Element 3: Feedback, Data
Systems and Monitoring
The facility puts systems in place to monitor care and services, drawing data from multiple sources. Feedback systems actively incorporate input from staff, residents, families, and others as appropriate. This element includes using Performance Indicators to monitor a wide range of care processes and outcomes, and reviewing findings against benchmarks and/or targets the facility has established for performance. It also includes tracking, investigating, and monitoring Adverse Events that must be investigated every time they occur, and action plans implemented to prevent recurrences.
QAPI is the merger of two complementary approaches to quality management, Quality Assurance (QA) and Performance Improvement (PI). QA and PI combine to form QAPI, a comprehensive approach to ensuring high quality care. Both involve seeking and using information, but they differ in key ways:
ELEMENT 3 – Feedback, Data Systems and MonitoringMaking Data Meaningful
How do you know if you are doing well?
Without a baseline or point of comparison, it is hard to judge your own
performance. A strong approach to quality management, such as QAPI,
uses performance indicators to monitor a wide range of care processes
and outcomes. Then it reviews findings against benchmarks or targets the
facility has established for performance.
Benchmark refers to a standard against which other things can be measured or judged. You can use external results that represent best practices and performances, often around quality, time, and cost as the standards for setting benchmarks. Benchmarking is the process of comparing a set of results to these best practices and performances. For example:
Good sources for benchmarks are Nursing Home
Compare and Advancing Excellence. Other sources are literature from
researchers and data analysis from industries that have similar
processes, and data from nursing home organizations that have been
recognized for leadership in a specific process area.
A target refers to an internal goal that refers to a specific level of performance that an organization is trying to reach. Options to determine targets include:
might set their target at the national average rate of 8%, or their state’s current rate of 7%.
Discussing targets is a good team
Thresholds are a measure of quality performance that the facility feels must be achieved or their facility is at risk. A threshold is a level which performance results must not go above or below.
QAPI Five Elements
Element 3 – Feedback, Data Systems and Monitoring
Use and make data meaningful
|Measure/Indicator Development Worksheet Measure/Indicator Collection and Monitoring Plan Instructions to Develop a Dashboard Goal Setting Worksheet Prioritization Worksheet for Performance Improvement Projects