SNF Quality Assurance Performance Improvement

QAPI Plan

Purpose

At Stanford Post Acute Rehab, our purpose is to provide excellent quality care to the residents we serve. We define "Quality Care" as meeting or exceeding the needs, expectations and requirements of our residents while maintaining good outcomes and perceptions of resident care in a cost-effective manner.

We utilize online Performance Improvement tools to systematically monitor, analyze and improve performance to ensure positive resident outcomes and regulatory compliance. We recognize the value in healthcare is the appropriate balance between utilizing good measures, excellent care, professional services and cost.

Scope

At Stanford Post Acute Rehab, we offer a full range of services that are included in our QAPI program. We provide:

• post-acute care,
• long term care,
• dementia care,
• hospice care,
• palliative care,
• rehabilitation services, and,
• transitional care.

Our QAPI committee consists of a chairperson and seven sub-committees with representation from administration, the medical director, nursing, dietary, housekeeping, laundry, maintenance, health information management, activities, infection preventionist, staff development, therapy, human resources, and the business office.

Our QAPI Program is Chaired by John Edwards, Administrator.

Our seven subcommittee's each has a chairperson who leads the committee and assigns indicators to members on a monthly basis. Each committee has a QAPI dashboard where assigned Indicators are viewed and automatically emailed to members on the first of each month for completion.

Regulatory Indicators are current with the Final Rule and written in the same order as the State Operations Manual and correspond directly with a specific regulation and Ftag. Indicators provide for a cursory review of a selected resident sample to identify potential deficient practices that should be examined further. Committee members can populate their assigned indicators with a sample of resident names at random or by selecting admissions, discharges, MDS, or EHR.

Subcommittees

1. Resident Choice addresses the regulatory requirements of Resident Rights, Admissions, Transfers and Discharges and Resident Behaviors and Facility Practices. Individualized goals for care are addressed at care conferences, through the formal survey processes, and with rounding. This subcommittee meets monthly to review the Resident Choice dashboard to view potentially deficient practices, identify trends, and develop a plan of correction to be implemented to ensure substantial compliance. Potentially deficient practices display RED on the dashboard and are automatically reassigned until found to be in substantial compliance.
   
   Current Resident Choice subcommittee members:
   
   

   Chairperson John Edwards, Administrator in Training Judy Jenkins, Administrator Committee Members Jody Lanier, 1 Dawn Huffman, 1 Frank Gonzales, 1 Lisa Hurst, 1