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Quality Assurance Performance Improvement (QAPI) Self-Assessment


Thank you for participating in this webinar
on how to complete the QAPI self-assessment and use it to plan action steps to implement
and monitor QAPI in your organization I am Jane Pederson, Medical Affairs Director
at Stratis Health, part of the Lake superior Quality Innovation Network. I was part of
the team, which included Stratis Health and the University of Minnesota under contract
with CMS, that developed QAPI implementation strategies, tool, and resources for nursing
home implementation. The objectives for this webinar are to help
you recognize the self-assessment tool as valuable for QAPI implementation and to know
how to apply the completed self-assessment to improve QAPI implementation. The self-assessment tool was developed to
help organizations monitor their progress with QAPI.
The tool should be completed by the team that is implementing and monitoring QAPI and is
responsible for the quality programs. We have seen this tool completed in a couple of ways.
We’ve seen organizations where QAPI team members and organizational leadership have
a meeting where they review each item and as a group assess their progress and choose
a rating. We’ve also seen organizations where each person completed the assessment,
shares their ratings during the meeting and the team then decides as a group the rating
for the assessment. Either way, the key is to have a team with knowledge of the organization’s
quality improvement policies, procedures and practices complete the assessment. Participants
give honest statements about their level of awareness and candidly share their perspectives.
The team’s reflection and discussion of the vision of QAPI and current status is the
most important aspect. The area of the self-assessment follow the
QAPI 5 element framework. Design and Scope; Governance and Leadership; Feedback; Data
systems and Monitoring; Performance Improvement Projects and Systematic Analysis and Systemic
Action. The team will assess how well their progress
is with QAPI by reflecting on questions like, How well has QAPI been incorporated into our
organization’s culture? Are we using small tests of change before
implementing more broadly? Has QAPI been incorporated into our new staff
orientation and training? Are we focusing performance improvement opportunities
on making changes to systems and processes? Rating progress on these items will take honest
reflection by the team, and lead to focused discussions on what needs to be accomplished
to fully implement QAPI. The assessment looks like this. During team discussion and for recordkeeping,
one copy of the assessment should be completed. The date of the current review is filled in. Then the team begins rating 24 statements
related to QAPI. The statements should be rated by how they currently fit your organization
using a 5-point scale. Not started
Just starting On our way
Almost there or Doing Great There is no right or wrong answer. The team
discussion of where your organization is can be the most important step. You will also
notice there is a place for notes along with each statement. This is a good place to record
highlights or insights from the team discussion. After the team rates where their organization
is with each statement, the statements are then reviewed. Remember the goal is to use
the statements to direct the work that’s needed to establish or further integrate QAPI
into your organization. The self-assessment provides information about the organization’s
QAPI strengths and areas for growth. What areas are going great? What areas could
be improved? Is there an area that hasn’t been started. The team then decides which
areas to work on. Create a plan once the area or areas are decided.
What actions or changes will occur? Who will carry out the changes?
When will the changes take place? What resources are needed?
Who do you need to communicate with? For example, your team decides that QAPI needs
to be incorporated into new staff orientation. What needs to happen? Are there current resources
that can be adopted or will they have to be developed?
Who will carry out the changes? What resources are needed to accomplish this?
When will a draft be ready for the team to look at and who will need to know about this? Then take action! Implement the plan. Use
PDSA cycles to develop orientation materials, have them reviewed by staff, organizational
leadership, residents, your board or any others that either participate in orientation or
care about that process. Once the action plan is started, the team
should decide when they’ll review the self-assessment again. Self-assessment is an ongoing process
and not a one-time occurrence. Periodically assessing progress over time identifies the
strengths of the organization as well as areas for growth, and monitors whether QAPI is being
sustained. It doesn’t matter where the organization starts as long as there’s progression towards
a positive outcome. If you’re in the early stages of QAPI implementation,
the team may want to review the assessment every month or every 3 months. If you’re
farther along, it may be every 6 months or annually. Completing the self-assessment
Helps the team’s awareness of how effectively they are addressing QAPI and helps develop
a strategic plan with clearly defined short and long term goals, measureable objectives,
identified resources and outcomes. QAPI is developed along a continuum of growth.
The self-assessment can assist the QAPI team in developing a shared vision and provide
a snapshot on where the organization is at a certain point in time. There is also benefit
to the organization in self comparison over extended periods of time to show where growth
has occurred. The self-assessment tool can be found at this
link. http://www.cms.gov/medicare/provider-enrollment-and-certification/QAPI/downloads?PAPISelfAssessment.pdf The QAPI self-assessment is a valuable tool
for organizations. The information can assist and help develop,
monitor and sustain Quality Assurance and Performance Improvement in any organization. For further information about the QAPI self-assessment
tool or the National Nursing Home Quality Care Collaborative, please contact your state
lead in the Lake superior Quality Innovation Network. Thank you for your participation.


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