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.

Compliance Probes Checklist for Administrators (F867):

General:

[ ] Does the facility have comprehensive, written policies and procedures for QAPI activities, specifically covering feedback, data collection, monitoring, adverse event monitoring, systematic analysis, systemic action, setting priorities, medical error/adverse event tracking, PIPs, and QAA committee functions?

[ ] (Health Equity – General) Is health equity integrated throughout the QAPI policies, procedures, and documented activities as applicable (feedback, data, prioritization, adverse event analysis)?

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

🗣️ Feedback Systems (§483.75(c)(1)):

[ ] Is there documented evidence of systems to obtain feedback from direct care staff, other staff, residents, and resident representatives?

[ ] How is this feedback used to identify high-risk, high-volume, problem-prone issues or improvement opportunities? (Review meeting minutes, action plans)

[ ] (Health Equity) Is there evidence that feedback related to health equity concerns (e.g., accessibility, communication for LEP, cultural needs) is actively solicited and considered?

[ ] Is there a system to provide feedback to staff, residents, and representatives regarding actions taken or system changes made based on their input?

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

[ ] Does the facility have systems to identify, collect, and use data from all departments?

[ ] Is data from the facility assessment (§483.71) incorporated into QAPI?

[ ] How is collected data used to develop and monitor performance indicators? (Review PIs)

[ ] (Health Equity) Is the facility collecting and monitoring data related to outcomes for specific sub-populations (e.g., by race, ethnicity, language, disability) to identify potential health equity gaps?

[ ] Is the data collection methodology consistent, reproducible, and accurate?

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

[ ] Are performance indicators developed, monitored, and evaluated?

[ ] Is there a defined methodology and frequency for developing, monitoring, and evaluating these indicators? (Review policies, QAA minutes)

[ ] Are results compared over time and to benchmarks (if available)?

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

[ ] Is there a systematic process to identify, report, track, investigate, and analyze adverse events?

[ ] How is data from adverse events used to develop preventive activities? (Review event analyses, action plans)

[ ] (Health Equity) When analyzing adverse events, are factors related to health equity considered as potential contributors?

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

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

[ ] When problems are identified, are actions taken to improve performance?

[ ] How is the success of these actions measured?

[ ] How is performance tracked to ensure improvements are sustained? (Review monitoring data, follow-up reports)

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

[ ] Do policies describe how a systematic approach (e.g., RCA) is used to determine underlying causes of system-level problems? (Review RCA examples)

[ ] Do policies describe how corrective actions are developed to effect system-level change?

[ ] Do policies describe how the facility monitors the effectiveness of PI activities to ensure improvements are sustained?

III. Program Activities (§483.75(e))

⭐ Priority Setting (§483.75(e)(1)):

[ ] How does the facility set priorities for PI activities? (Review QAA minutes, priority lists)

[ ] Do priorities focus on high-risk, high-volume, or problem-prone areas?

[ ] Is consideration given to incidence, prevalence, and severity of problems?

[ ] Do priorities affect health outcomes, resident safety, autonomy, choice, and quality of care?

[ ] (Health Equity) Is there evidence that factors affecting health equity and outcomes for the facility's diverse resident population are considered when setting priorities?

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

[ ] Are medical errors and adverse resident events tracked?

[ ] Are their causes analyzed?

[ ] Are preventive actions implemented?

[ ] Is there evidence of feedback and learning throughout the facility regarding these events and actions? (Review staff training, communication)

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

[ ] Does the facility conduct distinct PIPs?

[ ] Do the number and frequency of PIPs reflect the facility's scope, complexity, and resources (as identified in the facility assessment)?

[ ] Is at least one PIP conducted annually that focuses on a high-risk or problem-prone area identified through data collection and analysis? (Review PIP documentation for the past year)

[ ] Can the facility demonstrate the process for these PIPs (e.g., team, RCA, interventions, monitoring)?

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

📣 Reporting & Action (§483.75(g)(2)):

[ ] Does the QAA committee report to the governing body on its activities and QAPI implementation? (Review governing body minutes)

[ ] Does the QAA committee develop and implement appropriate plans of action to correct identified quality deficiencies? (Review QAA minutes, action plans)

[ ] Does the QAA committee regularly review and analyze data collected under the QAPI program and data from drug regimen reviews?

[ ] Is there evidence that the QAA committee acts on available data to make improvements? (Link data review to specific actions/PIPs)

The April 28, 2025, regulatory update to F867 marks a pivotal moment for long-term care facilities, signaling a clear mandate to embed health equity into the very fabric of Quality Assurance and Performance Improvement activities. As we've explored, this is not merely a compliance exercise but a profound opportunity to enhance the quality of care, improve resident outcomes, and foster a truly inclusive environment for every individual we serve.

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