Nursing homes are required to develop, implement, and maintain an effective, comprehensive, and data-driven Quality Assurance & Performance Improvement (QAPI) program to improve the quality of life and quality of care delivered to residents.  Establishing an effective QAPI program is more than meeting the regulatory mandate to develop a written QAPI plan.  All members of an organization are to be involved in continuously identifying opportunities for improvement The QAPI plan should be a living document that the organization will continue to review and revise. The written QAPI plan should be made available to a state agency, federal surveyor, or CMS upon request.

The QAPI plan includes the policies and procedures that describe how the facility will:

      • Identify and use data to monitor its performance
      • Establish goals and thresholds for performance measurement
      • Utilize resident and staff input
      • Identify and prioritize problems and opportunities for improvement
      • Systematically analyze underlying causes of systemic problems and adverse events
      • Develop corrective action or performance improvement activities

Crucial steps to putting the QAPI plan into action include:

Step 1: Identify the Indicators for Improvement

      • Utilize reports that provide measurable data that can be used to set quantifiable goals for improvement including the CASPER Quality Measure report, SNF QRP report, Five Star Preview reports
      • Identify benchmarking opportunities to provide industry comparative data
      • Identify any current internal facility reports that are being used to track data (wound reports, weights)
      • Review resident grievances to identify issues that may be concerning to the residents/family (i.e. call bell response time, dietary and/or laundry/housekeeping issues)
      • Utilize resident and staff satisfaction surveys to identify and trend areas for improvement.

Step 2: Prioritize Indicators for Improvement

      • How does the identified indicator impact patient care?
      • Which indicators are most concerning to the patient care and/or safety?
      • Which indicators will help to improve quality of care with measurable outcomes?
      • What changes can be made that will facilitate improvement?
      • Are the performance improvement areas identified consistent with the organizational goal related to quality of care?

Step 3: Charter Performance Improvement Projects (PIPs)

      • Select indicators for improvement from the prioritized list for PIPs
      • Identify any obstacles to improvement for the indicator
      • Consider the following factors when selecting an indicator for a PIP:
        • What is the significance of the problem?
        • How does it impact quality patient care?
        • Is it a high risk, high volume or problem prone process?
      • Correlate the PIP with the missions and values of the facility
      • Utilize root cause analysis to validate that the interventions developed as part of the PIP are aimed at the issue identified in order to facilitate improvement

Step 4: Selecting a Performance Team

      • Including the right people on the team is critical for successful improvement efforts
      • Representatives from all stakeholders involved in the process identified for improvement should be included in the team
      • Each team should have a senior team member who takes responsibility for the PIP and serves as the team leader
      • Be sure to include staff from all appropriate departments and direct care staff as indicated
      • The size and composition of the team varies depending on the problem identified for improvement
      • Consider which disciplines are involved in and/or have the ability to impact the process identified for improvement
      • Develop a consistent process for PIP teams to provide written and verbal updates to the QAPI committee

Step 5: Promoting Sustained Improvement

      • Update relevant policies and procedures to support the change
      • Clearly define roles and responsibilities
      • Communicate change(s) and its purpose to all those needing to carry out any new actions
      • Identify and correct barriers that may prevent sustainable change
      • Integrate the new change(s) into employee orientation and training
      • Ensure that there is adequate funding to support the change

Through these steps, your facility can develop a strong QAPI plan that is implemented effectively for sustained improvement.   Make plans to join us August 17, 2022 for a session focused on QAPI program success as part of the Dynamic DON webinar series. Learn more at Dynamic DON – Proactive Medical Review or discover Proactive’s QAPI toolkit.



Christine Twombly, RN-BC, RAC-MT, RAC-MTA, HCRM, CHC
Clinical Consultant

Learn more about the rest of the Proactive team.