In the previous post we started talking about the Quality Improvement Programs in nursing homes and hospitals. We will continue it here with a discussion of the program hospitals should have in place.

Hospitals also have regulations that nursing home and hospital surveyors look at to see if the hospital is in compliance. They are a bit different than the nursing home regulations. The hospital regulations are located at CFR 482.21 and state:

The hospital must develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS.
§482.21(a)(1) – The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes and identify and reduce medical errors.
§482.21(a)(2) – The hospital must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service and operations.
§482.21(b) The hospital must ensure that the program data requirements are met.
§482.21(b)(1) – The program must incorporate quality indicator data including patient care data, and other relevant data, for example, information submitted to, or received from, the hospital’s Quality Improvement Organization.
§482.21(b)(2) – The hospital must use the data collected to–
(i) Monitor the effectiveness and safety of services and quality of care; and
§482.21(b)(2)(ii) – Identify opportunities for improvement and changes that will lead to improvement.
§482.21(b)(3) – The frequency and detail of data collection must be specified by the hospital’s governing body.
§482.21(c) The hospital must ensure that the program activities requirements are met.
§482.21(c)(1) – The hospital must set priorities for its performance improvement activities that-
(i) Focus on high-risk, high-volume, or problem-prone areas;
(ii) Consider the incidence, prevalence, and severity of problems in those areas; and
(iii) Affect health outcomes, patient safety, and quality of care.
§482.21(c)(2) – Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.
§482.21(c)(3) – The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained.
As part of its quality assessment and performance improvement program, the hospital must conduct performance improvement projects.
§482.21(d)(1) – The number and scope of distinct improvement projects conducted annually must be proportional to the scope and complexity of the hospital’s services and operations.
§482.21(d)(2) – A hospital may, as one of its projects, develop and implement an information technology system explicitly designed to improve patient safety and quality of care. This project, in its initial stage of development, does not need to demonstrate measurable improvement in indicators related to health outcomes.
§482.21(d)(3) – The hospital must document what quality improvement projects are being conducted, the reasons for conducting these projects, and measurable progress achieved on these projects.
§482.21(d)(4) – A hospital is not required to participate in a QIO cooperative project, but its own projects are required to be of comparable effort.
§482.21(e) The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following:
§482.21(e)(1) – That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained.
§482.21(e)(2) – That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated.
§482.21(e)(3) – That clear expectations for safety are established.
§482.21(e)(4) – That adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and reducing risk to patients.
§482.21(e)(5) – That the determination of the number of distinct improvement projects is conducted annually.

As you can see, these are much longer than the regulations for a nursing home. They pretty much mean the same thing, though. It is just spelled out a bit more prescriptively; actually, much more prescriptively. The nursing home and hospital surveyor will review the hospital’s quality program for each of these aspects, and again, as in a nursing home, the hospital is to be actively looking for problems and correcting them. There is no frequency in the hospital regulations for how often they meet, but they will need to meet frequently enough to be able to handle everything that is reqiured of them. They will need to gather and analyze data in order to determine where their areas of problems are and how they can improve those areas. The hospital must also be conducting quality improvement programs on a constant basis.

Both nursing homes and hospitals should have a system in place to allow visitors and patients/resident, as well as all staff, to bring issues and problems to the attention of the quality assurance/quality improvement program in the facility.

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Nursing Home and Hospitals are responsible for ensuring their systems are correct and are working. This involves quality improvement activities. Nursing homes and hospitals have federal and state regulations that address quality assessment and assurance.  The nursing home and hospital surveyors will use these regulations and the guidance at the regulations to determine if a nursing home or hospital is indeed in compliance with the regulations.

In nursing homes these regulations are located at CFR 483.75(o), which is F-tag 520.

The nursing home regulation states:
(1) A facility must maintain a quality assessment and assurance committee consisting of –
(i) The director of nursing services;
(ii) A physician designated by the facility; and
(iii) At least 3 other members of the facility’s staff.
(2) The quality assessment and assurance committee –
(i) Meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and
(ii) Develops and implements appropriate plans of action to correct identified quality deficiencies.
(3) State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section.
(4) Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

What this says, in a nutshell, is that the facility is responsible for finding out what its problem areas are and then is responsible for fixing them.

When a surveyor goes into a nursing home they will be looking to see that the nursing home has a quality assessment and assurance committee that includes the director of nursing, a physician, and at least three other staff. The physician on the committee does not have to be the Medical Director of the facility. The other staff, in a really good facility, will include staff who have the authority to change systems that need changing. This would include the administrator or the assistant administrator. It would also include the medical director, since part of his/her responsibilities includes guiding the facility in developing, implementing, and coordinating resident care & medical care. Other staff who should be involved in a good Quality Assessment and Assurance committee includes “front line” staff who do actual care for the residents. A nurse’s aide or two can provide valuable insight to help the committee determine where its weaknesses are. Therapy representatives, dietary staff, activity personnel, maintenance, housekeeping, and laundry staff would all be a part of an effective quality committee.

The nursing home and hospital surveyor will also look to see that the committee meets at least 4 times a year. In reality a good committee would me more frequently than that, usually once a month, but the requirement is only 4 times a year.

The committee needs to identify the problems in the facility and develop and implement policies and procedures to correct these problems. The committee also needs to monitor the things they implement to ensure they do correct the problem and that they continue to keep the problem corrected.

The committee looks at the entire facility, not just nursing areas, it looks at all levels of the facility staff, meaning the lowest person to the highest manager. It especially looks at all the issues that affect residents, meaning all issues, since all issues affect residents in one way or another. It looks at contracted services as well as services provided in house. The reason a good quality assessment and assurance committee looks at all these areas is to continually evaluate facility systems with in order to keep systems functioning satisfactorily and consistently. The committee is charged with preventing problems with care processes in the facility, and for correcting care processes that are not correct.

The QAA committee should be keeping minutes and documents to show the problems it identifies and the fixes it put into place to correct the problems, as well as documentation on the ongoing monitoring and surveillance that is performed throughout the facility. It is this ongoing monitoring and surveillance that will help the committee determine where the problems are and if the fixes are working. The committee’s minutes should include a thorough analysis of the problem(s) as well as action plans designed to correct the problem.

When a nursing home and hospital surveyor goes into the nursing home, he/she may not review the minutes of the committee, unless the committee chooses to provide them. It is usually suggested even if the facility provides them, that the surveyors not look at them. It is better for the surveyors to fid the problems through good methods of investigation than to rely on what the facility found. Not reviewing the facility minutes will help the survey agency if the facility decides to “fight” the deficiencies. They can’t say that the surveyors found the problems by looking at the facility’s own quality improvement activities.

What the nursing home and hospital surveyor does need to do, though, is look at the process the committee has in place and the types of documents they use to collect data.  When a facility has repeated, systemic problems, the quality regulation at F 520 is also usually in non compliance too. This is basically because a well functioning quality assessment and assurance committee should have found the problem and corrected it before the state survey agency did.

We will discuss Hospitals in the next post.


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