During my years working in home health, and all the agencies with which I have been associated have had a Quality Assurance Program (QA). Most state licensing programs and accrediting organizations require home health agencies to have a quality assurance program. Many agencies may view this as simply another burden to be tolerated, however, any good quality assurance plan naturally includes program improvement (PI). While all agencies focus on the QA, many neglect or minimize the value of PI, and are really doing a disservice to their agency and their patients. The QA program identifies areas for improvement, and the PI is the plan you put in place to actually improve the areas identified by your QA program.
According to the Center for Medicare/Medicaid Services (CMS) there are 5 elements to any effective QA/PI Program[i]:
- Design and Scope
- Governance and Leadership
- Feedback, Data Systems, and Monitoring
- Performance Improvement Projects
- Systematic Analysis and Systemic Action
Element 1: Design and Scope A QAPI program must be ongoing and comprehensive, dealing with the full range of services offered by the agency, including the full range of departments. When fully implemented, the program should address all systems of care and management practices, and should always include clinical care, quality of life, and patient choice. It aims for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for patients. It utilizes the best available evidence to define and measure goals.
Element 2: Governance and Leadership The governing body and/or administration of the agency develops and leads a QAPI program that involves leadership working with input from staff, as well as from patients and their families and/or representatives. The governing body assures the QAPI program is adequately resourced to conduct its work. They 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. 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 patient-centered rights and choice. The governing body ensures that while staff is held accountable, there exists an atmosphere in which staff is encouraged to identify and report quality problems as well as opportunities for improvement.
Element 3: Feedback, Data Systems and Monitoring The agency puts in place systems to monitor care and services, drawing data from multiple sources. Feedback systems actively incorporate input from staff, patients, families, and others as appropriate. This element includes using Performance Indicators 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 agency conducts Performance Improvement Projects (PIPs) to examine and improve care or services in areas that are identified as needing attention. A PIP project typically is a concentrated effort on a particular problem in one area of the agency; 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 agency 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 agency all involved systems to prevent future events and promote sustained improvement. This element includes a focus on continual learning and continuous improvement. [ii]
If you do not currently have a QA/PI program in place or would like to strengthen further, the following are some suggestions[iii][iv].
Education: Educate yourself and staff in your agency on the CMS QA/PI program, and key aspects and principles of performance improvement. Once a PI model has been identified, educate staff and utilize consistently when tackling PI projects. Some examples of performance are the IHI’s model for improvement using PDSA cycles, the Baldrige/AHCA Quality Program, or Lean Six Sigma using DMAIC to name a few.
Model programs: Identify organizations such as partner hospitals, nursing homes, or even other home health programs with a model QA/PI program which you can review and potentially replicate in your agency. Utilizing searches with Google, or literature review in peer reviewed articles can also serve as excellent sources for identifying model programs.
Empower: After educating staff and identifying model programs, encourage them to take an active role in developing a culture of excellence by restructuring or implementing new structures which will identify areas for potential improvement earlier, prioritize, and follow the PI model selected. Involving patients in these endeavors will not only yield valuable insight, but will also communicate the focus of your agency on excellence.
Data: Utilize data early in determining the scope of the area requiring improvement, and measuring progress towards the improvement being sought. It is clearly much easier to do so with the use of an electronic system than on paper, and the ability to extract data should be a requirement when examining vendors.
There are specific requirements of a QA/PI program for Medicare certified home health agencies found in the interpretive guidelines for surveyors[v].
Every agency should review these to be prepared for your survey.
If your agency isn’t utilizing a QA/PI program, you are at risk. It is an essential element to providing quality services to your patients and it is required. The Centers for Medicare & Medicaid Services have established Quality Improvement Organizations (QIO’s)[vi] which have are intented to assist CMS managed agencies with quality programs and program improvement
Your patients deserve the highest quality of care you can provide, and there is always room for improvement. Also, you certainly don’t want to be found lacking in this area when the surveyor comes. If you don’t have an effective program start one now! Good Luck.
Sources:
[i] http://www.ahcancal.org/facility_operations/survey_certification/Documents/NHQAPI%205%20elements.pdf
[ii] https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/fiveelementsqapi.pdf
[iii] http://www.ahcancal.org/facility_operations/survey_certification/Documents/QAPI%20Overview.pdf
[iv] http://www.ahcancal.org/facility_operations/survey_certification/Documents/Tips%20for%20Preparing%20for%20QAPI.pdf
[v] http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/som107ap_b_hha.pdf
[vi] http://www.qualitynet.org/dcs/ContentServer?pagename=QnetPublic%2FPage%2FQnetTier2&cid=1144767874793
which have are intented to assist CMS managed agencies with quality programs and program improvement
Your patients deserve the highest quality of care you can provide, and there is always room for improvement. Also, you certainly don’t want to be found lacking in this area when the surveyor comes. If you don’t have an effective program start one now! Good Luck.
