1. What is Quality Assessment and Performance Improvement (QAPI)?
Center for Medicare and Medicaid Services (CMS) has established Conditions for Coverage for ESRD programs. Part of the Conditions for Coverage is that all ERSD facilities have a Quality Assessment and Performance Improvement (QAPI) process. Integrating this process into your center’s culture helps to create a healthy facility.
- The Lead medical director should actively oversee and lead the center’s monthly Facility Health Meeting (FHM)
- Associate medical directors must attend the portion of FHM for the modality they oversee
- All FHM activity occurs with the Lead medical director and at the CCN (CMS Certification Number) level
- Scope includes ALL services/modalities provided under the certification (CCN)
- Written Improvement Plans for facility process improvement drafted by the facility health team
- Accountable to ESRD, State Health Depts, and CMS
2. WHY does a QAPI program operate at the CCN level?
FHM is meant to have a facility-wide scope across DVA facility lines. QAPI is a facility-level assessment and improvement of care.
3. Why do we have a QAPI program?
The Conditions for Coverage require us to develop, implement, maintain, and evaluate an effective data driven QAPI program with participation by the professional members of the interdisciplinary team. We must keep a record of that program for CMS review.
4. Why is our QAPI program named Facility Health Record (FHR)?
The new Core Survey emphasizes the importance of having strong processes in place. When our processes are effective, we ensure both a healthy facility and facility record. The Facility Health Record (FHR) uses the DaVita application for documentation, which helps tell a comprehensive story for both internal and external surveyors.
5. Who is part of the QAPI team?
The medical director (facility leader and leads the FHM), the FA, CNM or CC, RD, MSW, and Biomed Tech are all members of the QAPI team and contributors to the health record. PD/HHD RNs can attend and contribute to the conversation, as well as DaVita SNF Dialysis (DSD) Regional Operating Managers (ROMs) and Pediatric Teammates.
6. What does QAPI have to do with PCTs and nurses taking care of the patients?
Everything we do for our patients is reflected in the QAPI program: P&Ps, infection control, education, emergency drills, patient outcomes, are a few.
7. How can I help make our Health Record better?
- Focus on facility process breakdowns across the population, as opposed to patient-level conversations
- Ensure you review all modalities within CCN
- Collaborate with associate medical directors
- Think about tracking and trending. E.g. Which category are we doing well in and which do we have some process breakdowns at the facility-level?
- For any process breakdowns, understand what commonalities exist? E.g. Same shift/same tx day/ same transportation company, etc.
8. What are the mandatory QAPI elements?
A facility's QAPI program is expected to involve continuous participation from all facility-based staff in monitoring both the clinical outcomes of patients and the operations of their facility. Staff members are responsible for identifying areas where performance improvement is needed and implementing tailored actions that address the specific needs of the facility and its patient population. These actions should aim to enhance patient safety and the quality of care provided.
Mandatory elements include:
- AKI Management
- Biomed/Water/Dialysate
- Facility Operations/Safety
- Patient Experience
- Regulatory and Audit
- Transplant Management
- Access management
- Adequacy Management
- Anemia Management
- Census, Growth, Transfer & Loss
- Error/Injury/Near Misses
- Fluid Management
- Hospitalizations
- Infection Prevention & Management
- MBD and Nutrition Management
- Missed Treatments
- Mortality
- Patient Psychosocial Care
- Other