Using QAPI to Improve Your Infection Prevention and Control Program

The Centers for Disease Control (CDC) states that over 4 million persons admitted to or reside in Skilled Nursing Facilities (SNFs) each year. There are 2.8 million infections in SNFs every year, including UTI, respiratory infections, skin infections, and gastroenteritis. Of the 2.8 million infections, approximately 380,000 result in death each year. 

It is up to those working in the SNF to make the necessary changes and improvements to impact the rate of infections and misuse of antibiotics. To make these improvements, we need to incorporate infection control into our QAPI process. What are some benefits of using QAPI to improve infection prevention efforts?

• The facility uses their own data to identify opportunities for improvement and for ongoing monitoring
• Fulfillment for caregivers, as they become active partners in performance improvement incorporating caregivers in the QAPI mission 
• Developing Performance Improvement Project (PIP) interdisciplinary teams 
• Self-identification of facility-wide opportunities for improvement along with the ability to solve complex problems and prevent the recurrence of the identified issues
• Improvement of the overall quality of care and outcomes for residents

Let’s do a quick QAPI refresher. CMS defines QAPI as, “the coordinated application of two mutually reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI).” Phase 3 of the Mega Rule was effective on November 28, 2018. Phase 3 included the mandate that all skilled nursing facilities must have an Infection Preventionist and Coordination of QAPI plan with the incorporation of an Infection Preventionist. QAPI has 5 distinct elements that work together to provide the SNF with the roadmap needed to move toward continuous improvement.

Incorporating the 5 Elements of QAPI into your infection prevention program:

Design and Scope – Proactive and continuous study of processes with the intent to prevent or decrease overall facility infections.

Governance and Leadership – The facility should use its QAPI program to identify opportunities for improvement and then prioritize actions. Action plans will be used to address system inefficiencies or failures and are then reviewed for efficacy based on resident and staff safety, quality of care, resident rights and choice, and best practice.

Feedback, Data Systems, & Monitoring – This includes having an infection surveillance process and following IP practices. You also want your data to come from multiple sources: Lab data on antibiotic resistance, pharmacy data on antibiotic use, and resident medical records for signs and symptoms of infections. Lastly, you will establish facility benchmarks and implement a feedback process including reporting to an infection control or QAPI committee and sharing data with front-line staff/providers.

Performance Improvement Projects (PIPs) – First, you need to understand the problem. This can be accomplished by gathering information, examining the current process, evaluating the results, improving care processes, and monitoring the impact of the changes.

Systematic Analysis & Systemic Action – The facility will use a systematic, organized, and structured approach to determine when in-depth analysis is needed to fully understand the problem, its causes, what causes exacerbation, and implications of a change. With the findings, you will develop policies and procedures which include systematic actions to prevent future adverse events, promote sustained improvement, and provide ongoing education.

QAPI activities should involve staff from all levels of your organization to best identify facility opportunities for improvement. Working together, you will address system/process gaps and develop corrective action plans. After you have implemented your plan, you will continue to monitor for effectiveness through quality measurement.

Quality measurement is the process of using data to evaluate performance against recognized quality standards and can be used to improve the care in your facility. An example would be preventing the overuse, underuse, and misuse of antibiotics. There are multiple ways you will want to review your progress when looking at antibiotic use:

1. Short term goal, i.e. ____% reduction in the overall process and outcome measures from facility baseline
2. Long term goal, i.e. ___% reduction in the overall process and outcome measures from facility baseline
3. Process measures, i.e. decrease by ___ % for the treatment UTIs that do not meet criteria
4. Outcome measures, i.e. decrease by ____ % of new antibiotic orders for all UTIs

All of these measures are important to the overall improvement of antibiotic use in a facility and all should be included in your ongoing QAPI process. These same goals and measures can be applied to other infection control related issues such as: device-associated infections, hand hygiene, PPE compliance, environmental cleaning, equipment cleaning, influenza and pneumococcal vaccines, and Multi-Drug Resident Organisms.