Please
note that these answers are only intended as a resource for Rural
Health Clinics. Ultimately, CMS and the state surveyors will make
the final determination of what constitutes an appropriate QAPI
program. Most of these questions and answers are drawn from comments
and responses published in the Federal
Register
What is a Quality Assessment and Performance
Improvement (QAPI) program?
There are two distinct steps in any QAPI program.
The first step is to assess the quality of care and identify potential
areas for improvement. Ideally, improvements will be focused on
high volume/high risk procedures or other services that stand to
substantially improve quality of care. The assessment should be
based on solid data (i.e. large number of patients presenting with
a particular chronic condition or information from chart reviews).
When available, RHCs are expected to utilize current practice guidelines
and professional practice standards when comparing the care they
provide.
The second step is to correct or improve processes
of care and clinic operations in a way that is expected to improve
overall quality. Some data should be available to monitor the effect
of this improvement. This data should be reviewed with an eye towards
using the results to modify, strengthen or alter the intervention
accordingly. If this process is followed, regularly collecting and
analyzing information will result in a continuous improvement in
patient care.
What are some available resources for implementing a quality
assessment and performance improvement program in an RHC?
This site contains a wealth of information and
is continuously being updated with new material. The file RHC
Quality Improvement Resources contains a list of websites and
articles relevant to those seeking to implement a quality assessment
and performance improvement program. In particular, The Agency
for Healthcare Research and Quality has a wide array of information
on quality improvement.
Are rural health clinics required to complete
a specific number of quality assessment and performance improvement
projects to fulfill their QAPI requirement?
No. Section 491.11 provides Rural Health Clinics
with the flexibility to tailor the amount and flexibility of individual
performance improvement projects to the clinic's available resources.
It is not expected that small RHCs will have a quality improvement
program that is as comprehensive as an RHC that is part of a large
integrated system. However, all RHCs must have a QAPI program.
What types of performance measures might be used in an RHC QAPI
program?
Section 491.11 provides RHCs with tremendous flexibility
with regards to performance measures. RHCs may design their own
or may draw on measures from outside sources. Surveyors will check
to see that the measures are relevant to the clinic's QAPI program
and that the data, or information, collected will enable a clinic,
with its available staff and resources, to assess change or improvement.
For example, a clinic seeking to increase access by reducing patient
wait time might measure the time between a patient presenting and
being seen by a physician or mid-level practitioner. Various clinical
practice guidelines detail a variety of measures for managing chronic
diseases. The American
Academy of Family Physicians has suggested guidelines for physician
office practice performance measures and the Agency
for Health Care Research and Quality has published a guide to
performance measures for quality improvement.
What are the characteristics of Rural Health
Clinics with outstanding quality assessment and performance improvement
programs?
Most rural health clinics that have implemented
a successful quality program cite the need for a "cultural
change" in the way practitioners and staff deliver medical
care. They acknowledge that implementing a quality improvement program
was difficult at first, but eventually thinking in terms of quality
becomes second nature. Ultimately, quality improvement is about
"practicing medicine better tomorrow based on what you are
learning today." Quality-oriented Rural Health Clinics are
continuously questioning their policies and procedures and looking
for better ways to improve care. All practitioners and staff are
comfortable identifying weaknesses and suggesting improvement, and
clinic employees work collaboratively to improve care.
Is there a list of best practices in Rural
Health Clinic Quality Improvement?
The Office of Rural Health Policy is currently
speaking with RHCs and attempting to compile a list of best quality
improvement practices. If your RHC has a quality improvement program,
no matter how seemingly small, ORHP would like to hear about it.
Please e-mail or call Craig
Williamson at (301) 443-4784.
Does the new QAPI requirement mean that I will
have to hire an expensive consultant to ensure sure that I am compliant?
Some Rural Health Clinics may choose to
hire outside consultants, and they are certainly entitled to do
so. However, sufficient flexibility was built into the regulation
that most RHCs, if they use this website and other resources that
are available to them, should be able to independently implement
a QAPI program that is compliant with Section 491.11
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