8 Questions on Using Data in QAPI
We recently held a webinar focused on collecting, analyzing and communicating data in Quality Assurance Performance Improvement (QAPI). By November 2019, all skilled nursing facilities will need a QAPI program that focuses on systems of care, outcomes of care and quality of life.
Below are the top questions from the webinar. Like many skilled nursing providers, you may have similar questions as you build your QAPI program.
1. Does the infection preventionist need to be different than the control director?
The requirements say that they can have dual roles if the responsibilities are incorporated into those roles.
2. Does a clinical operations nurse consultant qualify as part of the QAA committee for leadership?
The requirements say that if the consultant is not staff, they wouldn’t qualify. Make sure there is true ownership for your QAPI program. These members should be part of your staff or Board.
3. How long should QAPI meetings take?
It should be as long as needed to have a meaningful meeting. The more critical part is how much time is spent in preparing for the meeting. Make sure you have an agenda and that your attendees come prepared. For example, if you have reports to review at the meeting, send these to attendees at least 2 days before the meeting.
4. Phase 2 says to present the QAPI plan to the State Surveyor by 11/28/17. How should this get presented to CMS?
The Centers for Medicare & Medicaid Services (CMS) is specific that you begin your QAPI program with a comprehensive QAPI plan: “We propose in new §483.75(a)(2) that the facility must submit the QAPI plan to the state agency or federal surveyor, as the agent of the secretary, at the first annual recertification survey that occurs at least one year after the effective date of these regulations.”
5. What are the CMS and CDC citations for QAPI?
6. What are good references to help in setting goals for UTI?
The Center for Disease Control (CDC) references in the question above provide guidance on goals, surveillance and tracking specific for long-term care. In addition, we recommend following Mc Geer Criteria for a suspected urinary tract infection (UTI) as surveyors will likely be looking for this as well.
7. Who would be considered a member of the community for the committee?
There is no mention that a member of the community be part of the QAA committee. The regulation states that the QAA committee must include the director of nursing, a physician, and three other staff. These additional members may include: the administrator; the medical director; staff with responsibility for direct resident care and services; staff with responsibility for the physical plant.
8. Are providers supposed to now to show the survey team our QAPI minutes, plans, etc.?
The facility is not required to release the records of the QAA committee to the surveyors to review and the facility is not required to disclose records of the QAA committee beyond those that demonstrate compliance with the regulation (F520). However, the facility may choose such disclosure if it is their only means of showing the composition and functioning of the QAA committee.
If the facility has provided the records for surveyor review, this information may not be used to cite deficiencies unrelated to the QAA committee requirement. It is recommended that surveyors not review QAA records (if provided) until after they complete their investigation of other tags. (source: guidance to surveyors)