Use these Plan-Do-Study-Act (PDSA) cycles as a guide to develop your own or try any that you think might work in your facility.
The QAPI plan will guide your organization’s performance improvement efforts. The QAPI regulation requires a written plan. This plan is a framework for an effective, comprehensive, data driven program that focuses on the indicators that reflect outcomes of care and quality of life.
This worksheet was designed to work in conjunction with the QAPI Guide for Developing a QAPI Plan. It will help you summarize the QAPI progress you have achieved and create an outline for writing your QAPI plan.
“Weak” interventions often not prevent the recurrence of the original problem. Whenever possible, use strong interventions, suchas simplifying a process or making physical or environmental changes, to “hardwire” the change into the existing system.
Prevent recurring problems by ensuring that all possible root causes have been identified and addressed. Remember to use systematic tools, such as the fishbone diagram or the “Five Whys” to dig below the surface.
For those areas that require a PIPs, PIP teams should use a methodic or standardized process for making improvements. PDSA is one well-known model, but there are others that may also work for your organization. e important point is to use a strategic methodology, and not a haphazard, “throw it at the wall and see if it sticks” approach.
Effective use of data will help ensure that decisions are made based on fact, and not on an assumption of the truth. Just as a physician needs data about a patient to diagnose a condition, QAPI teams and PIP teams will need data to ensure they are targeting the right areas.
Is the care provided by your facility tied to your organization’s fundamental purpose or philosophy? How do you determine programmatic priorities? Taking time to articulate the purpose, the guiding principles and the scope of QAPI will help you integrate these efforts into your organization.
QAPI at a Glance states that QAPI relies on teamwork in several ways. Do teams at your organization have a clear purpose? Do teams have defined roles for each team member to play? Do teams have commitment and active engagement from each member?
The facility leadership (i.e., medical director, administrator, director of nursing and other key managers) is responsible for setting the tone to help staff identify how to meet the organization’s mission, vision, guiding principles, standards and expectations. Without strong leadership, change efforts often fail or are not sustainable.