F-Tag Library On-Demand Series-F867 QAPI/QAA Improvement Activities

Video Transcription

Video Summary

This presentation focuses on F8-67, QAPI (Quality Assurance and Performance Improvement) activities in long-term care facilities, emphasizing regulatory compliance as detailed in Appendix PP of the SOM Guidelines. Facilities must establish written policies for collecting feedback from residents, staff, and representatives; data collection and monitoring; adverse event reporting; and performance indicator development and evaluation. Effective QAPI programs use systematic approaches, like root cause analysis, to identify and address systemic issues, prioritize high-risk or problem-prone areas, and implement corrective actions that sustain improvements.<br /><br />Facilities are required to conduct at least one annual performance improvement project targeting significant risks identified via data analysis. The Quality Assurance and Assurance (QAA) committee oversees these efforts, reporting to the governing body and addressing quality deficiencies through data-driven plans of action.<br /><br />Noncompliance can result from failures in feedback utilization, data handling, adverse event monitoring, or implementing effective corrective measures. Root cause analyses and tailored plans of correction are critical to address deficiencies and prevent recurrence, involving education and systemic process changes beyond mere training. Monitoring plans should be specific, adjustable, and thoroughly documented.<br /><br />Facility leadership must ensure comprehensive policy updates, staff education, robust data practices, and continuous monitoring to maintain compliance. Resources and training are available through APACN to support these requirements, and facilities are encouraged to utilize these tools for ongoing improvement and survey readiness.

Keywords

QAPI

long-term care

regulatory compliance

Appendix PP

performance improvement project

root cause analysis

Quality Assurance and Assurance committee