QAPI programs help to solidify strong processes for identifying and prioritizing problems and opportunities, and sustaining progress on quality objectives long term.  QAPI work plans target  organizational process, functions, and services provided to residents based on the analysis of performance indicator data,  resident and staff input, and other information. Each skilled nursing facility (SNF) is required by regulation to develop a QAPI program. During the annual survey process, surveyors will review your compliance with the QAPI regulations to ensure that:

      • The QAA committee develops and implements appropriate plans of action to correct identified quality deficiencies (F867)
      • The QAA committee consists of the minimum required members (F868)
      • The facility has a QAA committee that meets at least quarterly (F868)
      • The QAA committee puts forth good faith attempts to identify and correct its own quality deficiencies (F865)
      • The facility has a QAPI plan containing the necessary policies and protocols describing how they will identify and correct their quality deficiencies (F865)

5 Elements of QAPI

There are 5 elements that form the foundation of a QAPI program for nursing facilities:

      • Design & Scope
      • Governance & Leadership
      • Feedback, Data Systems, & Monitoring
      • Performance Improvement Projects (PIPs)
      • Systematic Analysis & Systemic Action

Facility leadership should use these elements to develop a QAPI program that is individualized to the facility’s specific characteristics, resident population, specialized services, and unique circumstances. With a QAPI program that is grounded in these five elements, you can  identify and strengthen areas of weakness,  and areas of strength can be made even stronger.

Where do I begin to develop or refresh the QAPI Program in my facility?

1) Understand the five elements of QAPI that should be implemented and review the regulations and Interpretive Guidance on QAPI programs for nursing facilities.

2) Develop a written QAPI plan, policies, and procedures and updated them periodically

3) Designate a QAPI Program leader or Designee and establish a QAPI Committee

4) Establish routine QAPI training. Communicate the goal of your facility’s culture of QAPI. QAPI training is generally recommended for new employees, contractors, and volunteers as relevant to their specific job roles as part of orientation and at least annually thereafter

5) Develop a method of collecting and monitoring data. This should include methods for obtaining feedback from staff and residents on opportunities for improvement that exist

6) Prioritize opportunities for improvement. Your QAPI PIP selection should be based on facility-specific risks that include identified situations, and processes that may cause harm to your organization. Determine priorities by conducting a facility risk assessment and prioritizing identified risks.

7) Develop a process for conducting Performance Improvement Projects that includes development of PIP sub-committees, conducting root-cause analysis to guide development of appropriate corrective actions, and the use of Plan, Do, Study, Act (PDSA) cycles to monitor effectiveness of PIP actions.

8) Periodic Review. A QAPI program is never finished; it should always be a work in progress. Periodic reviews for program effectiveness should be conducted to review strengths and weaknesses of the program.

Looking for resources to take your QAPI program to the next level?

  • Join us on June 1 or 2 for the webinar Driving Excellence through QAPI web training. This session will review the fundamentals of a QAPI program, processes for establishing facility specific priority QAPI goals, and leadership’s role in accountability for QAPI programs.
  • Check out Proactive’s SNF QAPI Program toolkit that contains the policies, tools, and resources you need to jump start your program without reinventing the wheel. The toolkit includes on-demand training on Implementing an Effective QAPI program.
  • Contact us today to develop a program or to request a review of an existing program to fill any gaps.





Blog by Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, CLNC, Proactive Medical Review

Click here to learn more about Shelly and the rest of the Proactive team.