Spring Branch Transitional Care Center, a 198-bed skilled nursing facility in Houston, was referred to the TMF Quality Innovation Network-Quality Improvement Organization (QIN-QIO) due to COVID-19 infection rates. A new leadership team within the facility recognized how the TMF QIN-QIO could assist them and reinforce Spring Branch’s commitment to quality care.
In August 2024, the new leadership team identified a need for improvement with their Quality Assurance Performance Improvement (QAPI) program to prioritize COVID-19 vaccination rates and lower infection rates, as well as other opportunities that were identified as opportunities for improvement.
“We were our own biggest barrier,” said administrator Ken Hiscox. “Our TMF QIN-QIO specialists never pushed that they could solve all our problems in this process; instead they said, let us help you reinforce your existing efforts so you get credit for what you are likely already doing and maybe don't even realize.”
Spring Branch and the TMF QIN-QIO worked together on a QAPI plan to identify opportunities for improvement, as well as how to execute their solutions.
According to the Centers for Medicare & Medicaid Services (CMS), QAPI is a data-driven and proactive approach to quality improvement. Quality assurance is a process used to ensure services are meeting quality standards and assuring care reaches a certain level. Performance improvement is a proactive approach that continuously studies processes with the goal to prevent or decrease the likelihood of problems in care delivery.
A QAPI plan should reflect input from caregivers and residents at all levels of the facility — it is a “living document” that needs to be continually updated. The five elements of a QAPI plan include:
- Design and scope
- Governance and leadership
- Feedback, data systems and monitoring
- Performance improvement projects
- Systematic analysis and systemic action
Click here for a
Guide for Developing a QAPI Plan
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An on-site visit by the TMF QIN-QIO team allowed for hands-on collaboration with Spring Branch staff. Together they walked the building to observe opportunities for improvement, reviewed their CMS timeline, and translated the data into an actionable QAPI plan.
“The QAPI agenda [download MS Word template] gives our team a tangible tool that allows us to easily see our building’s strengths and weaknesses through data [download Excel template], instead of our subjective perspectives of what we think we are doing well or struggling with,” Hiscox noted. The entire Spring Branch staff is actively involved in the quality improvement efforts.
According to Hiscox, the data helps their team see how quality assurance efforts are having positive impacts in the community, while also providing a safety net to catch issues in need of performance improvement projects.
For example, during a QAPI evaluation, Spring Branch identified residents with inconsistent code statuses and immediately corrected the problem. Within two weeks, the facility was also able to reduce antianxiety medications 5% due to the suggestion of adding them to QAPI monitoring (and not just focus on reduction of antipsychotics), and has reduced the number of resident falls with assistance from their TMF QIN-QIO specialists.
“Laying out goals for each focus area with supporting data really allowed us to see the areas we are succeeding in, and the areas where we might need to ramp up our efforts,” said Hiscox. “Something we discussed with the TMF QIN-QIO specialists during the on-site collaboration was to stop taking action based on opinions of how we are doing, and instead lead our efforts based on data. There were things we were giving ourselves too much credit for doing well, and things we didn’t even realize were an issue until we used these tools and feedback.”
Spring Branch Transitional Care Center is committed to staying the course on its quality improvement efforts. “We are going to continue to show that we are a team that cares deeply about our residents and the care we provide,” Hiscox emphasized.
The TMF QIN-QIO is contracted by CMS to assist nursing homes in COVID-19 and vaccination-related challenges by providing resources, education, reporting and quality improvement assistance free of charge. To find out how the TMF QIN-QIO can help your facility, email NHconnect@tmf.org.