Illustrating QAPI in Action
The scenario below illustrates how a QA committee might develop a plan of correction in response to deficiencies identified during an annual survey. The example shows how facilities often react to regulatory non-compliance with a “band-aid” approach. The activities described are representative of the types of plans of corrections that are often submitted to Survey Agencies and accepted. It addresses the immediate problem, and then takes steps assumed to prevent recurrence of the problem.
The Issue: The nursing home, (“Nursing Home”) received deficiencies during the annual survey because residents had unexplained weight loss, and weights and food intake were not accurately and consistently documented. What Nursing Home did: The QA Committee developed a Plan of Correction, which contained the following components: Re-weighing all residents, and updating the weight records for the affected residents; in-servicing the Nursing Department on obtaining and documenting weights and intake. They stated they would conduct 3 monthly audits of weight and intake records, with results reported to the QA committee. This plan of correction was accepted by the State Survey Agency.
The next case study shows a facility with effective QAPI systems in place to identify issues proactively, before trends become serious problems. A nursing home chooses a limited number of PIP projects in “high-risk, high volume, problem-prone” areas.
The Issue: During the monthly QAPI meeting at “Nursing Home“, staff discovered a trend of unexplained weight loss among several residents over the last two months. During the discussion, a representative from dining services noted that there had been an increase in the amount of food left on plates, as well as an increase in the amount of supplements being ordered. Although other issues and opportunities for improvement were identified at the meeting, the QAPI Steering Committee decided to launch a Performance Improvement Project (PIP) on the weight loss trend because unexplained weight loss posed a high-risk problem for residents.
What Nursing Home did: The QAPI Steering Committee chartered a PIP team composed of a CNA, charge nurse, social worker, dietary worker, registered dietitian, and a nurse practitioner. The team studied the issue, and then performed a root cause analysis (RCA) to help direct a plan of action. The RCA revealed several underlying factors, which included:
- No process existed for identifying and addressing risks for weight loss such as dental condition, diagnosis, or use of appetite suppressing medications
- No system existed to ensure resident preferences are honored
- Staff lacked an understanding of how to document food intake percentages
- Residents reported the food was not appetizing
Based on the identified underlying causes, the PIP team recommended the following interventions:
- Development of a protocol for identifying residents at risk for weight loss to be done on admission and with each care plan. This protocol included a review of medications (appetite suppressants), new diagnoses, and resident assessments, including dental issues
- Development of standing orders for residents identified as “at risk” for weight loss. These would include bi-weekly weights, referral to attending physician and dietitian for assessment, and documentation of meal percentages
- Development of a new program for CNAs to be “Food Plan Leads” for at risk residents. The program would include identification of food preferences and accurate documentation of meals – laminated badge cards with pictures of meal percentages were distributed to all CNAs
- Revision of the menu to focus on favorite foods, adding finger foods and increasing choices outside of mealtimes
The interventions were implemented in one area of the building that was home to 25 residents. The PIP team collected data from dietary (food wasted and supplement use), CNAs (observation of resident satisfaction and meal percentages), residents (satisfaction surveys), and weights.
After 3 months, they found that 5 residents gained weight, 15 remained stable, and 5 lost weight, but the weight loss was not unexpected and consistent with their clinical condition. Food costs did not increase and supplement costs decreased by 12%.
“Nursing Home” decided to adopt and expand the changes to other areas of the facility. They received no deficiencies in the areas of nutrition on their annual survey. Using QAPI allowed them to identify and correct developing issues before they escalated to larger problems.