Project Objectives

Project Overview
The structure of the QAPI toolkit and initial staff education will be completed within the eight
weeks of the professional practicum. The NP will then take on the specifications, establishment,
and publishing of the toolkit as it applies to the policy in the clinical setting as those aspects will
take a longer time.
Purpose Statement: The purpose of this project is to provide the Bay Pines VA dialysis unit
with a Quality Assurance and Performance Improvement (QAPI) tool to demonstrate evidence of
the facility’s quality assessment and performance improvement program according to the new
Centers for Medicare and Medicaid (CMS) conditions for coverage 494.110. This tool will be
available to the dialysis staff by March of 2018 and will be implemented in the fourth quarter of
fiscal year FY2018
Target Audience: Include the interdisciplinary care team (chief of nephrology, peritoneal
dialysis nurses, physicians, social worker, dietician, and nephrology NP).
Title: Develop and establish a Quality Assurance and Performance Improvement (QAPI) toolkit
for peritoneal dialysis (PD).
Revise policy to include up-to-date criteria’s.
Project Goal: Upon the completion of NUR 551 Professional Practicum I will be able to review
the overall care provided in a clinical setting and seek ways to improve systems and clinical
processes. 2) Be able to translate QAPI as an ongoing program, not just an isolated meeting,
event, or individual problems as they arise. This will be evident by documentation in google
documents, evaluation, and feedback from my preceptor, my professor, and fellow colleagues.
1) Identify peritoneal dialysis practice gaps by examining the current policy design and
perform revision for effective, efficient, and cost-effective patient outcome.
 QAPI objective 1 meet program objective 4
2) Demonstrate ethical obligations in a manner consistent with high-quality nursing
practice. Clearly represent self with respect to name, title, and role within the boundaries
of the nursing practicum role.
 QAPI objective 2 meet program objective 3
3) Demonstrate leadership abilities through effective communication, collaborating, and
consulting with other members of the interdisciplinary team to deliver the QAPI program
as a facility-wide initiative to include the review of all services provided: in-center,
dialysis treatments, home peritoneal dialysis, and home hemodialysis.
 QAPI objective 3 meet program objective 2
4) Formulate tracking tool for infection and hospitalizations and construct revisions to
facility specifications.
QAPI objective 4 meet program objectives 8 & 10
5) Use the Measure Assessment Tool (MAT) which list the expected outcome based on
community accepted standards and values as a reference and for further research in the
development of the peritoneal dialysis toolkit.
 QAPI objective 5 meet program objectives 5 & 6
6) Explain and discuss the condition for coverage outlined by the Centers for Medicare and
Medicaid (CMS) that mandates each dialysis facility must develop, implement, maintain
and evaluate an effective data-driven quality assessment and performance improvement
program.
 QAPI objective 6 meet program objectives 2, 7 & 8
7) Set up a working strategy for immediate accurate data entry into the crownweb system (a
web-based data collection system released in 2009 by CMS) to provide the most up-to-
date healthcare information on the veteran, therefore, providing better access to analyze,
trend and identify information that can be used to improve patient outcome.
 QAPI objective 7 meet program objectives 1 & 10
8) Design, implement and establish a QAPI toolkit for peritoneal dialysis by utilizing the
most recent MAT as well as measures from the end-stage renal disease (ESRD) quality
improvement program (QIP).
 QAPI objective meet program objective 5
9) Propose a conceptual framework based on nursing theory and research (Orem’s theory of
Self Care) to ensure that the quality of kidney care delivered to veterans meet or exceeds
the accepted national standards of practice by aligning VA dialysis program policies to
meet or exceed community dialysis standards stipulated by CMS.
 QAPI objective 9 meet program objective 6
10) Apply the PDSA cycle as the recommended model for process improvement in dialysis.
Use and integrate knowledge of dialysis and advance nursing practice to recognize each
outcome not meeting expected measure and prepare documentation of the improvement
plan.
 QAPI objective 10 meet program objective 8
11) Schedule and support quarterly participation of patient and or family in QAPI program
through attending the facility QAPI committee meetings or a portion of it. Engage patient
in self- management through connected technology including access to health records in
Myhealthyvet and secure messaging.
 QAPI objective 11 meet program objectives 7 & 10
12) Assemble a personal professional development plan committing to improving knowledge
and skills through lifelong learning.
 QAPI objective 12 meet program objective 9

Completion of the above outlined objectives will demonstrate fulfillment of the Masters
of Science in Nursing (MSN) program objective and will be acknowledged in the journal
postings upon completion.