Quality Assurance Performance Improvement: 12 Steps to Excellence!

Quality Assurance Performance
Improvement:
12 Steps To Excellence!
Harmony University
The Provider Unit of
Harmony Healthcare International, Inc.
(HHI)
Presented by:
Beckie Dow, RN, RAC-MT
Director of MDS and Nursing Education & Training

Speaker Bio
Over 20 Years Experience in Long-term
Care
Clinical and Reimbursement Accuracy in
Assessments
Quality Assurance Activities
Interrelation between MDS, Care
Planning, QA, and Clinical Excellence at
the Bedside
AANAC Master Teacher
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2

Improvement: 12 Steps to Excellence
Disclosures: The planners and presenter of this
educational activity have no relationship with
commercial entities or conflicts of interest to
disclose
Planners:
Elisa Bovee, MS, OTR/L
Diane Buckley, BSN, RN, RAC-CT
Presenter:

Harmony Healthcare International, Inc.
Criteria for Successful Completion
Complete Sign-in and Sign-Out on
Attendance Form
Attendance for entire session
Completion and submission of
speaker evaluation form
Copyright © 2013 All Rights Reserved 4

Program Objectives
Detail the five elements of QAPI and
relate the five elements to the twelve
action steps of QAPI
Discuss the QAPI demonstration project
Articulate how existing quality
improvement programs in SNFs and
other settings can benefit from the
QAPI materials

Program Objectives
Discuss problem solving models,
including Root Cause Analysis,
Directed Plan of Correction, Plan Do
Study Act
List three tools that the facility can use
to prepare for the implementation of
QAPI

“Don’t judge each day by the harvest you
reap, but by the seeds you plant”
-Robert Louis Stevenson

The CMS Nursing Home Action
Plan: A Three Part Aim

The CMS Nursing Home Action
Plan: Five Approaches
Enhance consumer engagement
Strengthen survey processes, standards,
and enforcement
Promote quality improvement
Create strategic approaches through
partnerships
Advance quality through innovation and
demonstration

F520 - Quality Assessment
and Assurance (QAA)
The facility has an ongoing QAA committee
that includes designated key members and
that meets at least quarterly; and
The committee identifies quality
deficiencies and develops and implements
plans of action to correct these quality
deficiencies, including monitoring the effect
of implemented changes and making needed
revisions to the action plans

QAPI Timeline
March 2010—Affordable Care Act passed
April 2011—QAPI announced
September 2011—prototype QAPI
program launched to test QAPI tools and
resources
May 2012—QAPI questionnaire
July 2012—Panel of experts assembled to
discuss the prototype tools and
questionnaire results

QAPI Timeline
December 2012—QAPI at a Glance guide
introduced in draft form
June 2013—Final version of QAPI at a
Glance published
June 2013—Announced that wave one
NHQI questionnaire results would be
available “in the near future”
TBD—wave two of the NHQI
questionnaire

The QAPI “Elevator Speech”
QAPI is a comprehensive program by
which an organization identifies
problems or issues early on, develops a
plan to address the root causes of
problems and prevent adverse events
throughout the system, and involves
the entire team in using data to
understand quality and work to
improve performance

What is QAPI?
The merger of two complimentary
approaches to quality management:
Quality Assessment – determining where
things are going well and where
opportunity to improve exists
Performance Improvement – the reaction to
the opportunity to improve

What is QAPI?
Improvement
Motivation Measuring compliance
with standards
Continuously
improving processes to
meet standards
Means Inspection Prevention
Attitude Required , reactive Chosen, proactive
Focus Outliers: “bad apples”
Individuals
Processes or Systems
Scope Medical provider Resident care
Responsibility Few All

What is QAPI?
“QAPI is about critical thinking. It
involves figuring out what is causing
certain problems, and implementing
interventions and solutions that address
the root causes of the problems, rather
than just the symptoms”
Karen Schoeneman
Past Technical Director, CMS Division of Nursing Homes

The Challenge…
“Not all change is
improvement, but all
improvement is change”
Donald Berwick, MD
Former CMS Administrator

The Goal of QAPI and/or Other
Quality Improvement Models
The Goal: Meet or exceed the expectations of
our customers
Meeting customer expectations = meeting
the mission!
Who are the customers?
External customers: The reason the organization
exists
Internal customers: Anyone within the
organization

Nursing homes are in the best position
to assess, evaluate, and improve their
care and services, because each home
has first-hand knowledge of their own
organizational systems, culture, and
history
Effective QAPI leverages this
knowledge to maximize the return on
investments made in care improvement

QAPI will take many nursing homes
into a new realm in quality:
Systematic
Comprehensive
Data-driven
Proactive
Performance Management and
Improvement

When nursing home leaders promote
the QAPI philosophy the results may:
Prevent adverse events
Promote safety and quality
Reduce risk for residents
Reduce risk for caregivers

The goal of QAPI is not to
merely meet minimum
standards—it is about
continually aiming
HIGHER!

A Culture of Caring
“I take care of my staff, and they take
care of the patients,” said one DON. “If
I treat them badly, they will treat the
patients badly.”
Source: Beyond Unloving Care by Susan Eaton, June 2000

Are You Already Doing QAPI?
QAPI principles are not new to
healthcare
QAPI builds on our existing QAA
regulations
Your facility may already be
participating in QAPI activities, and can
use existing activities as a foundation
for QAPI

Does your facility…
Create systems to provide care and achieve
compliance with nursing home regulation?
Investigate problems and try to prevent
their recurrence?
Track and report adverse events?
Compare the quality of your home to that
of other homes in your state or company?

Receive and investigate complaints?
Seek feedback from residents and front-line
caregivers?
Set targets for quality?
Strive to achieve improvement in specific
goals related to pressure ulcers, falls,
restraints, or permanent caregiver
assignment, or other areas (Advancing
Excellence campaign)

Have a commitment to balancing a safe
environment with resident choice?
Strive for deficiency-free surveys?
All of these activities are part of QAPI

Are You Already Doing QAPI…But
Could “Take it to the Next Level?”
Some QAPI components are new for
many nursing homes
QAPI emphasizes quality care for
residents and an improved work
environment for caregivers
QAPI uses a systems approach to
actively pursue quality, not just respond
to external requirements

Use data to identify quality problems,
opportunities for improvement, and
setting priorities for action
Building on residents’ own goals for
health, quality of life, and daily
activities
Building meaningful resident and
family voices into setting goals and
evaluating progress

Incorporating caregivers broadly in a
shared QAPI mission
Developing Performance Improvement
Project (PIP) teams with specific
“charters”
Performing a Root Cause Analysis
(RCA) to get to the heart of the reason
for a problem

Undertaking systemic change to
eliminate problems at the source
Developing feedback and monitoring
systems to sustain continuous
improvement

QAPI: The Five Elements
Your QAPI program should contain all
five elements, which are closely related
Your QAPI plan will be based on your
own center’s needs, current programs,
and unique residents

QAPI: The Five Elements
1. Design and Scope
2. Governance and Leadership
3. Feedback, Data Systems and
Monitoring
4. Performance Improvement Projects
(PIPs)
5. Systematic Analysis and Systemic
Action

The 12 Action Steps to QAPI
The 12 steps do not need to be achieved
sequentially, but each step builds on
other QAPI principles
The most important aspect of QAPI is
effective implementation

Step 1: Leadership Responsibility
and Accountability
Support “from the top” is essential, and
that support should foster the active
participation of every caregiver
Executive leadership sets the tone and
provides resources
Executive leaders help other leadership
flourish in the nursing home
Be available for residents & caregivers,
tour and meet where they work

Step 1: Leadership Responsibility
and Accountability
Develop a steering committee to
provide QAPI leadership
Provide resources for QAPI—
equipment, training, and staff time
Climate of open communication and
respect (“just culture”)
Understand the culture of your home
Expect and build effective teamwork

Step 2: Develop a Deliberate
Approach to Teamwork
Teamwork is a central concept to an
effective QAPI program
An effective team has a clear purpose,
defined roles for each member to play,
and each member is committed to
active engagement in the team’s
activities

Step 2: Develop a Deliberate
Approach to Teamwork
Characteristics of an effective team
include the following:
Having a clear purpose
Having defined roles for each team
member to play
Having commitment to active engagement
from each member
The roles of team workers may grow out of
their original discipline or their defined job
responsibilities

Step 3: Take your QAPI “pulse”
with a Self-Assessment
Self-assessment tool is provided in the
QAPI at a Glance guide
Can be used at the beginning of the
QAPI journey, and then for semi- or
annual evaluation thereafter
The results will direct you to areas you
need to work on to effectively establish
QAPI in your organization

Step 3: Take your QAPI “pulse”
with a Self-Assessment
See Handouts for the Self-assessment
Tool
This should be an honest assessment
and reflection of your organizations
progress
Helps you to determine how you know
whether QAPI is taking hold

Step 4: Identify your
Organization’s Guiding Principles
Establishing a purpose and guiding
principle will unify the organization
Many caregivers do not know the
guiding principles of the organization!
Taking time to articulate your
organizations purpose will assist your
organization to develop a written QAPI
plan
See Handouts for the guide

1. Locate or develop your organization’s
vision statement
2. Locate or develop your organization’s
mission statement
3. Develop a purpose statement for QAPI

4. Establish guiding principles
5. Define the scope of QAPI in your
organization
6. Assemble the Document

Step 5: Develop your QAPI Plan
Your plan will assist you in achieving
what you have identified as your
organizations purpose, guiding
principles, and scope
Tailor-made program that is a living,
breathing document
Amend or change your plan as your
organization changes and grows
See Handouts

Step 6: Conduct a QAPI
Awareness Campaign
Let everyone know about your QAPI
plan - often and in multiple ways
Ongoing and varied caregiver training
Ensure that consultants and outside
agencies that work within your
organization are aware of your QAPI
program
Discuss the hard questions

Awareness Campaign
This is your opportunity to convey the
positive message of QAPI and let
caregivers from all disciplines know
that their participation is key to success
If systems don’t exist, they may need to
be developed
If systems impede quality, they must be
changed

Awareness Campaign
All residents and families should be
made aware that their views are sought,
valued, and considered in facility
decision-making and process
improvements
Make announcements in resident and
family council or other communication
venues

Step 7: Develop a Strategy for
Collecting and Using QAPI Data
QAPI includes the routine monitoring
of data from multiple sources
Set targets for performance in the areas
you are monitoring
Identify benchmarks for performance
Develop a plan for the data you collect
to ensure it is used, not just collected
You are already collecting valuable data

Data sources you may already have:
Clinical care areas (falls, ulcers, infections)
Medications (antipsychotics, narcotics)
Complaints from residents and families
Hospitalizations and other service use
Resident satisfaction
Caregiver satisfaction

Data sources you may already have:
Resident and caregiver experiences living
and working in the setting
State survey results and deficiencies
Results from MDS assessments
Business and administrative processes
(finances, caregiver turnover, staffing
patterns, sick calls, staff injuries)
Admissions and discharges

Use your data to set benchmarks
Every facility is unique, so individual
benchmarks based on your own
performance are key
This data will require systematic
organization and interpretation in order
to achieve meaningful reporting and
action

Step 8: Identify your Gaps and
Opportunities
Review your sources of information to
determine if gaps or patterns exist
These gaps may result in quality
problems (“quality themes”)
Look for areas where there is
opportunity for improvement
Take notice of things you are doing well
Set priorities for Performance
Improvement Projects (PIPs)

Step 9: Prioritize Quality
Opportunities and Charter PIPs
Prioritizing opportunities for
improvement is a key step in the
process of translating data to action
Consider areas that are high risk, high
frequency, and/or problem prone, or
may affect the psychological well-being
and comfort of residents
Charter a PIP team

The term “charter” is used in
conjunction with the PIP to indicate that
it is more than just a casual effort
The PIP will entail a specific written
mission to look into a problem area
The PIP will include people in a
position to explore the problem
(caregivers, discipline specific)

Performance Improvement Projects
(PIPs)
What do we target?
Any area – even if things are going well,
there may be the opportunity to improve
Identify opportunities to optimize:
Effectiveness
Efficiency
Safety

(PIPs)
Essential steps/elements of a PIP:
Define the nature of the problem
Develop change ideas
Determine your actions
Test the actions
Determine if change has occurred and if it
is an improvement

(PIPs)
Team activities
Meet regularly
Develop the pilot study
Once the successful change is determined,
roll it out organization-wide
Continue to monitor and ensure sustained
improvement

(PIPs)
What should the PIP team expect?
3-6 month commitment
Management and staff support
Be prepared to participate in the
organization-wide implementation of the
change

Caregivers on a PIP should be
empowered to view their participation
as a valuable assignment that the team
takes seriously
Caregivers should have the PIP
meetings built into their assignment for
the day
Make sure floor duties are covered

Step 10: Plan, Conduct, and
Document PIPs
Focus your PIP by defining the scope,
so the team does not get overwhelmed
Identify the information the PIP team
needs and a timeline for completion
Identify and request any materials or
supplies needed
Residents’ perspective is key
Use a problem-solving model, like
PDSA

The PDSA Model for Improvement

Document PIPs
Plan: The team learns more about the
problem, plans for how improvement
would be measured, and plans for any
changes that might be implemented
Do: The plan is carried out, including
the measures that are selected

Document PIPs
Study: The team summarizes what was
learned
Act: The team and leadership
determine what should be done next,
which could include adapting (and re-
studying), adopting (perhaps expanded
to other areas), or abandoning

Step 11: Getting to the “Root”
of the Problem
No problem can be effectively addressed
without thoroughly exploring the problem
The problem may involve multiple factors
and may affect several departments
Root Cause Analysis (RCA) is a systemic
process for identifying contributing causal
factors that underlie variations in
performance

Step 11: Getting to the “Root”
of the Problem
There is danger in starting with a
solution without thoroughly exploring
the problem
Multiple factors may have contributed,
and/or the problem ma be a symptom
of a larger issue
What seems like a simple issue may
involve a number of departments

Root Cause Analysis
RCA requires a systematic, intensive,
and in-depth review to learn the most
basic reasons for the adverse event
Formal logic and defined methodology
Goal is to understand the problem in
sufficient depth to effectively eliminate
the risk of future injury
See Handouts

Root Cause Analysis
Where Traditional Methods will: Root Cause Analysis will:
Expected staff to perform flawlessly
24/7 and blamed individuals when
they didn’t
Encourages the development of
systems that are designed to
compensate for human limitations
and looks to system fixes when an
error occurs
Expected staff to adapt their
practice to available equipment and
regular procedures
Stresses the development of
equipment and procedures that are
designed for safety
Relied on a chain of command in a
facility to investigate errors and
impose corrections
Relies on teamwork among all staff
to analyze problems and to propose
and implement solutions
Punished errors Stresses learning from errors
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
Source: Oregon Patient Safety Commission
67

Root Cause Analysis
RCA also recognizes that adverse
events usually result from a number of
factors that are all part of the normal
process of providing care and service
Adverse events are rarely a single error
made by one person
RCA process examines the various
contributing factors that led to the
adverse event happening

Root Cause Analysis
RCA helps you look at the safeguards in
your systems or process of care to
determine how and why and adverse
event happened, and helps you plan to
improve those systems to decrease the
chances of a similar event happening
again
Identifies how systems have failed to
keep the resident safe

Root Cause Analysis
The purpose of RCA event investigation
is to indentify which imperfections in
your safety systems had a role in the
adverse event, and then strengthen the
protections so that future providers and
resident will not be caught in the same
set of circumstances

Prepare for Success with RCA
Make sure that you clearly understand
the facts surrounding the issue,
complaint, or concern/allegation at
hand
Suspend any judgment about how or
why it may have happened until you
have gathered the facts
Start with a “clean slate” attitude

Inquire with those that might have
information
Make a sample list of what you hope to
learn from each of these sources
Gather documentation that may be
relevant and note any personal
observations of equipment, general
conditions, etc that will contribute to
your understanding

Set aside a time and a place to talk to
people privately
Be clear about what you want to say
and how you want to approach them
Address fears that the person may have,
such as how the information will be
used and what may happen as a result
of the information they provide

Take time to gather all resources you
will need in order to have successful
interviews
Acknowledge that the RCA process
builds on your current investigation
approach, but with several key
differences

Root Cause Analysis
Step 1 – Gather initial information
Step 2 – Fill in the gaps
Step 3 – Analysis
Step 4 – Action plan development
Step 5 – Evaluation of results

Root Cause Analysis
Step 1 – Gather Initial Information
Immediate data gathering; get the facts
first
Focus on what happened, not “who did
it”
Keep an open-minded attitude

Root Cause Analysis
Step 1 – Gather Initial Information
What to watch out for:
Emotions of grief and fear altering
perceptions during interviews
Rote responses assigning blame or denying
responsibility
Making assumptions about the cause

Root Cause Analysis
Step 2 – Fill in the Gaps
Discuss the incidence as a team
Identify gaps and reconcile differences
of views
Gather more information
Investigate the scene of the incident and
any involved equipment

Root Cause Analysis
Leaving gaps in information
Rote responses assigning blame or denying
responsibility
Making assumptions about the cause

Root Cause Analysis
Create a “safe table” for interview
Tell the interviewee you will take notes.
These notes can be copied and given to the
interviewee if he/she would like a copy.
Do not use information obtained during
the interview for disciplinary action. This
should be a separate process if the RCA
identifies it as an actual or contributing
cause.

Root Cause Analysis
Create a “safe table” for interview
Be unbiased and nonjudgmental
Do not interview more than one person at a
time
Do not discuss who else will be
interviewed or what other interviewees
have said

Root Cause Analysis
Step 3 - Analysis
Ask why until you can’t ask it anymore!
Review contributing factors
Document
Conduct the “Common Sense Test” on the
conclusions or the investigation
Described using specific/objective words?
If you eliminate this cause will it go away?
Is human error really the cause?
If procedure was violated, why?

Root Cause Analysis
Step 3 - Analysis
Focus on finding the most fundamental
reasons (the root cause!) for the event
Create conclusion or findings
statements that link the causes to the
effect or result
Use statements that lead to strong
action plans

Root Cause Analysis
Step 3 - Analysis
Easy answers that don’t address the
fundamental causes
Stopping at the first or second answer to
the question “why”
Omitting findings because “we can’t do
anything about that”—create an action
plan

Root Cause Analysis
Step 4 – Action Plan Development
Develop an immediate plan as well as
(if needed) a long or short term plan
Use the S.M.A.R.T.S. system for action
plans
Document the plan
Implement the plan
Consider the application of the plan to
others

Root Cause Analysis
Focus on the most fundamental reasons
(the root causes!) for the event
Develop physical and natural
protections/safety systems as much as
possible
Develop preventative actions that keep
a different person from the same or
similar adverse event

Root Cause Analysis
Setting policies that rely on individuals
“trying harder” or “paying more
attention”
Trying to change people

Root Cause Analysis
Step 5 – Evaluation of Results
Track the implementation
How are other residents affected?
Measure how each plan is doing and
how you will track and trend
Celebrate success
Did you identify & solve an
organizational/system problem?

Root Cause Analysis
Step 5 – Evaluation of Results
Slippage over time as people return to their
old routine
Not providing feedback to staff on
progress
Tiring of the measurement

Step 12: Take Systemic Action
Implement changes that will result in
improvement or reduce the chance of
an event recurring
Choose actions that are tightly linked to
the root cause and lead to a system or
process change
Corrective action should target the
elimination of the root cause

Pilot test the change in one area of your
facility before launching facility-wide
Pilot testing gives the team the
opportunity to correct unintended
consequences of the change
Choose strong methods of corrective
action for facility policy to increase
success

Weak corrective actions rely on staff to
remember their training or what is
written in policy
Double-checks
Warnings/labels
New policies/procedures/memoranda
Training/education
Additional study

Intermediate corrective actions are
somewhat dependent on staff
remembering to do the right thing, but
they provide tools to help staff to
remember or to promote clear
communication
Decreased workload
Software enhancements/modifications

Intermediate corrective actions (Cont.)
Eliminate/reduce distraction
Checklists/cognitive aids/triggers/prompts
Eliminate look alike and sound alike
Read back
Enhanced documentation/communication
Build in redundancy

Strong corrective actions do not depend
on staff to remember to do the right
thing
Change or re-design the process
Detect and warn so there is an opportunity
to correct before the error reaches the
patient
Hard stops which will not allow the
process to continue unless something is
corrected

Strong corrective actions (Cont.)
Physical changes in environment
Forcing functions or constraints (different
connection ports so only the correct line
will connect)
Electronic Medical Records (cannot
proceed until all fields filled in)
Simplifying (unit dose packaging)

Group Activity
See Handouts for the Group Activity
Scenario
Use the Goal Setting Worksheet in your
Handouts to make a plan for quality
improvement
Work in small groups
Be creative! There are no wrong
answers!

QAPI Principles Summarized
QAPI may not be new for you—build
on what you have
QAPI leadership starts at the top with
executive management, Board of
Directors, Owners or Trustees and
includes top management in each home
Systems, Systems, Systems

Involve the people directly working in a
process in order to improve that process
Organization-wide inclusion to truly
understand what is going on
Continuous communication about
QAPI throughout the organization, and
built-in to an educational effort that
involves caregivers, residents, and
families

Residents’ perspective is key in setting
QAPI priorities for PIPs
Two key activities are setting priorities
and chartering PIPs, and everyone
should have the opportunity to
participate in both
Create a log of your QAPI activities
Celebrate and reward success!

Benefits of a QAPI Program
Competencies that equip you to solve
quality problems and prevent their
recurrence
Competencies that allow you to seize
opportunities to reach new goals
Fulfillment for caregivers, as they
become active partners in performance
improvement (“buy in”)
Better care and quality of life

The Demonstration Project States
California
Florida
Massachusetts
Minnesota

Demonstration Activities
Develop and implement QAPI plans
Participate in virtual and in-person
meetings
Receive tools and resources
Offer feedback
Generate best practice ideas

Expectations of the demonstration
participants:
Implement all elements of QAPI
Provide an environment that encourages
quality improvement
Develop systems to identify problems and
address them
Conduct quality improvement projects

Benefits to participants:
A liaison to assist each facility
Technical assistance
On-line instruction
Learning collaborative
Early access to tools

Getting Ready for QAPI
Nursing Homes can use a variety of
resources to select their Performance
Improvement Goals
Many tools are available online, free of
charge
These tools can be used to develop a
facility-specific plan

Advancing Excellence in America’s
Nursing Homes Goals
The Advancing Excellence in America’s
Nursing Homes campaign is designed
to improve the quality of life for both
nursing home residents and the staff
who serve them
To participate, a nursing home will
voluntarily pledge to work on three or
more goals
Goals were updated August 2013

Nursing Homes Goals
Process Goals:
Increasing Use of Consistent
Assignment
Safely Reducing Hospitalizations
Increasing Person-Centered Care
Planning and Decision Making
Improving Staff Stability

Nursing Homes Goals
Clinical Outcomes Goals:
Preventing and Managing Infections
Safely (C. diff)
Using Medications Appropriately
Increasing Resident Mobility
Decreasing Symptoms of Pain
Reducing the Prevalence of Pressure
Ulcers

Nursing Homes Goals
The Advancing Excellence campaign
uses a model called The Circle of
Success
See Handouts
Aspects of this model correlate well
with the QAPI 12 Steps
Facilities can begin their QAPI journey
by participating in the Advancing
Excellence campaign

Nursing Homes - Goals for 2012
Check the Excellence in America’s
Nursing Homes Web site for
updated tools to assist you in your
efforts:
www.nhqualitycampaign.org

Consider Quality Indicator Survey
(QIS) Tools as QAPI Data Sources
Available at www.QTSO.org
Use tools consistently and without
bias
Go beyond Stage I tools
Stage II tools help ensure in-depth
investigation

The DPOC Model:
Great for Problem Solving
DPOC = Directed Plan of Correction
Assessment of causative factors
Steps/interventions undertaken
Triggers/parameters to signal an
evolving problem
How the facility will measure the
success of its efforts

Final Thoughts…
“Excellence is an art won by training and
habituation. We do not act rightly
because we have virtue or excellence,
but we rather have those because we
have acted rightly. We are what we
repeatedly do. Excellence, then, is not
an act but a habit.”
-Aristotle

Final Thoughts…
The goal of providing the best possible
quality of care and life for those
entrusted to our care does not change
Success depends on us evolving and
always striving to redefine and achieve
excellence
Successful QAPI will not be a
department, it will be a way of life in
the organization

References
Nursing Home Quality Assurance &
Performance Improvement (CMS)
website
http://www.cms.gov/Medicare/Provider-
Enrollment-and-
Certification/QAPI/NHQAPI.html
CMS Advancing Excellence In America’s
Nursing Homes website
http://www.nhqualitycampaign.org/

References
S&C Letter Quality Assurance and
Performance Improvement (QAPI) in
Nursing Homes- Activities Related to
QAPI Implementation
http://www.cms.gov/Medicare/Provider
-Enrollment-and-
Certification/SurveyCertificationGenInf
o/Downloads/Survey-and-Cert-Letter-
12-38.pdf

References
Root Cause Analysis Materials for Long
Term Care Facilities
http://oregonpatientsafety.org/healthcar
e-professionals/nursing-homes/root-
cause-analysis-materials-for-long-term-
care-facilities/283/

References
QAPI at a Glance guide
http://newsmanager.commpartners.com/fhca/do
wnloads/SC13-
05%2002_%20attach_QAPI%20at%20a%20glance
%204.pdf
S&C Letter dated 12-14-12
http://www.cms.gov/Medicare/Provider-
Enrollment-and-
Certification/SurveyCertificationGenInfo/Policy-
and-Memos-to-States-and-Regions-Items/Survey-
and-Cert-Letter-13-05.html

References
Quality Improvement Organization
(QIO)
http://www.cms.gov/Medicare/Quality-
Initiatives-Patient-Assessment-
Instruments/QualityImprovementOrgs/
index.html?redirect=/qualityimproveme
ntorgs/

Questions/Answers
bdow@harmony-healthcare.com
Harmony Healthcare International
1 (800) 530 – 4413
www.Harmony-Healthcare.com

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CASE MIX ANALYSIS
for your Facility?
Perhaps your facility has potential for additional revenue
Benchmark your facility against key indicators and national norms
Email us at for more information
RUGS@harmony-healthcare.com
Analysis is cost & obligation free
Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 123

Quality Assurance Performance Improvement: 12 Steps to Excellence!

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