In-person surveys for nursing home facilities have restarted for the first time since the COVID-19 pandemic began in 2020. In this fifth installment of a seven-part series, get tips on how being organized can help your staff and center be survey ready.
Quality improvement plays an essential role in identifying, tracking and resolving any barriers to or issues with meeting appropriate quality of care standards. These tools and processes can help you manage, track and assess resident quality of care.
- Administrators should review the CASPER reports every month to see if data looks correct, see what issues are listed and whether those issues have been investigated and documented .
- Make sure everyone who touches the minimum data set (MDS) gets a copy of the CASPER report.
- Our CASPER Quality Measure Data Tracking and Trending Tool supports tracking and trending of quality measure data from the CASPER Facility-Level Quality Measure Report.
- We recommend that your quality assurance and performance improvement (QAPI) committee meet monthly and discuss recent issues when details are fresh. That way, staff involved in the issues may still be at the facility and can play a role in the performance improvement project (PIP) process. Use our QAPI Meeting Agenda Guide to plan your meetings.
- This prioritization worksheet can help you decide which PIPs to work on first. Review the worksheet during QAPI committee meetings, then discuss the selected PIPs with staff. Explain why those PIPs were selected and the reason for their ranking .
Advice From a Surveyor
“Many tags are due to the quality of care as a result of short staffing such as pressure ulcers and ADLs,” said one surveyor. “Facilities can audit and educate staff on the importance of finding ways to meet those basic resident needs.”
Use these resources to improve processes and train certified nursing assistant (CNA) staff about quality improvement processes.
- Root Cause Analysis Tool — Analyze specific quality issues and identify their main causes.
- Plan-Do-Study-Act (PDSA) Essentials and Worksheet — After you have identified the root cause(s) of quality issues, plan, implement and assess the effects of changes to address the issues.
- QAPI for Certified Nursing Assistants Toolkit — Short, interactive QAPI training program for CNA staff. Includes:
- Making a Difference — Video introduction to QAPI
- Roleplaying and Discussion — Script for acting out common situations and applying QAPI to them
- Quiz — Short quiz about QAPI basics
- In-Service Facilitator's Guide — Guide to conducting training using the QAPI for CNAs Toolkit. Includes quiz answers.
Other Survey Readiness Topics
Getting Focused – Team and Tools
Staffing, Competencies, Vaccine Tracking & Documentation