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QAPI—an Approach Supporting Nursing Home Success in Health Reform

QAPI logoQuality Assurance Performance Improvement (QAPI) is a proactive, data-driven, systems-based approach that prepares nursing homes well to provide care with better outcomes—improved quality of life, care, and services.

The Affordable Care Act outlined the requirement to develop QAPI regulations and technical assistance for the nursing home setting. QAPI’s performance improvement focus builds on the strong foundation of quality assurance practices already used by nursing homes.

How QAPI Drives Improvement

Like Total Quality Management and Six Sigma, which are widely adopted across business sectors, QAPI is a foundational quality management philosophy.

Monitoring and improving quality are major elements of QAPI. Nursing homes should establish benchmarks for performance and monitor how well they are performing against them. They need to objectively collect meaningful data on performance and proactively look for improvement opportunities.

When performance varies from a standard or goal set by the nursing home, staff perform an in-depth analysis and develop a plan for performance improvement.

Robust data helps nursing homes prioritize potential areas for improvement, know when they achieve their aims, and whether outcomes were met.

QAPI aims to shift everyone working in long term care to creating quality proactively. When QAPI is implemented, quality becomes a shared responsibility of all staff at the nursing home, with problem-solving that involves staff across all disciplines and departments, as well as residents and their families.

“Organizational change skills allow nursing homes to make complex changes, which are more likely to be sustained,” said Jane Pederson, Stratis Health director of medical affairs and geriatrician with Allina Senior Care Transitions.

Implementing Systems-based Change for Improving Care

The University of Minnesota and Stratis Health developed a QAPI technical assistance program and tested it with 17 nursing homes across the county from 2011 to 2013, on behalf of the Centers for Medicare & Medicaid Services (CMS). The intensive pilot offered insights about how nursing homes can implement and leverage QAPI to enhance care.

“Administrators and nursing staff are adept at looking at data to improve individual resident care. They have less experience applying quality improvement methods and using data to plan for system-based performance improvement,” said Pederson.

A comprehensive approach like QAPI can seem daunting, especially when implementation competes with numerous other priorities. Through the pilot, nursing homes identified the greatest opportunities of QAPI as:

  • Promoting engagement and commitment of all staff in QAPI
  • Supporting an ongoing culture of QAPI, despite changes in leadership
  • Involving residents and families in QAPI in a meaningful way
  • Using systems thinking in all quality efforts
  • Understanding and using data to inform and drive meaningful action
  • Using root cause analysis effectively
  • Making changes at a system and process level
  • Committing to a QAPI plan that evolves with the needs of the nursing home

Building the Foundation for Success

Understanding the changes needed for QAPI, and building support and skills across staff takes time and thoughtful planning.

Nursing homes that have participated in other quality programs, such as the American Health Care Quality Award Program or the Baldrige Performance Excellence Program, will find the QAPI framework familiar. For other nursing homes, QAPI may not come naturally.

The available educational activities, tools, and resources provide structure and guidance to help build skills. From the CMS QAPI demonstration project, Stratis Health found that tools are not sufficient for embedding a new organization-wide quality improvement philosophy. Training and technical assistance may be needed at a corporate or facility level.

Stratis Health is working with nursing homes to implement QAPI. Many are excited about this shift to a culture of continuous improvement.

Striving to meet best practices will not only improve outcomes for nursing homes, but it will position them well for meaningful collaborations and partnerships across care settings and with the community to impact population health.


Quality Assurance Performance Improvement (QAPI) Tools and Resources

Our QAPI tools and resources for nursing homes are available on the federal QAPI website.