Guest Columns

Should SNF therapy vendors use QAPI?

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Tara Roberts
Tara Roberts

The Centers for Medicare & Medicaid Services has entered into the implementation phase of the Quality Assurance and Performance Improvement roll out. This is in spite of no formal date for LTC regulatory compliance to QAPI.

While some long-term care providers have been slower to look at QAPI processes, others are ready to implement. Therapy vendors also should be considering adopting and operationalizing QAPI.

That's because QAPI is a "data-driven, proactive approach to improving the quality of life, care, and services in nursing homes. The activities of QAPI involve members at all levels of the organization to: identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor effectiveness of interventions. 

Rehab vendors can self-improve and actively assist facilities with quality improvements. This is especially important when there are identified areas of potential or actual deficient practices related to rehab services.


As a clinician, it's easy to get caught up in QAPI application only to clinical concepts. In light of recent headlines recognizing the lack of oversight of rehab vendors and billing practices QAPI could be a long-term care provider's solid methodology of ensuring quality, compliance and ongoing performance improvement for rehab services. On the flip side, rehab providers who provide care consistently and appropriately, but desire to implement self-monitoring and compliance measures, also should consider the QAPI process.

For confirmation and guidance of whether or not rehab vendors should adopt QAPI, we don't have to look further than the QAPI essential five elements.

Element 1: Design and Scope — A QAPI program must be ongoing and comprehensive, dealing with the full range of services offered by the facility, including the full range of departments. When fully implemented, the QAPI program should address all systems of care and management practices, and should always include clinical care, quality of life, and resident choice. It aims for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents (or resident's agents).  It uses the best available evidence to define and measure goals. Nursing homes will have in place a written QAPI plan adhering to these principles.   

Element 2: Governance and Leadership — The governing body and/or administration of the nursing home develops a culture that involves leadership seeking input from facility staff, residents, and their families and/or representatives.  The governing body assures adequate resources exist to conduct QAPI efforts. This includes designating one or more persons to be accountable for QAPI; developing leadership and facility-wide training on QAPI; and ensuring staff time, equipment, and technical training as needed. The governing body should foster a culture where QAPI is a priority by ensuring that policies are developed to sustain QAPI despite changes in personnel and turnover. Their responsibilities include, setting expectations around safety, quality, rights, choice, and respect by balancing safety with resident-centered rights and choice. The governing body ensures staff accountability, while creating an atmosphere where staff is comfortable identifying and reporting quality problems as well as opportunities for improvement.    

Element 3: Feedback, Data Systems and Monitoring —  The facility puts systems in place to monitor care and services, drawing data from multiple sources. Feedback systems actively incorporate input from staff, residents, families, and others. This element includes using Performance Indicators to monitor a wide range of care processes and outcomes, and reviewing findings against benchmarks and/or targets the facility has established for performance. It also includes tracking, investigating, and monitoring Adverse Events that must be investigated every time they occur, and action plans implemented to prevent recurrences.  

Element 4: Performance Improvement Projects — A Performance Improvement Project (PIP) is a concentrated effort on a particular problem in one area of the facility or facility wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements. The facility conducts PIPs to examine and improve care or services in areas that the facility identifies as needing attention. Areas that need attention will vary depending on the type of facility and the unique scope of services they provide.     

Element 5: Systematic Analysis and Systemic Action — The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. The facility uses a thorough and highly organized/ structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered. Additionally, facilities will be expected to develop policies and procedures and demonstrate proficiency in the use of Root Cause Analysis. Systemic Actions look comprehensively across all involved systems to prevent future events and promote sustained improvement.  This element includes a focus on continual learning and continuous improvement.

No doubt rehab vendors will eventually be exposed to facility QAPI programs their customers establish. I suggest those rehab vendors that Internalize and operationalize QAPI will be more desirable and more responsive to LTC customers when the needs arise for the development and implementation of quality assurance and performance improvement. 

Tara Roberts is the corporate director of rehabilitation and wound care services at Nexion Health Management, Inc.
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