Author: Kimberly Mulquin-Shumway, MSN, MBA, RN, CPHQ, DNS-CT, LSSMBB
Several changes are coming in January for the home health industry. As a matter of fact, for the entire home-based care industry, several changes are coming next year. How do you keep up with and comply with these changes? A well-run QAPI program is the foundation that will support your agency.
This article discusses why you need to have a QAPI program and the benefits of a QAPI program. It will provide a high-level overview of QAPI, discuss implementing a QAPI program, and how to prioritize the PIPs you want to do in preparation for 2023 and the future.
Sadly, the main reason for a QAPI program is that you must. I say sadly because there are so many benefits to a QAPI program that we should all voluntarily want to have one. I'll discuss that later.
The Conditions of Participation (CoPs) for home health and hospice say the agency “must develop, implement, evaluate, and maintain an effective, ongoing, HHA/hospice-wide, data-driven QAPI program.” QAPI is not only for home health and hospice; QAPI is a CoP in just about every healthcare setting. If it is not in the CoPs or there are no CoPs for your care setting, it is an accreditation standard for The Joint Commission, ACHC, and CHAP. I'll cover other reasons for a QAPI program when I discuss the benefits of QAPI.
What is QAPI?
QA = Quality Assurance, which measures compliance with specific criteria. An example of QA would be a checklist to ensure all the required elements are present in a chart audit. QA assures care reaches acceptable levels. If all the necessary elements are present, you've met the minimum standard. QA is focused on the provider. The provider can be the person doing the documentation in the chart you are auditing or the agency in aggregate. QA is reactive. You've done the chart audits; what are the results? What do you need to fix?
PI = Performance Improvement, which improves processes to improve outcomes. It decreases problems by identifying opportunities for improvement. It is generally focused on the patient and is proactive. Using the chart audit example, you've identified a problem when compiling the audit results. What can you do to close that gap and prevent it from reoccurring? QA can turn into PI. An example of PI would be when you want to shorten the time staff spends documenting outside the patient’s home. You know it's important for work/life balance and staff satisfaction. How can you improve documentation efficiency? You gather data, start a PIP, and begin brainstorming. No problem was identified, but you know the significance of a healthy work/life balance.
As I mentioned earlier, you have a QAPI program because you must; however, it has many benefits.
Benefits of QAPI
- QAPI creates a culture of continuous improvement. If you are running a QAPI program versus just going through the motions because you must, staff won’t be afraid to bring up suggestions and get involved in the PIP.
- You'll see fewer mistakes because processes have been reviewed, revised, and implemented to prevent errors. Therefore, staff won't' go around a process that doesn't work.
- As a result, you will see improved patient care and outcomes and enhanced quality and efficiency of care. This will lead to improved staff and patient satisfaction, which impacts your STAR ratings, reimbursement, and referrals.
I hope you can see that a well-run QAPI program is the foundation for building a successful agency.
Now that you all love QAPI because it's good for us, how do you ensure you are meeting the QAPI requirements and doing it right? It all starts with a QAPI plan. Per CMS, there are 5 elements of a QAPI plan.
- Design & Scope – This is the how. “A QAPI program must be ongoing and comprehensive,” considering the full range of services offered by the agency, the patient population, and all departments. The QAPI program should focus on not only systems of care but also management practices. It aims for safety and high quality and utilizes the best available evidence to define and measure goals.
- Governance & Leadership – The governing body & leadership need to ensure sufficient resources are available to conduct QAPI efforts. This includes designating someone responsible for overseeing QAPI, developing training on QAPI, and providing staff time, equipment, and technical training as needed. Leadership is also responsible for setting expectations around QAPI and ensuring an atmosphere where staff is comfortable identifying and reporting quality problems as opportunities for improvement.
- Feedback, Data Systems & Monitoring – A system is in place to monitor care and services, drawing data from multiple sources. Feedback systems actively incorporate input from staff, patients, families, and others. This element includes using your KPIs to monitor care processes and outcomes and reviewing your results against the selected benchmark and/or target goal.
- Performance Improvement Projects (PIPs) – A Performance Improvement Project (PIP) is a concentrated effort on a particular problem in one area; it involves gathering information systematically to clarify issues or problems and intervening for improvements. PIPs examine and improve care or services in areas that are identified as needing attention.
- Systematic Analysis & Systemic Action – A systematic approach is used when you want to dive deeper into a problem to fully understand the problem, its causes, and the implications of a change. Systemic actions look at all processes and departments involved to prevent future events and promote sustained improvement.
I know this sounds like a lot, but it is not if the QAPI program is properly implemented.
It takes a team!
QAPI involves everyone and every aspect of operating an agency. Get everyone involved. A successful program must include ALL departments, team members, and services. Let's run through a high-level process:
- To operate an agency, you need patients – what is marketing/business development's role? What data are they tracking? What data can you track? Referral sources? Lead sources? Conversion rates?
- Now you have the referrals. What is admissions tracking? The number of non-admits, reasons for non-admits, and completion of necessary paperwork.
- Now you have the patients and need staff to see those patients. What is HR tracking? Staff satisfaction? Turnover? Competitive rates?
- You have the staff – what is clinical monitoring? This category has a lot of data and is where agencies tend to spend most of their QAPI efforts; how do you know what is important to track? We'll cover this a little bit later.
- Patient services have been provided; it's time to bill. What is finance monitoring? Timeliness of billing? Denials? ADR? Non-affirmations? What are reasons behind all of these?
- Operations – how do you know you are operating a successful agency? What do you need to know? What data would tell you that something has the potential to go awry, and you need to intervene quickly before it does?
This list is not all-inclusive, but what I see as the big buckets within an agency.
The QAPI team will need a designated leader(s) and representation from each discipline of services you provide from all departments. Consider including someone with working knowledge of your EMR. The QAPI Committee must meet at least quarterly. The PIPs will mostly likely meet monthly or even weekly as they begin. Make sure everyone on the QAPI team is invested, understands their roles, and is able to present their data.
- It is key to involve the people who do the job and go to the source. These are the people who know the barriers patients face, the hurdles they must jump over to get the job done, and the struggles of using the provided tools such as the EMR, billing software, etc.
- Keep in mind that your data is not exclusive to star ratings, Home Health Compare, CASPER, CAHPS, etc., and that you can only manage what you can measure. We all have those anecdotal stories of how bad something is but is it really a concern? You must know your data and understand where that data is coming from. What does the data say? How do you compare to the benchmark(s)?
- Prioritize – rank potential areas for improvement by what is important to your agency (e.g., compliance with CoPs may have a weight of 10 but syncing a mobile device daily may have a weight of 2)
- Utilize your EMR to the max capacity – your EMR is the keeper of your data; it most likely has several reports to help you manage your QAPI program. USE IT and make your life easier.
There is a lot of data out there; not everything needs to be monitored closely. How do you know what to focus on?
- Conduct an operations assessment to identify gaps. This can be a rapid high-level assessment looking at simple things such as productivity, visit utilization, order statuses, workflow, STAR ratings, OASIS/HIS submissions, A/R, and accreditation survey results.
- Identify your high-risk, problem-prone areas. What diagnoses have a high return to hospital rate? What are your UTI and fall rates? PAE? Do you have a high volume of live discharges?
- What are your high-volume areas? What is your top admitting diagnosis? Do you do a lot of complex wound care? What does your chart audit say? Does the care match the diagnosis?
- You want to monitor your STAR rating on the Medicare compare site and your CAHPS survey results, as this can affect your referrals and the agency’s reputation.
- As mentioned previously, use the reports in the EMR that are not included in the reports you already receive from CMS, which can be 6 – 12 months behind.
Are you monitoring the right stuff now that you have all this data? This is where the prioritization comes in. Create a grid like your disaster preparedness risk assessment and score each item below the selected benchmark. Rank the items, usually the highest to the lowest, and start working on the highest scores first. Note that sometimes the highest-ranking score may not be feasible to work on for some reason, such as cost.
I can't emphasize this enough. A QAPI program is data-driven. What does the data tell you? People have a lot of anecdotal information. You don't want to go down the rabbit hole for a problem that only happens once in a while but impacts the person sharing the information tremendously. What does the data say?
Preparing for 2023 and Beyond
- Look at your comprehensive assessment data. The comprehensive assessment data is used to calculate a lot! Look at the assessment items used in these calculations and see if you can identify opportunities for improvement through staff training.
- Look at our STAR ratings. What items are used in the calculation of these scores? Is there an opportunity for training?
- CAHPS surveys – does the staff know that patients are completing these? Do they know the importance of these surveys? Do they know what the questions are?
- Value-based care – Home health has value-based purchasing (HHVBP), which looks at claims data, OASIS items, and CAHPS data. Hospice has the Health Care Index (HCI), which is claims-based. If you are in a MA area, you have value-based reimbursement (VBR/VBID), a combination of CMS and agency-reported data that are not publicly reported.
- Familiarize yourself with how items are calculated, what items are used, and where the data is pulled from – (e.g., within EMR), then start your education and training!
- Education & Training
- Start those conversations with the people who do the job.
- Validate the gaps with data
- Review and validate the data
- Form PIPs
If you need help, give us a call, MHA has a team of post-acute industry veterans passionate about helping home health and hospice providers thrive amid healthcare’s disruptive environment. Contact us at [email protected] today.