now all facilities should have the first two phases in place and be conversant with their requirements.
Phase III, the full implementation of the entire QAPI plan, consists of the following elements:
- effective data collection and monitoring programs;
- identification of sources for data collection;
- identification and description of measures and or indicators to be assessed;
- establishment of goals;
- identification of deficiencies and opportunities;
- creation of Performance Improvement Projects (PIPs) to address specific issues; and
- process of feedback, evaluation, and implementation of all measures designed to improve quality of life for residents and the efficient functioning of the facility.
Ultimately, it is the purpose of QAPI to create a data driven program that focuses on systems of care, outcomes of care, and quality of life.
It is worth repeating—for those who might not yet have gotten so far in their preparations—that the QAPI regulation requires a written plan which must spell out a framework for an effective, comprehensive program focused on the indicators that reflect outcomes of care and quality of life.
The QAPI plan is not, however, written in stone: it must be a flexible document which can be changed according to requirements and circumstances. The facility should also be flexible and ready to make its written program available to any responsible state agency, federal surveyor, or CMS upon demand.
