Your hospital’s Quality Assessment and Performance Improvement (QAPI) program is under more scrutiny than ever before. And with 86 percent of adverse events not reported to hospitals’ QAPI program, it’s no wonder that this is a major focus for the Centers for Medicare & Medicaid Services (CMS) and surveyors.
CMS recently identified more than 1,700 deficiencies related to patient safety, according to hospital compliance expert Sue Dill Calloway in her webinar, “Tackle Hospital Compliance Challenges: CMS QAPI Worksheets & Standards.” So you shouldn’t be surprised that CMS is scrutinizing hospitals’ compliance with the QAPI standards – and it’s imperative that your patient safety and risk management process is up-to-snuff.
Take a Fresh Look at Quality Measure Options
One of the biggest QAPI-related problems that many hospitals face is selecting the most appropriate performance measures or metrics, according to Health Tech S3.
Do this: To choose the right indicator, you should start with the end in mind. Ask yourself:
- What are you trying to improve?
- Can you measure performance directly?
- If you can’t measure performance directly, is there a proxy indicator?
- Does the indicator give you enough information to drive improvement?
- Is this a “lead” or “lag” indicator?
- What drill-down indicators will help you meet your goal? (Hint: Think Root Cause Analysis.)
Definitions: A “lead” indicator is a measure preceding or indicating a future event used to drive and measure activities carried out to prevent and control injury (for example, safety audits, types of ergonomic opportunities), Health Tech S3 explained. A “lag” indicator measures incidents in the form of past accident statistics (for example, worker’s comp cases, injury with frequency and severity).
Prioritize Your Performance Indicators
On the Hospital QAPI Worksheet, the surveyor must select three distinct quality indicators to review. The indicators must be related to your hospital’s QAPI activities or projects.
Hidden trap: Don’t fall into the same hole as some hospitals by trying to tackle too many performance indicators. But don’t cut down your list of performance indicators either: “hospitals should be very careful about reducing the number of tracked indicators due to time and resource constraints, because that could potentially have a damaging effect on the organization,” warned Prista Corporation.
Prioritizing your data collection within your QAPI program is key. You can’t monitor every single area – that’s impossible, Prista noted. CMS wants hospitals to focus on high-risk, high-volume, or problem-prone areas; it doesn’t cite any specific areas.
Try this: The Center for Improvement in Healthcare Quality (CIHQ) recommends prioritizing performance indicators that CMS frequently cites as missing from hospitals’ QAPI programs. Some examples of such indicators include:
- Medication Use
- Sterile Compounding and IV Admixture
- Management of Hazardous Medications
- Medication Administration Practices for High-Risk Meds
- Infection Prevention & Control
- Sterilization of Instruments and Supplies
- High-Level Disinfection of Instruments and Supplies
- MDRO and Isolation Practice
- Disinfection and Cleaning of Dialysis Machines and Equipment
- Clinical Services
- Ordering Restraint and Seclusion
- Monitoring Patients in Restraint and Seclusion
- Administration of Blood and Blood Products
- Protection of Patients at Risk of Self-Harm
- Administration of Sedation/Anesthesia
- Surgical and Invasive Procedures
Collect Data the Right Way
Next step: As part of the QAPI process, CMS expects your hospital to monitor the effectiveness, safety, and quality of the care and services you provide, according to Accreditation Resource Services (ARS). And you need to collect, aggregate, analyze, and act upon data related to the performance activities.
To create a good data construct for each performance measure, you should include the following:
- A definition of the measure;
- The population you’re measuring (including criteria for inclusion and/or exclusion);
- A calculation formula if rate-based (a defined numerator/denominator);
- The minimum sampling size to assure statistical validity;
- The frequency of data collection/aggregation;
- The methodology by which you will collect the data;
- The entity primarily responsible for data collection;
- The manner in which you will display aggregated data; and
- The entity/entities to which you will report the aggregated data for analysis and action.
Bottom line: To understand the QAPI standards and what CMS expects from your hospital’s program, make sure you know what policies and procedures you must have in place, and be sure to review the QAPI Worksheet that state and federal surveyors use to assess compliance, Calloway stresses.