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With an increasingly aging population and growing regulatory scrutiny, it has never been more essential for long-term care professionals to understand and implement QAPI (Quality Assurance and Performance Improvement) principles in their facilities. 

What is QAPI? QAPI is a systematic, data-driven approach to improving the quality of care and services provided to residents in long-term care facilities, such as nursing homes and assisted living facilities. It combines Quality Assurance (QA) and Performance Improvement (PI). Quality Assurance (QA) aims for a consistent level of care and services by ensuring that established standards and regulatory requirements are met. Performance Improvement (PI) emphasizes improvement through the identification, analysis, and resolution of performance gaps.

When did QAPI commence? QAPI originated with the Affordable Care Act (ACA) passed in March 2010. This legislation recognized the need for a more comprehensive and proactive approach to quality assurance and performance improvement in long-term care settings. The Centers for Medicare and Medicaid Services (CMS) was provided with the mandate to establish and implement a QAPI program for nursing facilities, focusing on the development of standards and the provision of technical assistance for best practices.

An SNF resident in a facility where the staff have understood QAPI meaning and its implementation.
Section 6102(c) of the ACA mandated the development and implementation of QAPI programs for all skilled nursing facilities.

How does QAPI impact long-term care? Section 6102(c) of the ACA specifically targeted the quality of care in skilled nursing centers. This section of the ACA mandated the development and implementation of QAPI programs for all skilled nursing facilities (SNFs), demonstrating the importance placed on continuous improvement and quality management in long-term care settings.

Then, in September 2011, the CMS took a significant step forward in promoting quality improvement in nursing homes by launching a prototype QAPI program. This pilot initiative involved a limited number of nursing homes and aimed to gather best practices for upgrading quality programs, offering valuable insights for the broader implementation of QAPI in long-term care settings.

What has the CMS learned from QAPI? The prototype QAPI program allowed the CMS to learn from real-world examples and observe how QAPI principles and strategies could be effectively applied in long-term care facilities. The CMS was able to identify common challenges, successful strategies, and practical solutions, which helped the government organization refine its approach and develop more targeted guidance and resources for the broader nursing home community.

The CMS included QAPI requirements in its revised Requirements of Participation (RoP) for nursing centers, which were published in October 2016. By incorporating QAPI into the RoP, the CMS emphasized its commitment to ensuring that SNFs prioritize quality improvement and develop comprehensive, data-driven programs focusing on systems of care, outcomes of care, and residents’ quality of life.

Understanding the QAPI Meaning Through Its Five Elements

The QAPI meaning we articulated above is that it is a data-driven approach to improving outcomes. But there is far more we need to know about how QAPI works from start to finish. To do so, here we will share the five elements of QAPI:

1. Design and scope

QAPI  involves creating a comprehensive plan that outlines a healthcare organization’s commitment to quality, the expected care outcomes, and the goals and objectives to achieve those outcomes. The scope of a QAPI program should be customized according to the size, specialty, and patient or resident’s needs in the healthcare facility. And it must encompass all departments, services, and patient populations. Also, it should be flexible enough to adapt to changes within the organization or industry.

2. Governance and leadership

The governing body and leadership of an organization must be actively involved in developing, implementing, and maintaining the QAPI program. Long-term care leaders are responsible for establishing a culture of quality and safety, allocating necessary resources, and ensuring staff accountability and teamwork for performance improvement efforts. Leaders must also promote open communication and transparency, encouraging staff to report issues, share ideas, and participate in improvement activities.

3. Feedback, data systems, and monitoring

Healthcare staff having a short meeting where they analyze data relevant to QAPI.
Monitoring enables healthcare staff to identify trends, detect potential issues early on, and make data-driven decisions.

Organizations must establish effective feedback and data systems that track performance, identify areas for improvement, and evaluate the success of improvement initiatives. Examples of data sources include the following: 

  • Patient satisfaction surveys
  • Incident reports
  • Clinical outcomes
  • Process measures. 

When conducted over a long period of time, monitoring enables SNF staff to identify trends, detect potential issues early on, and make data-driven decisions that enhance care quality and staff performance.

4. Performance Improvement Projects (PIPs)

These are structured, focused efforts to address specific areas of concern or opportunity identified through data analysis and monitoring. PIPs follow a systematic process that includes identifying the problem, setting SMART goals, designing and implementing interventions, and evaluating the outcomes. 

PIPs should be prioritized based on the potential impact on resident care, the prevalence of the issue the facility is facing, and the available resources. Ideally, long-term care facilities should have multiple PIPs ongoing at any given time that cover a diverse range of quality and safety concerns.

5. Systematic analysis and concerted action

Systemic analysis involves identifying the underlying causes of problems and addressing them in an organized fashion. To do so requires a thorough investigation of healthcare events, processes, and systems to uncover the root causes of issues and prevent their recurrence. 

Systemic action may also mean changes to policies, procedures, training, or the physical environment that long-term residents are exposed to. By addressing these root causes, long-term care providers can achieve long-lasting improvements in quality and safety.

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Best Practices for QAPI Program Implementation

We’ve looked at the origins of the CMS’ QAPI program and why QAPI matters to long-term care facilities. In addition, we have addressed the question, “what are the 5 elements of QAPI?” Here, we will list the best practices to be observed. When implementing QAPI, meaning long-term care facilities must:

A healthcare team meeting to discuss the progress of the QAPI program implemented in their facility.
Leaders should encourage the development of a culture in which staff regularly track improvement efforts.
  • Establish progress indicators: These are quantifiable measures used to track and evaluate the success of a QAPI program. By using progress indicators, long-term care facilities can better identify areas of strength and weakness in their QAPI program. Examples of progress indicators include patient satisfaction scores, hospital readmission rates, and staff turnover rates. 
  • Utilize OASIS review: The Outcome and Assessment Information Set (OASIS) is a standardized tool used to assess the functional status and care needs of residents in long-term care facilities. By regularly reviewing OASIS data, facilities can identify patterns and trends in resident care that may require improvement. 
  • Measure progress and track areas for improvement: Culture is an important part of any healthcare facility; hence leaders should encourage the development of a culture of regular measurement and tracking of improvement efforts. This includes routinely reviewing progress indicators, monitoring the effectiveness of implemented interventions, and adjusting strategies whenever needed. 
  • Involve leaders more: Finally, long-term care leaders should actively participate in the planning, implementing, and evaluating QAPI initiatives. By involving themselves in the QAPI process, they can better ensure that improvement efforts are aligned with the organization’s goals, mission, and vision.
  • Identify and address the root cause: Root Cause Analysis (RCA) is a problem-solving technique that involves a systematic investigation to determine the origin of a problem, and how it is a vital part of QAPI. CMS encourages facilities to conduct a thorough RCA to identify the factors contributing to an issue and develop targeted strategies to address it. By way of RCA, skilled nursing facilities learn to identify and understand the root causes of deviations or non-conformities from expected outcomes. Once they have identified these causes, long-term care facilities can implement targeted corrective actions to prevent similar problems from recurring in the future. 

Why is RCA so valuable? RCA contributes to the overall effectiveness of QAPI programs by promoting a systematic approach to problem-solving and continuous improvement. The tools and techniques that can be used for RCA include:

  • Events and causal factor analysis (timeline creation)
  • Fault tree
  • Process mapping
  • Interviews and observations
  • Five whys
  • Pareto chart
  • Fishbone diagram
  • Failure Mode Effects Analysis (FMEA)

Of course, while it’s a vital aspect of QAPI, it’s not the only activity involved in a comprehensive quality improvement program. By recognizing the broader scope of QAPI and incorporating a variety of proactive and reactive strategies, SNFs can ensure that they continuously improve the quality of care and services provided to their residents.

One particularly effective strategy for improving the standard of care is implementing and utilizing intuitive senior care software with easy-to-read data analytics. To learn more, read here.  

QAPI Challenges and How To Overcome Them 

Successfully implementing a QAPI program in a nursing home is a complex process that involves a number of challenges. One such challenge is that of a lack of precedent; QAPI is still relatively new, which means many nursing homes will not have a clear starting point or established priorities. The absence of a significant precedent can make it difficult to build a QAPI program from scratch, identify the most impactful performance improvement projects, and determine the best course of action for executing plans. 

To overcome the challenge of a lack of precedent, nursing homes can consider partnering with a consultant who has proven expertise in designing and implementing QAPI programs for long-term care facilities. By leveraging the experience and resources of these experts, nursing homes can develop a more effective QAPI program and pave the way for improved quality of care.

Another challenge facilities may face is culture adjustment; QAPI programs require a significant shift in organizational culture. Critical questions about the facility’s processes will be raised, and adopting a new work culture can be challenging, as resistance to change from staff is a common obstacle. 

To overcome this challenge, leaders should be heavily involved and promote open communication and active participation from all nursing and non-nursing staff, encouraging everyone to take ownership of the QAPI program. By fostering a culture of continuous learning and improvement, nursing homes can effectively navigate the challenges of culture adjustment and successfully implement a QAPI program.

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Elijah Oling Wanga