QAPI for Dummies

by Keith Grunig

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What is QAPI in Home Health?

Most of the time, when people hear the word QAPI, they usually roll their eyes, grumble under their breath, or go glassy eyed and remember therapy recently completed therapy sessions.  QAPI is something in home health that people don't really like to do, but have to do it.  

So, what is it?  QAPI means Quality Assessment and Performance Improvement.  QAPI is required for home health agencies as a condition of participation.  It is listed as this in the link for conditions of participation.  

484.65 Condition of participation: Quality assessment and performance improvement (QAPI).  You can read all about reading the  Conditions of Participation.  It is some light reading.  

One of the biggest headaches we hear about is QAPI.  It is the job no one really wants to do, has to get done, and is easily overwhelming.  

What are the 5 Elements of QAPI?

Here is the text of the introduction for QAPI from the CMS website.  Develop, implement, evaluate, and maintain are just some of the words.  Not only does it have to be on going, but it has to be data driven.  Here is what it says:

"The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS."  But wait, there's more:

Here are the 5 Standards of QAPI per the Conditions of Participation (COPs).

  • Program Scope
  • Program Data
  • Progam Activities
  • Performance Improvement Projects
  • Executive Responsibilities

We will briefly go over these 5 things, and then offer some suggestions on how we can help with some of these elements. 

Program Scope

An Agency's QAPI program needs to show measurable indicators and that those indicators will improve outcomes, patient safety, and quality of care.  Basically, it's saying that you have to measure something that is measurable and helpful to patients and the agency.  Agencies then need to be able to track certain quality indicators "including adverse patient events" and other key indicators that shows that an agency is trying to and tracking improvement in outcomes and operations.  

Program Data

Agencies need to use OASIS driven data, along with other relevent data, to track the indicators in designing the QAPI program.  The agency then needs to actually do something with the data that can track and monitor the effectiveness of the QAPI program and identifies areas of improvement.  

Program Activities

QAPI must focus on the high risk, high volume, or problem prone areas.  Agencies need to be able to understand the what, where, how, how much and how often, and why of operational challenges that could impact patient health and safety.  These activities need to track adverse patient events and then find out what and how those events happened, and then put corrective action plans in place so those things can be eliminated or avoided in the future.  "The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained." 

Performance Improvement Projects

Agencies must now do something about the areas of improvement that have been identified and track them.  These projects need to reflect the complexity of the agency, document the projects undertaken, why they were undertaken, and the measurable progress achieved from the projects.  

Executive Responsibilities

Home health leadership must be involved in the QAPI program and its oversite.  Management needs to make sure that the program is defined, implemented, and maintained.  It needs to be managed by managers! Further management needs to set priorities for QAPI and its efforts to improve the quality of care, patient safety, operational excellence, and that the improvement actions are evaluated.   If any fraud or waste is discovered, then it needs to be immediately addressed and corrected.  

What is a QAPI Plan?  

Home Care Answers not only provides quality service through coding and OASIS review to ensure OASIS is correct, we also provide data analytics to help agencies improve.  We provide you with your own data in a way that you can do something with it!  Agencies need to use OASIS driven data for the QAPI program.  Do agencies know and understand what OASIS questions are most frequently answered incorrectly?  Do they know that by Clinician?  Well, we can help!  Below, you will see a chart that shows an agency that recently signed on to work with us.  We provide data analytics for several groups of OASIS questions.  Below, you can see what ADL questions we are suggesting changes on the most often.  


M1860 Ambulation 107 / 155 Changed 69.030%
M1830 Bathing86 / 155 Changed 55.480%
M1850 Transferring82 / 155 Changed 52.900%
M1810 Dress Upper Body61 / 155 Changed 39.350%
M1820 Dress Lower Body53 / 155 Changed 34.190%
M1840 Toileting52 / 155 Changed 33.550%
As you can see, M1860 we are suggesting changes on this question 69% of the time.  Bathing, 55% of the time.  These questions certainly can impact quality outcomes patient safety.  If a clinician scores a patient as independent, but the patient has advanced Parkinson's disease, dimentia, and other issues, the patient very likely is not independent and needs at least supervision for bathing an ambulating, if not more.  Incorrect understanding and a knowledge gap on ADL questions can certainly impact patient safety and outcomes.  Agencies can use this data to identify and track these two questions as they are relevant to the agency.  
Below, an agency can track the improvement, or lack of improvement, through our reporting system.  As an example below:
The agency uses our data to identify that there is a knowledge gap on M1860, M1830, and M1850 quarterly.  The plan is to conduct training for all staff on these questions in January with follow up monthy and track the progress every quarter.  Below is what the data shows the agency for a benchmark in the 1st Quarter ending 3/31/21.  
ADL Questions for QAPI Project
Let's say that there is a training specifically on these three M Questions on April 1.  We can then track from April 1 until now to see what the progress is.  
QAPI ADL questions after training
Notice, that we suggested changes on M1860, M1850, M1830 as follows: The agency went down to 65% from 70% in M1860, that's improvement!  M1850 went up to 58% from 51%, a decrease.  Bathing went from 58% to 49%, that's improvement also!  So, the agency needs to focus and document training on M1850 to show improvement.  These questions can certainly help with patient help and safety, we help with data driven analysis of the QAPI project, and it is absolutely in scope of the agency.  QAPI accomplished!
We would love to help you with QAPI.  It is a difficult job that never ends, is hard to remain relevant for staff, and can be cumbersome.  Management can use the data to make sure that staff understands the importance of the project, give support to agency staff for QAPI, but can give a lot of the legwork to us, so that you can document and file the activities and projects to remain compliant with conditions of participation.  Let us help you use data to tame QAPI!  Click here to contact us for a free review of charts to identify problem areas for your staff.  Claim your FREE 10 chart review!


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