• Affordable Care Act: Quality Assessment and Performance Improvement Program
  • November 21, 2012 | Author: W. Cory Phillips
  • Law Firm: Weltman, Weinberg & Reis Co., L.P.A. - Cleveland Office
  • For more than twenty (20) years, federal law has mandated that nursing homes maintain a Quality Assessment and Assurance committee. The federal law requires certain members of the committee to meet quarterly with the purpose of “develop[ing] and implement[ing] appropriate plans of action to correct identified quality deficiencies.” While the statute and requirement outlined within it is noble, no one took the time to outline any guidance regarding the means and/or methods to achieve the objective of identifying and correcting quality deficiencies.

    In 2010, however, President Barrack Obama signed into law the Patient Protection and Affordable Care Act (ACA), which was upheld by the United States Supreme Court in June of 2012. Of the many provisions of the ACA, it mandates that the Centers for Medicare/Medicaid Services (CMS) develop standards and guidelines for Quality Assessment and Performance Improvement (QAPI) programs to address the shortcomings under the existing federal law.

    The standards (regulations) and technical assistance to nursing homes currently are on-going, commencing with a random survey conducted this summer, to better understand current practices and barriers to implementing change. The ACA explicitly requires nursing homes to develop a plan that will implement the standards created by CMS. The required plans must be submitted to CMS within one-year from the date the regulations are promulgated by CMS. While gathering data and developing criteria for each QAPI, CMS has identified five (5) key elements or concepts found in effective quality assessment programs. Accordingly, CMS strongly encourages nursing facilities to incorporate the identified elements into their QAPI programs. Below are the key elements and descriptions of each as expressly stated by the CMS:

    Element 1, Design and Scope: A written QAPI program that must be ongoing and comprehensive, dealing with the full range of services offered by the facility, including the full range of departments. When fully implemented, the QAPI program should address clinical care, quality of life, resident choice, and care transitions. The program should aim for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents (or resident’s agents). Finally, the program should utilize the best available evidence to define and measure goals.

    Element 2, Governance and Leadership: The governing body and/or administration of the nursing home should develop and lead a QAPI program that involves leadership working with input from facility staff, as well as from residents and their families and/or representatives. The governing body assures the QAPI program is adequately resourced to conduct its work. This includes designating one or more persons to be accountable for QAPI; developing leadership and facility-wide training on QAPI; and ensuring staff time, equipment, and technical training as needed for QAPI. The governing body and executive leadership are responsible for establishing policies to sustain the QAPI program despite changes in personnel and turnover. The governing body and executive leadership are also responsible for setting priorities for the QAPI program and building on the principles identified in the design and scope element. The governing body and executive leadership are also responsible for setting expectations around safety, quality, rights, choice, and respect by balancing both a culture of safety and a culture of resident-centered rights and choice. The governing body ensures that while staff are held accountable, there exists an atmosphere in which staff are not punished for errors and do not fear retaliation for reporting quality concerns.

    Element 3, Feedback, Data Systems and Monitoring: The facility should put in place systems to monitor care and services, drawing data from multiple sources. There should be feedback systems that actively incorporate input from staff, residents, families, and others as appropriate. Performance Indicators should be used to monitor a wide range of care processes and outcomes, and reviewing findings against benchmarks and/or targets the facility has established for performance. It also includes tracking, investigating, and monitoring Adverse Events that must be investigated every time they occur, and action plans implemented to prevent recurrences.

    Element 4, Performance Improvement Projects (PIPs): The facility should conduct Performance Improvement Projects (PIPs) to examine and improve care or services in areas that are identified as needing attention. A PIP typically is a concentrated effort on a particular problem in one area of the facility or facility wide. It involves gathering information systematically to clarify issues or problems, and intervening for improvements. PIPs are selected in areas important and meaningful for the specific type and scope of services unique to each facility.

    Element 5, Systematic Analysis and Systemic Action: The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. The facility uses a thorough and highly organized/structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered. Additionally, facilities will be expected to develop policies and procedures and demonstrate proficiency in the use of Root Cause Analysis. Systemic Actions look comprehensively across all involved systems to prevent future events and promote sustained improvement. This element includes a focus on continual learning and continuous improvement.

    Whether or not the ACA remains enforceable law, or is recalled or amended by new leadership, the concepts are worth taking seriously. Leaders or key stakeholders, such as the board of directors for your facility or facilities, need to begin thinking about how to structure or re-structure their quality programs. Even though it may take time for the CMS to announce its criteria and guidelines, each facility should already begin by reviewing current programs and determine if they at least incorporate the five elements listed above.