In November 1999, the Institute of Medicine (IOM) published their landmark report on the medical error crisis in U.S. healthcare called To Err Is Human: Building a Safer Health System. This was followed in March 2001 with an IOM report on healthcare quality called Crossing the Quality Chasm: A New Health System for the 21st Century. This follow-on report advocated for a fundamental redesign of the U.S. health care system that focused on addressing unnecessary overuse of medical resources and treatment, underutilization of resources or treatments with known benefits, and misuse (failing to execute care safely and correctly) of health care resources and treatments.i
Despite these wake-up calls to healthcare organizations that they need to relook at how they monitor and support their quality of service, change has been painfully slow; considering that 20 years of increasing complexity in health care has passed plus contending with a global pandemic. We must ask ourselves if we have truly crossed over the chasm or are we hanging over it?
Quality is Job #1
The Ford motor company advertisement of “Quality is Job #1” started in the early 1980’s. The priority in Detroit was “Don’t worry about what the car is like, just get them out on time”. Quality had taken a backseat to throughput. Japanese automakers, such as Honda and Toyota, had steadily taken over as major players in the automotive market with greater emphasis on producing highly reliable, quality cars.ii Although Detroit has worked on improving the quality of American produced vehicles since then, it has done so painfully slow.
Healthcare organizations cannot afford to take decades to improve on quality of care. Transparency of healthcare quality reporting has become increasingly evident through accrediting agencies reporting, hospital grading platforms such as Leapfrog, and social media. Health care consumers have more ability to be informed on hospital quality than ever before and are expecting organizations to deliver. Otherwise, customers will take their business elsewhere. Lost revenue from customers seeking care at more reliable institutions coupled with reimbursement penalties, will unfavorably impact a poorly performing hospital.
Quality care has got to be the banner under which the organization operates. Even more important is that they deliver on that promise. Without a structured approach to how quality will be embedded within the organization, it will be challenging to cross the quality chasm.
The QAPI Plan: Your Guide Across the Chasm
A well-developed QAPI plan will guide your organization’s performance improvement journey across the quality chasm. It must be sufficiently detailed to guide your team in identifying, developing, executing and monitoring quality initiatives. It is the navigation chart that charts your course for the journey.
Key steps and processes in setting up your QAPI plan include:
I. QAPI Goals: Define what your plan is attempting to accomplish. As Franklin Covey has stated, “Begin with the end in mind”. What is your end-state? Goals should be specific, measurable, actionable, relevant, and have a timeline for completion. A plan is not complete without setting forth expectations and determining a destination.
II. Scope: How does your plan describe how QAPI is integrated within the care and services of your organization? The QAPI Plan needs to address each discipline and/or department and ensure their quality initiatives align with the organization’s mission, vision and goals. Remember that those services that you provide through contractual arrangement must also be a component of your QAPI Plan. Your plan should also describe how QAPI will utilize the best available evidence (e.g., data, national benchmarks, published best practices, clinical guidelines) to define and measure goals and determine degrees of improvement.
III. Guidelines for Governance and Leadership: Leadership is what drives quality. It is also ultimately accountable for the quality initiatives for the organization. Therefore, it is important that provisions are included in your QAPI plan that describe their role and standards that they must meet to support success. Your plan should describe the operational structure, individual responsibilities and accountabilities of top-level management and the Board of Directors/ Governing Body.
IV. Feedback, Data Systems, and Monitoring: For a QAPI plan to be effective, the processes that will be put in place to monitor care and services must be documented. Describe the process for collecting and analyzing data and information. Include the sources that will be monitored (adverse events, input from staff/patients/families, complaints, and performance indicators). Describe how information will be communicated and what specific groups will receive it (leadership, work groups, the customer and always the Governing Body).
V. Guidelines for Performance Improvement Projects (PIPs): QAPI plans should include provisions on conducting performance improvement initiatives based on opportunities identified through data monitoring and trending. Established guidelines will support greater success with quality initiatives. These guidelines should include how PIPs will be identified, prioritized, and executed. Remember, CMS assigns the Governing Body to establish priorities and allocate resources as needed. Additionally, the oversight and frequency for reporting processes on the progress or lack of progress should be defined. Performance Improvement Projects should be time limited and focused on scope.
VI. Systematic Analysis and Systemic Action: QAPI initiatives can have unintended consequences such as the impact on systems or processes. Your QAPI plan should describe how your organization will address these potential actions through greater analysis and monitoring.
VII. Communications: Your QAPI plan should identify the audiences for quality and improvement communications. The frequency and structure of communications should be described as well. It is essential that the organization have a communication process that keeps all employees and care providers informed of the changes in processes and aware of the improvements being made.
VIII. Evaluation: It is important that the organization periodically evaluate their QAPI plan to ensure they are adequately addressing the performance improvement needs of their staff and patients. An annual review is often required by regulatory agencies. The QAPI Plan should indicate the frequency for reviews and how past performance data is used to set goals.
IX. Establishment of Plan: The final step is to date your plan, obtain necessary approvals through the Organized Medical Staff and Governing Body and communicate it through the organization to ensure a smooth implementation. Periodic check points should be scheduled to ensure all project work is advancing as planned.
Resources for Quality Assurance and Performance Improvement:
There are a number of QAPI Program resources that can provide you with guidance on how to establish or reinforce your program.
The AHRQ Quality Measure Tools and Resources link provides a comprehensive resource to address quality improvement measurement, tools, and information, including AHRQ Quality Indicators Hospital Toolkit and ambulatory clinical performance measures. Their toolkit is available at this link: https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/index.html
The Joint Commission Performance Improvement link provides tools and resources for your quality journey: https://www.jointcommission.org/performance-improvement/
The Centers for Medicaid and Medicare Services (CMS) Quality, Safety & Oversight – General. CMS maintains oversight for compliance with the Medicare health and safety standards for laboratories, acute and continuing care providers (including hospitals, nursing homes, home health agencies (HHAs), end-stage renal disease (ESRD) facilities, hospices, and other facilities serving Medicare and Medicaid beneficiaries), and makes available to beneficiaries, providers/suppliers, researchers and State surveyors information about these activities. It can be located at this link: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo
The focus on quality should be ever present in an organization’s systems and processes. Successful implementation and sustainment of a robust QAPI program will support positive patient outcomes and staff satisfaction. The foundation for success lies within a comprehensive and well-defined QAPI plan. Without a QAPI plan that sets the expectation for quality integrated into an organization, hospitals will struggle with creating a culture of quality and safety. Completing the journey across the quality chasm requires a strong foundation of guidance and accountability. Organizations do not plan to fail; Rather, organizations often fail to plan.
iBerwick, Donald (2002). “A User’s Manual for The IOM’s ‘Quality Chasm’ Report” (PDF). Health Affairs. 21 (3): 80–90. doi:10.1377/hlthaff.21.3.80. PMID 12026006..
iiMcGavin, Stephanie (2016). “Robert Cox, ad man behind Ford’s ‘Quality is Job 1’ pitch, dies”. Automotive News.