On-Demand Webinar: From QM To QAPI - How to Get in Shape-From QM To QAPI

Video Transcription

Video Summary

In this educational presentation, Denise and Jesse explore how nursing facilities can improve quality measure (QM) outcomes through effective collaboration between Nursing Assessment Coordinators (NAC) and Directors of Nursing Services (DNS). They emphasize that improving QMs is akin to a fitness routine—it requires consistent, daily attention rather than occasional review. The session outlines a multi-step approach starting with gathering key reports from CMS, including facility characteristics and resident-level QM data, to identify and prioritize which QMs need intervention. Facilities should focus on high-risk measures first, such as falls with major injury or significant decline in activities of daily living (ADLs).<br /><br />A crucial early step is auditing Minimum Data Set (MDS) accuracy to ensure QM triggering reflects resident realities. This involves understanding MDS assessment periods, accurate coding—especially for Section GG functional status—and reviewing clinical documentation for support. A thorough assessment also includes staff training, medication reviews, and evaluation of assistive devices and restorative programs. Root cause analysis tools like Fishbone Diagrams and the Five Whys help identify systemic issues like staffing shortages or communication gaps.<br /><br />The presenters stress the importance of realistic, system-focused interventions that include weak to strong actions, from staff training to leadership involvement and process redesign. Collaboration between NAC and DNS is vital throughout—NACs typically handle training and accuracy checks, while DNSs enforce standards and support necessary policy changes. Sustaining improvements requires integration into the facility’s QAPI program with ongoing audits and adjustments.<br /><br />Q&A highlights practical concerns about QM triggering durations, MDS correction protocols, and strategies to maintain gains. The session offers resources, including APAC tools and guides, to support ongoing QM improvement efforts. Overall, the program advocates a comprehensive, team-based continuous quality improvement process to enhance resident outcomes and facility performance.

Keywords

Nursing facilities

Quality measures (QM)

Nursing Assessment Coordinators (NAC)

Directors of Nursing Services (DNS)

Minimum Data Set (MDS) accuracy

CMS reports

High-risk measures

Root cause analysis

Fishbone Diagram

Five Whys

QAPI program

Continuous quality improvement