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 you have established and tracked your objective measures and have determined that an improvement project is in order, you need to make a decision as to which of the available methods and tools that you will use to perform your project. While the tendency will be to rush to begin the project, keep calm and chose the right tool for the right job.
Our previous blogs on Quality Assessment and Process Improvement (QAPI) in this series have focused on designing objective measures and using those to monitor key aspects of our transplant programs. Today, we want to discuss what to do with those measures and how to translate them into successful process improvement projects.
In our last blog, we discussed the development of objective measures in your Quality Assessment and Process Improvement (QAPI) program and using a SMART approach as described by Doran in Management Review in 1981. Today, we are going to focus on some additional considerations and discuss how to manage these measures so as to yield demonstrable and actionable improvement through the use of process improvement projects.
In our first blog of this series, we discussed the model framework for developing a Quality Assessment Process Improvement program. Today, we will discuss how to develop objective measures that are used in three of the aspects of the program, namely Feedback, Data Systems and Monitoring; Systematic Analysis and Systemic Action; and Performance Improvements. The directive to emplo y objective measures is provided in the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (§482.96(a) Standard: Components of a QAPI Program) that states...
In our previous blogs, we have reviewed some aspects of transplant operations, how to stay compliant and how to address concerns raised by regulatory agencies such as the United Network for Organ Sharing (UNOS) and the Centers for Medicare and Medicaid Services (CMS) when issues arise. Our next series of blogs will focus on how transplant programs can proactively track their progress and address potential problems before theybecome major issues. During this series, we will review the structure, operations and tools of an effective Quality Assessment and Process Improvement Program (QAPI). First, let’s review the 5 aspects that create the conceptual framework for a QAPI program under the Medicare requirements.