F867 QAPI/QAA Improvement Activities

The April 2025 update to F867 is a clear call to weave health equity into the very fabric of your QAPI process. This means facilities now must actively think about and tackle how things like race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, where someone lives, or their preferred language can affect their access to care and their health outcomes. Get ready to collect feedback, crunch data, set priorities, and look at adverse events all through a health equity lens!

Key Requirements for F867 Compliance:

I. Program Feedback, Data Systems & Monitoring (§483.75(c))

📝 Written Policies & Procedures: Must exist for feedback, data collection, and monitoring (including adverse events).

🗣️ Feedback Systems (§483.75(c)(1)):

➡️ Maintain effective systems to obtain and use feedback from direct care staff, other staff, residents, and resident representatives.

➡️ Use this feedback to identify high-risk, high-volume, problem-prone issues, and improvement opportunities.

➡️ Health Equity: Specifically consider feedback related to concerns about health equity (e.g., needs of individuals with disabilities, limited English proficiency, different cultural/ethnic preferences).

➡️ Provide feedback to staff, residents, and representatives about actions taken.

📊 Data Collection Systems (§483.75(c)(2)):

➡️ Maintain effective systems to identify, collect, and use data from all departments (including the facility assessment §483.71).

➡️ Use this data to develop and monitor performance indicators.

➡️ Health Equity: Collect and monitor data related to outcomes of sub-populations to address health equity issues (e.g., by race, sexual orientation, socioeconomic status, preferred language).

🎯 Performance Indicators (§483.75(c)(3)):

➡️ Develop, monitor, and evaluate performance indicators.

➡️ Define methodology and frequency for these activities.

⚠️Adverse Event Monitoring (§483.75(c)(4)):

➡️ Systematically identify, report, track, investigate, analyze, and use data from adverse events.

➡️ Use this data to develop activities to prevent future adverse events.

➡️ Health Equity: Data analysis of adverse events should include an evaluation of factors known to affect health equity.

II. Program Systematic Analysis & Systemic Action (§483.75(d))

🚀 Performance Improvement Actions (§483.75(d)(1)):

➡️Take actions aimed at performance improvement.

➡️Measure success and track performance to ensure improvements are realized and sustained.

⚙️ Policies for Systematic Approach (§483.75(d)(2)):

➡️Use a systematic approach (e.g., RCA) to determine underlying causes of problems impacting larger systems.

➡️Develop corrective actions designed for systemic change to prevent quality of care, quality of life, or safety problems.

➡️Monitor the effectiveness of PI activities to ensure improvements are sustained.

III. Program Activities (§483.75(e))

⭐ Priority Setting (§483.75(e)(1)):

➡️Set priorities for PI activities focusing on high-risk, high-volume, or problem-prone areas.

➡️Consider incidence, prevalence, and severity of problems.

➡️Focus on affecting health outcomes, resident safety, autonomy, choice, and quality of care.

➡️Health Equity: Consider factors that affect health equity and outcomes for the facility's resident population.

🩹 Medical Errors & Adverse Events (§483.75(e)(2)):

➡️Track medical errors and adverse resident events.

➡️Analyze their causes.

➡️Implement preventive actions.

➡️Include feedback and learning throughout the facility.

🏗️Performance Improvement Projects (PIPs) (§483.75(e)(3)):

➡️Conduct distinct PIPs reflecting the facility's scope, complexity, and resources (from facility assessment §483.71).

➡️Conduct at least one PIP annually focusing on high-risk or problem-prone areas identified through data collection and analysis.

IV. Quality Assessment and Assurance (QAA) Committee (§483.75(g)(2))

📣 Reporting & Action (§483.75(g)(2)):

➡️ QAA committee reports to the governing body on QAPI implementation.

➡️ Develops and implements appropriate plans of action to correct identified quality deficiencies.

➡️ Regularly reviews and analyzes data (QAPI program data, drug regimen review data) and acts on it to make improvements.

To get this information, along with compliance probe checklists, in a downloadable .pdf file, check out our store at theadministratorsdilemma.com/nursing-home-administration-store.

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