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QAPI Realized: Governance and Leadership (Part 2 of 5)

    Part 2 in our 5-part QAPI guide, “Governance and Leadership”, discusses the importance of a QAPI management team. This team of dedicated leaders shall oversee the QAPI program as planned in its design and scope. Clear work objectives should be set first, emphasizing patient safety and quality care while prioritizing patient rights and choices. This leadership team should promote a QAPI-centered culture across all departments and staff by ensuring that policies and procedures maximize QAPI efforts and opportunities.

    This list of common responsibilities of a QAPI team will help you pick the right people :

    Systematic approach  – Build a committee of leaders with knowledge in systems thinking to steer your QAPI initiative. Ideally, choose people from your current staff– they can be department heads, your Director of Nursing, or anyone that can supervise and add value to the program. It’s also a plus to put people with good motivational skills.

    Access to data sources – For big picture analysis and identifying problem areas, the team should make sure that information is available for basis and reference. Office managers and department heads play a vital role here . Keep in mind that you may need to reevaluate  your office management practices and archiving & data systems as needs arise.

    High-risk problems vs. Areas of improvement –  It is important that the QAPI team can differentiate between the two: high-risk problems often incur adverse results and therefore need immediate action and solution, while areas of improvement can be addressed by other heads and staff concerned. Seeking and utilizing reports and feedback mechanisms provided by subcontractors and business associates will be useful for monitoring all areas of operations to identify problems and improvement opportunities.

    Effective problem solving  –   Developing effective policies and solutions that appropriately address identified problem areas is the most important QAPI task . Solutions should be written out in detail, specifying 1) step by step actions to be taken, 2) expected outcomes and 3) key persons and defined roles. Indicate a timeline for a more guided approach. The QAPI team should then execute and supervise the implementation proactively and modify as loopholes are discovered. Do regular post evaluation and monitor effectiveness through quantitative reports.

    For everything else to run smoothly, the QAPI team should promote an atmosphere where everyone feels motivated to improve processes, despite work pressures and with shared common organizational goals in mind.


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