WHAT IS IN THE MANUAL FOR YOU? Hospitals should know what's happening in LTC and vice versa!!!!
HOSPITAL FNS LEADERSHIP: While the federal QAPI "A" tags (A 263-317) for hospitals have been out for a few years, CMS has given little guidance to hospitals. As of 11/28/17, the LTC (Nursing Home) Regulations have been revised and implemented for QAPI after two years of an extensive pilot program and guideline (The Affordable Care Act mandated that CMS train and assist Nursing Homes in Performance Improvement.) This is extremely valuable information and most hospital leaderships are unaware. CMS offers specific "5 Elements of QAPI", with detailed Tools for developing PIPs (Performance Improvement Project.) There has been pressure on The Joint Commission to align its Standards with CMS Regulatory Requirements: So in 2016, The Joint Commission issued its revisions and incorporated the "5 Elements of QAPI" into its Standards. This will be discussed. The concept of "Good Faith Effort" is a directive to surveyors in evaluating YOUR efforts to identify high risk/weak areas and to have corrective actions. This can save you many deficiencies, and of greater importance, give better care, and prevent negative /adverse outcomes. This author has represented many facilities in litigation as a direct result of poor QAPI systems. CMS wants YOU to provide a GAP ANALYSIS of where you are and where you want to be. Then identify the ROOT CAUSE ANALYSIS for improvement and sustainability. Many examples of deficiencies. Please read the message to Nursing Home Leadership:
NURSING HOME FNS LEADERSHIP: (Read the above message to Hospital Leadership) The new revised tags for QAPI (F 865) are demanding. In the past, surveyors have not had detailed expectations for QAPI in LTC and few deficiencies were given. This has now changed!!!! The Dietitian and the Dietary Managers are a team who must collaborate to meet these expectations.
1. GAP ANALYSIS: How would you proceed to develop a GAP Analysis (of weak areas that need improvement or staff training ) of your facility?
2. POLICIES: HOW can you demonstrate that you have established effective "Policies"/Standards/Criteria to train staff ( based upon evidenced based industry standards and regulatory requirements)?
3. TRAINING: HOW can you train effectively so each staff person has confidence and competency? Even the new Abuse tag (F 600) has the stated expectation that ALL STAFF are oriented and competently trained to meet the needs of the residents, or it is considered "Abuse." t Is your staff, trained, and check off for competency in all their duties?
4. MONITORING: How can you measure and evaluate for performance improvement? There are simple effective audits tools to assure CMS that the intent of all regulations are met.
5. PERFORMANCE IMPROVEMENT PROJECTS: Using the CMS Tools, especially the simple PDSA with 3 basic questions.
Dietary leadership can no longer be "silo", but must learn how to effectively "collaborate" with other IDT team members, especially nursing in QAPI PIPs. Many, many examples of PIPs: Nutrition Care, Sanitation, Food Service, Dining/Tray Delivery