QAPI Phase III: The PIP Cycle, Analysis, and Implementation

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 the all-important Performance Improvement Project (PIP) element.

As discussed in a previous article, a PIP team needs to be created to address specific problems identified from a data analysis system, and must have its own goals, guidelines, measures, and outcomes. This means that the PIP team must analyze the collected data to determine if the findings met the team’s expectations or failed to meet the preselected goal.

The analyzed data must also be communicated to the parties that need to know. This can include residents, residents’ families or spokespeople, employees, and others, as per any legal requirements. The feedback system can include newsletters, posters, resident council meetings, family meetings, employee meetings, etc.

It is often useful to include the concept of “system thinking,” or root cause analysis, in the workings of a PIP team. This is helpful in getting staff to understand how different parts of a process influence each other as a whole, and to not just consider the disparate elements on their own.

Staff also need to be made aware that the act of not reporting data can be interpreted as fraud, waste, or abuse by CMS, and that it is therefore vital that all incidents are noted. For example, not reporting a complaint of lost laundry, not reporting a near miss, or not documenting a pressure ulcer, can all be used against the facility. In addition, inaccurate data can also fall under the category of fraud, waste, or abuse.

In essence, the PIP team must work according to a “Plan-Do-Study-Act (PDSA)” cycle. CMS has specific guidelines for setting up the PDSA cycle which include the following:

Determine the aim of the PIP;
Determine the measurable outcome which will produce a visible improvement;
Determine the changes that will result in an improvement. This includes an analysis of processes currently in place; the identification of opportunities for improvement, and what needs to be changed in the process.

This process can be summed up as follows:

Plan: What exactly is going to be done?
Do: When and how was it done?
Study: What were the results?
Act: What changes are going to be made based on the findings?

Under the “plan” heading, the PIP report must list its action steps along with person(s) responsible and a timeline. The “do” section must describe what actually happened when the test solution was piloted. The “study” section must describe the measured results and how they compared to the predictions. The “act” section must describe what modifications to the plan will be made for the next cycle from what has been learned.

Once this process has been completed, it will be possible to allocate facility-wide resources to solve the problem at hand and prevent all similar future events.