Quality Assurance and Performance Improvement Plan ...

Quality Assurance and Performance Improvement Plan Template (QAPI)

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TABLE OF CONTENTS

I. Disclaimer

II. Introduction to the Quality Assurance and Performance Improvement (QAPI) Plan Template

III. QAPI Goals A. Introduction to QAPI B. Organizational Mission, Vision and Values C. Goals

IV. Design and Scope A. Fundamentals of Performance Improvement 1 Key Elements 2 Key Focus Areas 3 Limits of the QAPI Plan 4 QAPI Effort\ B. Objectives of the QAPI Plan

V. Governance and Leadership VI. Feedback, Data Systems and Monitoring VII. Performance Improvement Projects (PIPs)

A. Identification of PIPs B. Prioritizing PIPs C. PIP Project Charter D. PIP Team E. PIP Team Reporting Process VIII. Systematic Analysis and Systemic Action A. Performance Improvement Process Cycle B. Root Cause Analysis (RCA) C. Benchmarking IX. Communications X. Evaluation XI. Establishment of Plan

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DISCLAIMER

This Quality Assurance and Performance Improvement (QAPI) plan template is presented as a model only by way of illustration. It has not been reviewed by counsel. Before applying a form to a specific use within your organization, it should be reviewed by a counsel knowledgeable concerning applicable federal and state health care laws, rules and regulations.

The QAPI plan template should not be used or relied upon in any way without consultation with and supervision by qualified physicians and other health care professionals who have full knowledge of each residents case history and medical condition.

The QAPI plan template is offered to nursing facilities as a guideline for developing QAPI plans and for informational and educational purposes only.

The development process included a review of government regulations, literature review, expert opinions and consensus. The guidelines strive to be consistent with these principles:

? Relative simplicity ? Ease of implementation ? Evidence-based criteria ? Inclusion of suggested, appropriate forms ? Application to various long term care settings ? Consistent with statutory and regulatory requirements ? Use of state and federal government terminology, definitions and data collection

Appropriate staff at each facility/program should develop specific policies, procedures and protocols to best assure the efficient, implementation of the QAPI principles.

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INTRODUCTION TO THE QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT (QAPI) PLAN TEMPLATE The QAPI plan template development process included a review of government regulations, relevant literature, various performance improvement programs, expert opinions and consensus. The QAPI plan template design is relatively easy to use and customize. Current, evidence-based criteria for defining, advancing and sustaining performance improvement strategies have been incorporated into the document, as well as suggested forms and analytical tools. The plan template may be used in nursing and skilled nursing facilities, and sub-acute care facilities to assist in developing a facilityspecific QAPI program and plan. Health Quality Innovators (HQI) recommends that each facility designate a team of knowledgeable senior leaders, day-to-day managers, key clinical care and service, directors/supervisors, front line staff, consumers, community leaders and consultants to carefully review this plan template. The team should make thoughtful, appropriate adjustments in the template to produce a comprehensive, organizationspecific QAPI plan. Then, the governing board and/or senior management should review the draft plan, make appropriate adjustments as needed, and approve the plan. The approved plan will be documented as appropriate. HQI suggests that each facility/program conduct a formal review and revision as needed of its QAPI plan at regular intervals, not to exceed every twelve (12) months.

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Quality Assurance and Performance Improvement (QAPI) Plan

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