QAPI Self- Assessment

Working to improve the quality of care delivery to nursing home residents.

Webinar "IPRO Electronic Self-Assessment Tool"

Objective:

  1. Introduction of the IPRO developed electronic QAPI self-assessment tool and guided instruction to its use
  2. Assist NHs with enhanced understanding of QAPI principles and link to the QAPI self- assessment tool, how to examine the questions and analyze the responses
  3. Assist NHs use of the QAPI self-assessment tool for assessing and developing focused improvement strategies

QAPI Self-Assessment Tool

The tool presents a picture or a starting point where in the organizations systems of care there may be need to focus some attention to achieve or sustain positive outcomes and avoid or lessen negative outcomes.

The day- to- day approach how you do business involves some key elements that help identify gaps in your systems of care and opportunities working to improve those gaps. The tool is a significant resource to evaluate the QAPI elements and link to the organizations internal workings. The most important aspect of completing the tool is that it be done as a team. The team focus or perspective is important because it gives a broad spectrum of the systems of care and potential holes that may be in need of repair.

Key QAPI elements - Building blocks that support a QAPI culture

  1. Design and Scope
  2. Governance and Leadership
  3. Feedback, Data Systems & Monitoring
  4. Performance Improvement Plan
  5. Systems Analysis & Systematic Action

The tool will show how the elements are best reviewed to capture the most reliable response.  The key elements link to the scorresponding self -assessment  questions. Some of the questions on the surface may not appear applicable; however, focus on the overall or broad concept of the question and impression of how the organization fares.

Some of the questions start with the term “QAPI;” remember the term QAPI is referring to the organizations quality of care and improvement framework

Closer look at the self-assessment elements

Design and Scope
The questions pertaining to design and scope are asking that you look at and assess whether your facility’s care interventions are ongoing and comprehensive,  and are inclusive of a full range of departments.  A full implemented design and scope addresses all systems of care: having diverse team members involved answering this question may spark areas in need of added inclusion.

Governance and Leadership
Question’s pertaining to Governance and Leadership ask that you assess your facility’s culture, whether you have built an organizational culture around resident centeredness and expectations around safety, quality, and accountability.  Again, the team input is significant for offering an enhanced perspective.

Feedback, Data Systems & Monitoring
Question’s pertaining to Feedback, Data Systems & Monitoring focus on whether the facility has in place a system to monitor processes and outcomes, care and services, a feedback mechanism that actively incorporates input from staff and residents, and action plans to prevent reoccurrences

Performance Improvement Plan
Questions’ pertaining to Performance Improvement Plan ask that you to assess if the facility has a consistent process for addressing problem areas or areas needing attention and that the plan used to address issues or problems includes gathering information systematically and distinct  improvement intervention.

Systems Analysis & Systematic Action
Question’s pertaining to Systems Analysis & Systematic Action ask that the facility to assess whether a consistent systematic or structured approach is used to determine when in-depth analysis is needed to fully assess problems,  causes,  and implications for change. This group of  questions looks across all systems within the organization and processes to prevent negative events and promote  continuous improvement.

Resources

Electronic QAPI Self–Assessment Tool (* the electronic version is equipped for NHQCC participants only)

VideoElectronic QAPI Self Assessment Tool

Hard Copy QAPI Self–Assessment Tool  (* accessible to all nursing homes)

Next Steps- Review and complete the initial self-assessment tool as a team to provide a broad perspective of the systems of care in need of focused improvement. The assessment is a snapshot of the facility’s QAPI status and as such, will provide an inventory of areas in need of attention. The team should be honest in its evaluation of each question since it is a tool for ongoing use and update.

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New York

Pauline Kinney, RN, MA, LNHA, RAC-CT
Senior Director, Health Care Quality Improvement
Tel: (516) 209-5402
Fax: (516) 326-0434
pauline.kinney@area-I.hcqis.org

Maureen Valvo, RN, BSN, RAC-CT
Senior Quality Improvement Specialist
Tel: (516) 209-5308
Maureen.valvo@area-I.hcqis.org

David L. Johnson, NHA, RAC-CT
Senior Quality Improvement Specialist
Tel: (518) 320-3516
David.johnson@area-I.hcqis.org

Dan Yuricic, MA
Senior Quality Improvement Specialist
Tel: (516) 209-5458
Danny.yuricic@area-I.hcqis.org

IPRO Nursing Home Team
ipronursinghometeam@ipro.org