QA/QI ?

QA is quality assurance. QI is quality improvement. Most facilities I know now use CQI- continuous quality improvement. You need a system to determine what problems you have in the building, a way to try to fix them, a way to audit outcomes, and a meeting to discuss it all.

Once a month, we have a QA/QI meeting. Some facilities have them every 3rd Q. Each department has a section to fill out on areas that need improvment based on findings of the previous month, quarter, etc. Nursing looks at falls, pressure ulcers, unintended weight loss or gains, grievances, infection control, average census, staffing issues, inservices, restraints, indicators >7, etc. Falls, infections, pu's can be tracked monthly with a blank building blueprint with highlighted areas of concern. Time of day the incident occured, shift it occured on, what location, room, lobby, bathroom, etc. Skin tears can also be tracked and trended, this is very important information to know where the trends fall. Then you can look at the bigger picture. Social services, dietary, maint., housekeeping all play a part in this also building wide. So you can see how QA/QI can improve resident care and correct issues before they get tagged. Then it is very important to place a plan of action in place.

Quality indicators are generated from CMS from the MDS's transmitted during certain time periods-one month, three months and six months. These numbers usually will not match your facility numbers, because MDS's are a little in arrears from the day to day monitoring of falls, UTI"s etc. Right now CMS is compiling 3.0 data to capture the numbers for the 21 quality indicators that have been chosen. They will probably be available again in January of next year, maybe sooner. The MDS coordinator will report on these in the QA mtg, which will give some idea as to where your facility needs to focus the QI process. Hope this helps a bit

ST