QAPI – Reset your QI Program to the New Conditions of Participation!

QA, QI, CQI, TQC, PI and so forth…for years our home health industry, as the rest of the healthcare industry has done some form or another of quality improvement.  So, the New Conditions of Participation (CoPs) for QAPI (Quality Assessment and Performance Improvement program) should not be brand new for most agencies!  In fact, if an agency is accredited, their standards are very similar to what CMS is now going to mandate beginning on July 13, 2017.

If your QI program isn’t quite there, it’s time to reset to the new QAPI standards!

Unfortunately, too many home health care agencies feel that QAPI or any kind of quality improvement program is just busy work, and they are just too busy to deal with it.  However, it is a key component of a well-run organization.  It not only assists in minimizing risk, but it also increases an agency’s quality and efficiency.  A good QAPI program should be incorporated into everyday operations and can lessen the day-to-day challenges!

So, What is the QAPI Condition?

CoPs are very specific and prescriptive, which should help agencies to develop their programs.  The Governing Body is given a major role in ensuring that the agency has a compliant QAPI program that focuses on improving patient outcomes.

The following is language in the Condition (484.65), although it is grouped together in a different manner:

The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. Program must involve all HHA services (including those under contract) and focus on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions. Program must take actions that address performance across the spectrum of care, including the prevention and reduction of medical errors.

The Governing Body must ensure that the program reflects the complexity of the organization and its services. They are responsible for ensuring the following: that QAPI is an ongoing program for quality improvement and patient safety is defined, implemented and maintained; that the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; that clear expectations for patient safety are established, implemented, and maintained; that any findings of fraud or waste are appropriately addressed. The frequency and detail of the data collection must be approved by the HHA’s governing body.

The QAPI program must be capable of showing measurable improvement in indicators that reflect improved health outcomes, patient safety, and quality of care.

The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance in order to assess processes of care, HHA services, and operations and to identify opportunities for improvement. Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions.

The HHA’s performance improvement activities must: focus on high risk, high volume, or problem prone areas; consider incidence, prevalence, and severity of problems in those areas; lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients.
The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained.

The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects.

So HOW Does an Agency take the Conditions and Build a QAPI Program? 

A good way to start is to review your Agency CASPER Outcome Reports (the CMS system that compiles the OASIS data of every certified home health agency at two time points – ex: SOC to DC, or ROC to DC and gives the outcome reports).

Key reports to analyze are:

  • Agency Patient Related Characteristics
  • Risk Adjusted Outcome Report
  • Potentially Avoidable Events
  • Process Based Quality Improvement

The 3 Bar of each report is a good one to use as it includes your current percent, your prior period percent and the national current percent.  The current period is the 12-month period up to the most recent CASPER report (there is about a three-month lag).  When analyzing the data, concentrate initially on the items with asterisks which means that data is statistically significant.

It is important to assign a monthly task for the person who has access to the CASPER data, to see if the reports have been updated.  If they have, these reports can be printed out or saved as a pdf.  The person responsible for analysis should review the reports and identify changes since the last update.

When identifying the outcomes your agency needs to address, an action plan can be written and then the QAPI indicators can be monitored.  For indicators from the CASPER reports, it is a good idea to have two different thresholds, one for the monitoring of improvement to national reference and one for the audit tool results.

Ex:  How often patients had less pain when moving around

Agency threshold (goal) is 73% in order to achieve at or above the national average of 72.5%.  Audit of patient clinical records of those who did not improve in pain – 90% to audit criteria.

The information in the Agency Patient Related Characteristics report includes many items that will be used to calculate your agency’s risk adjustment for the outcomes (similar to a golf handicap – or in healthcare terms, can denote your agency’s acuity in items on the OASIS).

This report includes items such as:

  • Demographics,
  • Payment sources,
  • Therapy days,
  • Length of stay,
  • Diagnoses, and
  • Results of many M items (including ADLs, ambulation, medications, dyspnea, pain, and confusion)

The Potentially Avoidable Events report is what was historically called Adverse Events.  It is recommended that you print off the Patient Tally listing for this report as well since it is important to audit the patient’s record in order to try to prevent any adverse event from occurring in the future.

This report includes:

  • Emergent care for falls,
  • Wound infections or deteriorating wound status,
  • Improper medication administration or medication side effects and hypo/hyperglycemia,
  • Development of UTI,
  • Increase in the number of pressure ulcers,
  • Decline in management of oral medications,
  • Decline of three or more ADLs, and
  • Discharged to community needing wound care, medication assistance, toileting assistance, behavior problems or an unhealed stage 2 pressure ulce

The Process Based Quality Improvement report indicates standards for best practices. Some of these are included in the 5 star ratings as well.

These standards are:

  • Timely initiation of care and physician notification,
  • Risk assessments – falls, pressure ulcer, depression and pain,
  • Interventions on the plan of care for depression, diabetic foot care and patient education, fall prevention, pain, and pressure ulcer prevention,
  • Implementation of these interventions in the documentation,
  • Heart failure symptoms addressed,
  • Influenza and pneumococcal vaccines, and
  • Medication issues identified and timely physician contact

Once you have identified and developed the QAPI indicators to monitor from the CASPER outcome reports, it is important to ascertain through the monitoring if the deficiency is from lack of understanding the OASIS M item intent and guidance from the OASIS C2 manual and/or if it is a care issue.  The QAPI monitoring should be set up to be able to determine this.

The earlier you share this CASPER outcome deficiency and QAPI indicator with the field clinicians the better, as this is information directly from the OASIS documentation. Involving the frontline staff will help you achieve relatively rapid and sustained improvement!

Homecare Agency Self- Assessment or Mock Survey

This is another valuable tool to help select areas to monitor in your QAPI program.  It is also the best way to ensure that you are in a state of continued survey readiness.

Assign qualified employees (often managers or QI staff) from your agency or another location if multi–site.  If no one is qualified to be able to ‘survey’ your agency internally, consider engaging a consultant with appropriate survey expertise.  Even if your own staff is performing the mock survey, do it formally as a surveyor would.

Items to Review

Previous regulatory survey reports and the agency’s approved plan of correction should be reviewed.  The previous deficiencies and the plan of correction may be necessary to include as a QAPI indicator in order to ensure that there is compliance.  This is extremely important as you want to avoid repeat deficiencies.  Even a standard level deficiency, if repeated, is vulnerable to escalating to a condition level deficiency.  Ongoing, formal monitoring in the QAPI program can help your agency to avoid repeat deficiencies.

Complaints, incidents including falls, and infection surveillance, are critical areas that are vulnerable to deficiencies.  Ensure that there is resolution documented for all complaints.  Trend these items so that you can see red flags early.  Those may then become QAPI indicators.  Examples include: increasing falls for patients without therapy services, complaints regarding staff competency, and increasing numbers of UTI’s would all be captured by trending so that you can effectively improve those results.

In-service, orientation and competency programs, and staff meeting minutes would be reviewed.  Human Resource files would be reviewed also.

Home visits should be done as a surveyor would perform.  Choose all disciplines with various care needs of patients such as wound care, multidisciplinary, therapy only, IV’s, and aide services.  Review the Clinical Record prior to visit so that the plan of care and subsequent physician orders, medications, and goals are known during the visit.

Interview the patient and/or caregiver.  Ask questions that a surveyor asks.  Examples include:

  • Have you had any complaints?
  • Can you reach the agency after hours?
  • Have the clinicians told you when they are coming?
  • Were you taught infection control?
  • Were you told about the hot line numbers, etc.

Locate and review the Home Folder, which should include copies of signed consents, a medication list, education materials, etc.

Observe the Visit.  Don’t intervene unless a safety issue is seen.

Note what was non-compliant to physician orders, medications, patient rights, infection control, aide care plan, etc.  Clinical record reviews include various types of records such as wounds, various diagnoses, post op, multidisciplinary, therapy only, and those with aides.  Ensure the audit tool is appropriate to capture all regulations.  Also, ensure that the auditor understands what to look for on both clinical record reviews and home visits.  It is very possible that you may have to train staff on how to perform these key areas of a mock survey.

Look for commonly seen deficiencies such as lack of coordination of care / communication between disciplines and/or physicians, not following physician orders – visits and treatments, aides not following aide care plans, and untimely supervisory visits.

Development of the QAPI Plan

List and prioritize the topics that you have found from the CASPER outcome analysis and the Mock Survey deficiencies.  Separate into items you can address and resolve immediately, and those that require more review and auditing.  Focus on the high volume, high risk, problem-prone areas in your agency.  These will be your QAPI Indicators for the plan!

Next, describe each indicator with the methodology, threshold (goal %), frequency, and responsible party.

Ex:  Development of UTI:  QAPI coordinator will review 100% of patients who develop a UTI during the homecare episode of care to ensure appropriate interventions, education and infection control were performed.  Frequency – Quarterly, Goal:  90% compliance to audit criteria.

Audit Tools must be developed for each indicator.  There are many variations to audit tools and tracking.  Make certain that they are objective in order to ensure accurate results.

Ex:  The QAPI coordinator will review 20% of patients going to the ER without hospitalization quarterly to ascertain if there was anything the HHA could have done to prevent the ER visit. Goal:  90% to audit criteria.  Goal to CASPER Outcome:  Less than 12% (current national average).

Ex:  Audit Criteria:

  • Was assessment on SOC complete?
  • Were appropriate disciplines ordered based on OASIS?
  • Were the frequency and duration appropriate?
  • Was the physician notified of any changes in patient condition?
  • Did disciplines communicate with each other regarding patient change?

What do you do with the Data?

Many agencies perform a lot of audits, gather a lot of data, but then don’t do the most important steps in a QAPI program.

Analyzing, Trending and Developing Action Plans

Ensure that your Action Plans are specific.  Often they will include educating staff on particular topics, process and/or policy change, and of course, the QAPI monitoring.

In QAPI, it is important to improve in an indicator being monitored and then sustain that improvement.  An annual QAPI calendar is an easy way to monitor this.


Whenever an indicator is lower than the goal, or has significantly varied over the time periods of collection, it is important to update the action plan.  Be more specific than simply stating to continue monitoring.  Drill down to the items that you will perform during this time period in order to improve and sustain.

QAPI Projects

You may find that a deficiency is high risk, high volume and problem prone.  It may be widespread, effecting many services as well as office and field staff.  This would become then a QAPI project!

Remember PIP – Performance Improvement Projects?  Most of us in healthcare have done many PIPs!  That is what the QAPI condition is requiring, but not until July 2018.  Don’t wait until then if you find a deficiency and/or problem area that is critical to patient care, safety and/or outcomes.

The projects will often involve performing a root cause analysis, where a task force of stakeholders does case studies, and drills down to all the various deficiencies that are involved.  Often communication is key – between clinicians, office staff, physicians and patients / caregivers.  And very often processes and policies need to be revised.  Several ongoing QAPI indicators may need to be developed as a result as well.

QAPI SUCCESS –  Get Everyone in your Agency Involved!

Having a large QAPI team and rotating them every six months to a year is a great way to get all staff involved.  The team will brain storm on action plans, indicators, audit tools, etc.  Assign team members to parts of the action plan, examples include clinical record reviews, education, and process development.

Your agency will improve in many ways when your staff is involved in QAPI!

QAPI never stops!  Indicators may be able to be discontinued once you find sustained and complete improvement.  But the evaluation must continue.  This diagram demonstrates the steps in a successful QAPI program:

In conclusion, a QAPI program is not just busy work that must be done because of the new CoPs, but is a true tool to enhance an agency’s outcomes, quality and operation.
Ensure you review CASPER outcome reports and perform an agency self-assessment (mock survey).  From those results develop QAPI indicators and audit tools.  Next, collect the data, review/analyze and trend the data.  Most importantly, develop specific action plans for sustained improvement.  And involve all your agency staff!  Your agency and your patients will benefit from a QAPI Program!

Southern Web SupportQAPI – Reset your QI Program to the New Conditions of Participation!
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