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12 steps of QAPI: Step 3: Self-assessment

March 17, 2014
by Nell Griffin, LPN, Ed
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Nell Griffin, LPN, Ed
  1. Leadership, Responsibility and Accountability
  2. Develop a Deliberate Approach to Teamwork
  3. Take your QAPI “Pulse” with a Self-Assessment
  4. Identify You Organization’s Guiding Principles
  5. Develop Your QAPI Plan
  6. Conduct a QAPI Awareness Campaign
  7. Develop a Strategy for Collecting & Using QAPI Data
  8. Identify Your Gaps and Opportunities
  9. Prioritize Quality Opportunities and Charter Performance Improvement Projects (PIPs)
  10. Plan, Conduct and Document PIPs
  11. Get to the “Root” of the Problem
  12. Take Systemic Action

For example, the 11th of the 24 self-assessment statements is: Leadership can clearly describe, to someone unfamiliar with the organization, our approach to QAPI and give accurate and up-to-date examples of how the facility is using QAPI to improve quality and safety of resident care. For example, the administrator can clearly describe the current performance improvement initiatives, or projects, and how the work is guided by caregivers involved in the topic as well as input from residents and families.

This statement reflects components of all five of the elements and aligns with several of the steps, including Step 1. The selected rating would depend on the context and applied interpretation of the statement. Because each statement is subjective, QIO facilitators are encouraging nursing homes to write notes detailing the reason for the selected rating at that time. There is a note section for each statement on the QAPI Self-Assessment.

Completing the QAPI self-assessment is a way to evaluate current processes and identify the components that are already in place. This is also a tool nursing homes can use to evaluate their ongoing QAPI progress and sustainment. Nursing homes can contact their state’s QIO for assistance or questions about completing the QAPI Self-Assessment. To locate your state’s QIO, go to www.qualitynet.org and click on the Quality Improvement tab. Every nursing home should complete the self-assessment and let its state QIO know this step in the QAPI process is finished.

QAPI is about strengthening the processes that are working and correcting the processes that aren’t by using data and evidence- based strategies. But more than just correcting and strengthening, QAPI requires nursing homes to sustain the improvements. Sustaining the improvements requires ongoing monitoring, evaluating and assessing. The function of the QAPI self-assessment tool is for nursing home to use to monitor, evaluate and assess their ongoing QAPI progress.

Nell Griffin, LPN, EdM, is a Healthcare Quality Improvement Facilitator, a certified TeamSTEPPS Master Trainer and author. She can be reached at nell.griffin@compcast.net.

Read about the other steps:

12 steps to QAPI: Step 1: Leadership

12 steps to QAPI: Step 2: Teamwork