What Makes an Effective QAPI Program: Part 6: A Real Example

How do your objective measures and process improvement plans fit together in your Quality Assessment and Process Improvement Program (QAPI)?  Are they all individual efforts, kept in binders and not communicated to the various stakeholders? Or is your QAPI program a vibrant living entity in which all stakeholders are actively engaged?  One of the key items that the Centers for Medicare and Medicaid Services looks for is a clear, cohesive and implemented plan that is reflected in your QAPI policy and it is a lack of this that is frequently cited as a deficiency during a CMS audit.  

Once the issues are identified, the objective measures identified, approach designed and data collected and analyzed, the information must be synthesized in such a way that hospital leadership can easily follow what was done, why it was done and what the outcomes were.  At this level, raw data and the tools used to acquire it are not particularly useful.  Rather, the data needs to be analyzed and results need to be displayed effectively, using tools such as:  run charts, control charts, summary graphs and comprehensive dashboards. 

Presentations to the hospital executive committee should focus on summary scorecards, composite dashboards, summary reports and summary meeting minutes to deliver the critical messages.  Your goal in these presentations should be to stay out of the weeds, provide the high level information needed and advocate for the needs of your program that you have identified through your well-structured QAPI efforts.  CMS’ expectation will be that you receive guidance from leadership, documented by bi-directional communication that will allow you to implement the changes that you have proposed.  As your needs will often require resources, CMS will look to see that the leadership is truly committed to the program’s efforts by the provision of appropriate assets.

One example of a QAPI project that we have facilitated at a client’s program was an improvement project focused on the length of their pre-transplant evaluation process which at the time of entering into a System Improvement Agreement averaged over 365 days, frequently necessitating re-testing even before the patient was listed. 

The first step involved an assessment of the reasons for this delay by analyzing a retrospective cohort of candidates.  This revealed that there were issues with, among other things, cardiac evaluation and psycho-social clearance and follow up. 

Following this, Lean Six methodology was employed to identify the key steps of the evaluation process from initial referral to listing with all stake holders involved.  Specific attention was focused on the areas that were identified as barriers by the objective data.  Once this was done, brainstorming was performed to identify what best practices would be in this institution.  Note that while the benchmark chosen by the organization was 90 days and established from the best practices of leading institutions, the solutions to the barriers were unique to the institution as solutions are not always importable from other programs.  These solutions were then implemented with by-in from the various stakeholders and championed by the transplant physician as the owner of the overall process. 

The objective measures initially evaluated for each individual component of the process were then again monitored and analyzed over a subsequent 3-month period. This suggested that while significant advances were achieved, additional benefit could be obtained by fine-tuning some of the implemented changes. These were sequentially introduced and the program was able to cut their referral to listing time by nearly 50%.  Continued monitoring of the project demonstrated ongoing improvement and no further adjustments were currently needed. 

One of the problems identified was that there were insufficient FTE resources at certain points of the process, for example during the initial financial clearance.  When presenting this to the hospital leadership, the program was able to successfully advocate for additional resources not by merely showing the number of patients being evaluated but by the improvement in the number of living donor transplant cases performed as well as an increase in downstream revenue by improving the evaluation through-put.  This demonstrates the inter-dependency of not only the quality of care process but also the financial performance of your transplant program.

We hope that you have enjoyed this series of blogs on the QAPI process and hope you will join us for our webinar on July 26th at 12 noon eastern time.  Please see the link below for registration information.


About the Author: Dr. John Daller MD, PhD, FACS