STEP 8: Identify Your Gaps and Opportunities
This step involves reviewing your sources of information to determine if gaps or patterns exist in your systems of care that could result in quality problems. Or, are there opportunities to make improvements?
Potential areas to consider when reviewing your data:
- MDS data for problem patterns.
- Nursing Home Compare (provides quality information about every certified nursing home in the country).
- State survey results and plans of correction.
- Resident care plans for documented progress towards specified goals.
- Trends in complaints.
- Resident and family satisfaction for trends.
- Patterns of caregiver turnover or absences.
- Patterns of ER and/or hospital use.
During this step, you may decide to spend more time discussing the quality themes you have identified with residents and caregivers. They may pick up patterns you have not yet identified, and they may have ideas about what is at the root of the problem. Consider hosting a series of small group meetings with your caregivers, and arrange to meet with your Resident Council. You may wish to provide refreshments and have an informal discussion.
This step should lead to the next steps involving PIPs. Such projects are expected to be chosen to deal with “high risk, high volume, problem-prone areas” related to quality of care or quality of life. Take time to notice the things you are doing well—that’s important too, and deserves recognition.
But while you are celebrating accomplishments, you can also begin to set priorities for improvement around issues that the team identifies.
https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads qapiataglance.pdf