The skilled nursing sector has seen a significant number of facility divestitures and closures in the last few years. Quite frankly, this negative trend is due in part to a reluctance by some operators to implement clinical-based care standards and a lack of honest self-evaluation to improve the clinical care provided at skilled nursing facilities. Outdated operating models – solely meeting the basic needs of patients – does not bode well for SNF operators to survive.
The colonial mantra “join or die” can be applied to SNF operators who do not adopt and implement robust clinical care standards. Operators who “join” will improve the types and quality of care provided to patients by adjusting current operations to incorporate Quality Assurance and Performance Improvement standards, advancing patients’ clinical care and outcomes, and shifting from considering patients a “resident” to, yes, a patient.
SNFs must implement a wide-scale, in-depth QAPI program reviewing all areas of operation and prioritizing patient care and quality of life in order to survive (and hopefully thrive) moving forward.
Many operators have been reluctant to really adopt QAPI standards due to the notion of it being just another government “we know better than you” program and uncertainty about the permanence of guidelines and standards developed as part of the Affordable Care Act. However, the shift from strictly fee-based to value-based care is progressing across the healthcare space, and it is here to stay.
Today’s successful SNF will be compelled to not just identify, but demonstrate, itself as a healthcare provider; it must walk the walk. Many facilities, however, are still operating under a model of “warehousing the elderly” – just caring for an individual’s basic needs but not comprehensively addressing all the patient’s post-acute healthcare conditions.
QAPI standards provide a roadmap for SNFs to systematically change and focus their operations as a healthcare provider, and adoption of these program guidelines will lead to improved quality outcomes which will ultimately make or break the business.
QAPI guidelines promote value-based care and clinical outcomes — and reimbursement tied to the level of care — will be the standard for the “Quality Payment Program.”
Many operators have carried on with business as usual without adopting QAPI standards and, not so surprising, some have received disastrous results on state and federal surveys.
What is in QAPI?
QAPI, simply broken down, is –
- QA (quality assurance) – specific standards of care and outcomes and a process throughout the organization for assuring adherence to those standards and
- PI (performance improvement) which is more forward–looking and is the continuous study of possible improvements and new approaches. In other words, “PI can make good quality even better.”
The intent of QAPI has been realized, it enhances quality care and, as a result, can improve the business and financial performance of facilities under its implementation. The five elements of QAPI provide a guide for operators to avoid substandard care and prevent poor outcomes:
- Design and Scope – A program must include all areas of operation and all facility staff members.
- Governance and Leadership – Facility leadership must ensure QAPI extends to all stakeholders (patients, families, and staff) and maintain open communication for improvement in all areas.
- Feedback, Data Systems and Monitoring – Facilities must collect data to ensure performance standards are being met and stakeholder feedback is being used effectively.
- Performance Improvement Projects – Operators must work with staff to address particular problems and take steps to improve them.
- Systematic Analysis and Systemic Action – SNFs must set ways to identify and analyze how issues have been caused and put in place systems of continual learning and continuous improvement.
Adopting a QAPI program and focusing on clinical care and patient outcomes will lead to improved health for patients and fiscal health for operators. Maximizing the implementation of a QAPI program will permit facilities to excel on state and federal surveys, earn higher ratings, and enhance their reputations and referrals. Embracing the QAPI model offers SNF operators the infrastructure they need to adapt to the changing healthcare landscape.
It’s no secret that SNFs have one of the highest staff turnover rates across all industries, creating a significant administrative burden on operators who must consistently hire, train, rehire, re-train, etc. leaving patients with inconsistent caregivers and care. Operators should work to hire higher-credentialed clinical staff – those with greater experience in clinical care. More qualified staff can decrease employee turnover rates, and lower the risk for mistakes, bad surveys, litigation, etc. and should lead to improved patient care and quality of life.
Despite political and policy uncertainties for the healthcare sector, SNF operators must be open to change and adopt new modalities that lead to patient health improvement.
QAPI is an effective model for operational success. Operators should view QAPI as a tool for improvement. Following QAPI guidelines should lead to more positive patient outcomes and continued, and perhaps increased, Medicare and Medicaid reimbursement to come. Now is the time for operators to embrace QAPI.
The Centers for Medicare & Medicaid Services recognizes your “business” of taking care of the frail elderly and has stated that “QAPI amounts to much more than a provision in federal statute; it represents an ongoing, organized method of doing business to achieve optimum results…..”
There is an abundance of information and a number of resources available on CMS’s website to explain and assist in the implementation of a QAPI program, for example, QAPI at a Glance and QAPI Written Plan How–To Guide.
Heck, sometimes the government gets it right.
Jeff Parrish of Waller in Nashville is a senior legal advisor to healthcare companies and lenders that value his counsel on day-to-day legal matters, government relations, regulatory compliance, litigation, mediation and arbitration matters. Prior to joining Waller, Jeff served for nearly 15 years as Secretary and General Counsel for a $250 million post-acute healthcare services provider.