Jeannine LeCompte, Publishing and Research Coordinator
A Quality Assurance and Performance Improvement (QAPI) program is focused on the development of systems which look at the identification, reporting, investigation, analysis, and prevention of “adverse events” in a long-term care facility (LTC). The program must have as its primary objective the maintenance of the best possible standard of care for residents, and its focus should always be preventative in nature.
According to the State Operations Manual F865, a facility must maintain and demonstrate evidence of an ongoing QAPI program which provides continual evaluation and feedback on the identification, reporting, investigation, analysis, and prevention of “adverse events.” The requirements include a system whereby all the processes involved in care and management practices are continually evaluated with the intention of preventing events.
A February 2014 Office of Inspector General (OIG) report revealed that 22 percent of all Medicare beneficiaries experienced “adverse events” during their LTC stays. In addition, a further 11 percent experienced “temporary harm” during their stays. Furthermore, the OIG report said, physician reviews of these incidents determined that 59 percent of these adverse events were “clearly or likely preventable.”
The OIG’s definition of adverse events includes all medication-related issues, falls or other trauma, constipation, hypoglycemic events, dehydration, thrombosis, exacerbation of pre-existing conditions, respiratory issues, pressure ulcers, and infections.
A QAPI program must have corrective actions in place to address identified lapses which have resulted in adverse events. It should have a focus on high risk, high volume, and problem prone areas of care, including what the Centers for Medicare & Medicaid Services (CMS) calls “near miss” or potential harm events that did not reach a resident. It must also have a process through which written policies and procedures for feedback, data collection, and monitoring are kept on record.
The LTC’s governing body has full legal responsibility for the existence and maintenance of the QAPI program, and must ensure that staff time, equipment, and technical training are implemented as needed.
Finally, the QAPI program must provide a performance improvement action plan. This plan must be able to demonstrate that the facility has taken every possible measure to prevent the recurrence of previous incidents.
