How to Form a QAPI (Quality Assurance Process Improvement) Committee

imageNursing homes all have quality committees that meet regularly to review key performance indicators and incidents. The committee has the responsibility for addressing any incidents and resolving the cause of the problem. Additionally, nursing homes have resident councils that meet regularly to discuss quality issues that are important to residents and families. The problem is that no residents sit on the quality council and no staff sit on the resident council.

In order to be really effective and not burden everyone with unnecessary meetings and duplicate work, the solution is to form a new steering committee to manage quality and QAPI in the nursing home.

The responsibility of the steering committee is to take on the leadership responsibility of leading, developing and implementing a QAPI plan. CMS has mandated specific guidelines for the make up of this steering committee. In order for this group to be effective, membership must be representative of all the key players. The steering committee must include:

  • the Administrator,
  • Director of Nursing,
  • Director of Social Services,
  • Quality Director,
  • Activities Director,
  • Business Office Manager.
  • Residents
  • Family representative (of a resident who is not on the committee)
  • Front line staff

The committee has a long list of responsibilities to ensure a QAPI plan is developed and implemented. They are responsible for ensuring the committee has the resources needed. They oversee the training and development of managers and staff on QAPI. They develop policies that ensure the sustainability of the QAPI plan despite any staff changes and turnover. The committee sets the priorities for the program, setting goals for safety, quality, delivery, productivity and cost, balancing quality and safety with resident rights and choice. This must all be done while developing a culture of accountability where everyone is responsible for what happens and everyone is encouraged to identify and repot problems and make suggestions for improvement.

This is a long list of tasks that may seem insurmountable . However, when we take a systems approach, as required by CMS, one step builds on another until we have a solid self sustaining framework for QAPI

The first step is to charter a QAPI steering committee. We have developed a QAPI charter to help guide you in this process.

If you would like a copy of the charter, please email us and we would be happy to send it to you.

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