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Quality Assurance Performance Improvement Program Building Blocks

Effective tools are needed to complete a task successfully. Depending on the nature of the task, the tool may take the form of a physical instrument, a guide for best practice, a data resource or a directional map.

In the post-acute care space, it is important that organizations implement a continuous study of patient outcomes and processes, with intent to improve services, ensuring high quality care is being delivered.

A Quality Assurance and Performance Improvement (QAPI) program, as well as performance improvement plans (PIPs), can represent all forms of tools mentioned above.

The Centers for Medicare and Medicaid Services (CMS) outlines how effective QAPI programs are critical to improving the quality of life, care and services delivered.

A properly planned and executed QAPI program is more than a concept; it can provide your organization with a physical instrument (Plan), an action strategy (Do), data (Study) and next steps (Act).

Physical Instrument (Plan)

Your QAPI plan is your framework. In essence, it is a map that helps you identify your current standing and the direction that you want to go. This plan should be data-driven, focused on scope of services and inclusive of indicators which reflect patient outcomes and quality care delivery. The plan should identify and prioritize issues, as well as opportunities for improvement, while also defining how these measures will be analyzed.

Action Strategy (Execute)

Your QAPI plan should include activities, best practices and action strategies that your organization utilizes to move toward established benchmarks, goals or targets. It is important that everyone understands and participates in the QAPI plan and that these activities are communicated with the governing body – along with their solicited feedback. Strategies for improvement may include providing education to staff, updating policy and procedures and implementing evidence-based best practices into care delivery.

Data (Study)

It is important that a QAPI plan is data-driven; therefore, the QAPI committee will need to study current performance measures prior to implementing your plan.

Upon completion of a determined measure of time, the committee should study the results of the plan to see if progress is being made toward expected outcomes. CMS notes that organizations must effectively identify, collect and use data and information from all departments and the facility assessment. They should identify data sources, the frequency of data collection, as well as targets and benchmarks to communicate data analysis. Clinical and administrative review of data points for selected measurements should take place at routine intervals and should compare with data points from previous cycles of the QAPI plan.

Determine Next Steps (Improve)

Once a plan has been executed, the data reviewed and analysis has been made, the QAPI committee can determine how the plan is working. If the plan is effective (even though the goal may not have been achieved yet), your organization may continue the same course of action. However, if the results are not met as evidenced by the data-driven analysis, then revised strategies for improvement may need to be determined at that time.

Think of your QAPI plan as a living tool that will be reviewed and revised on a continuous basis. It is intended to assist in achieving your purpose, guiding principles and overall scope, while assisting your organization in improving the overall quality of care and services delivered to your client.

Axxess Home Health, a cloud-based home health software, offers documentation features at the point of care for more accurate answers, with real-time results for a quick QA approval.


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