QAPI Phase III: The Identification of Indicators and Their Measurement
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, and the process of identifying and measuring the performance indicators is an important element.
It is vital that the Leadership Team and/or the facility’s QAPI Champion ensure that the measures and indicators are clearly identified so that there is no confusion over the task at hand. In order to do this, it has to be determined when and how often the measure will be studied, where the data will come from, and who is responsible for tracking the measure.
In addition, a performance goal or aim to be achieved has to be predetermined, along with a strategy of how the data findings will be tracked and displayed. For this purpose, the establishment of clearly-defined goals is essential for performance improvement measurement. They should also include a description of what the facility or team intends to accomplish.
When identifying gaps in service provision or opportunities for improvement, the leadership team must analyze the data in such a way that it is possible to identify trends. It is only through the study of such lineally-presented data that undesirable outcomes can be spotted, predicted, or prevented.
Special consideration should be given to data which fall into three important categories: “high-risk,” “high-volume,” or “problem prone.” “High Risk” factors are those which present the greatest risk to the facility in terms of legal impact, financial repercussions, damage to reputation, regulatory noncompliance, or harm to residents or staff. “High Volume” factors are those which affect the greatest number of residents or staff, or those with the potential to be affected, while “Problem Prone” factors are those whose incidence, prevalence, and severity mark them as important.
Data collected from topics which fall into the high-risk, high-volume, or problem prone areas should be assigned to a specific Performance Improvement Project (PIP). The PIP team members should then establish its own goals, the scope of its work, the timing (as determined by the severity of the topic), achievable milestones to measure its progress, and the responsibilities of all PIP team members.
