Q AA

The CMS QAPI Guide:

What You Need to Know
P I A Companion to QAPI at a Glance

This companion guide is designed to help Background

your team recognize and understand the In December 2012, the Centers for Medicare
major components of the Quality & Medicaid Services (CMS) issued a memo
Assurance/Performance Improvement announcing the release of QAPI at a Glance ,
Initiative (QAPI). Refer to it often as a
a step -by-step guide detailing 12 key action
support tool in your facility’s quality
steps to establish a foundation for quality
improvement e orts. This resource is not
assurance and performance improvement in
intended to replace QAPI at a Glance ; it can
nursing homes.
be used in conjunction with other materials
to help your team stay on track in reaching QAPI at a Glance is availab le online at
your quality improvement goals. http://tiny.cc/QAPI .

TOPIC PAGE

12 Action Steps to QAPI 2

QA vs. PI: What’s the D nce? 3

QAPI Tools 4

Plan-Do-Study-Act Model for Improvement 5

Root Cause Analysis 6

Frequently Asked Questions 7

QAPI Worksheets, Steps 1-12 8 – 19

Suggestions for Implementing QAPI 20

purposes and is not intended to provide or replace the independent judgment of a

California, under contract with the Centers for Medicare & Medicaid Services (CMS), an
agency of the U.S. Department of Health and Human Services, from material originally
prepared by Ohio KePRO. The contents presented do not necessarily reflect CMS policy.
 Q A 12 Action Steps to QAPI
P I
According to QAPI at a Glance, there are twelve action steps on the pathway to QAPI implementation. These twelve
steps do not need to be achieved sequentially; however, the steps do build on one another. Following them
sequentially can be a great way to begin your strategic approach to implementing QAPI.

STEP 1: Leadership Responsibility &

Accountability

STEP 2: Develop a Deliberate

Approach to Teamwork

STEP 3: Take your QAPI “Pulse” with a

Self-Assessment

STEP 4: Identify Your Organization’s

Guiding Principles

STEP 5: Develop Your QAPI Plan

STEP 6: Conduct a QAPI Awareness

Campaign

STEP 7: Develop a Strategy for

Collecting & Using QAPI Data

STEP 8: Identify Your Gaps and

Opportunities

STEP 9: Prioritize Quality

Opportunities and Charter
Performance Improvement Projects
(PIPs)

STEP 10: Plan, Conduct and

Document PIPs

STEP 11: Get to the “Root” of the

Problem

STEP 12: Take Systemic Action

The CMS QAPI Guide: What You Need to Know Page 2 of 21
 Q A QA vs. PI:
P I What’s the Difference?
What’s New about QAPI?
While nursing homes have long-since been required to have quality assessment and assurance programs, pending
changes to the regulations will require that a formalized approach to performance improvement is also part of a
facility’s ongoing systems.

Quality Assurance (QA)

Quality assurance can be characterized as a focus on current outcomes, with a retrospective (look-back) view of
“what happened.” Often, this is done out of a need to ensure compliance and proper follow-up of identified issues.
While the scope of a quality assurance committee may include such actions as conducting a root cause analysis and
developing action plans, current regulations do not require any specific or formal improvement processes to be
used.

Performance Improvement (PI)

Performance improvement can be thought of as a system that makes things better. Unlike quality assurance, which
focuses on compliance, performance improvement focuses on “systems issues” that cause poor outcomes. While
there are many formalized performance improvement tools, QAPI at a Glance refers to the Plan-Do-Study-Act (PDSA)
model for improvement.
Tip: See page 5 of this document for more information about PDSA cycles.

Putting It Together
When QA initiatives and PI efforts are blended together, the result can be significant improvements to important
outcomes: residents can experience fewer adverse clinical effects, satisfaction rates can improve and staff can
become more engaged as facility processes are stabilized; all of this can lead to improved operational performance
for your organization.

QUALITY ASSURANCE PERFORMANCE IMPROVEMENT

Motivation Measuring compliance with standards Continuously improving processes to meet
standards
Means Inspection Prevention
Attitude Required, reactive Chosen, proactive
Focus Outliers: “bad apples” Processes or systems
Individuals
Scope Medical provider Resident care
Responsibility Few All
QA + PI = QAPI
Source: QAPI at a Glance

The CMS QAPI Guide: What You Need to Know Page 3 of 21

 Q A QAPI Tools
P I
QAPI Self-Assessment Tool (QAPI at a Glance,
page 26)
This five-page, 24-item questionnaire is part of Step 3 of
QAPI at a Glance. The Self-Assessment Tool is found in
Appendix A, and will help your team determine the extent
to which various QAPI practices are already established
in your organization. It is recommended that you
complete this self-assessment tool prior to beginning any
QAPI planning, and re-assess your organization at routine
intervals to show your progress.

Guide to Develop Purpose, Guiding Principles and

Scope for QAPI (QAPI at a Glance, page 31)
This important three-page guide will help you determine the manner in
which your QAPI plan will be supported by your organization; it will
serve as a solid foundation from which to continue building your QAPI
practices. Using this tool can help guide your team through the
creation of a separate document that may be used as the preamble to
your QAPI plan.

Guide to Developing a QAPI Plan (QAPI at a Glance,

page 34)
This action-based, three-page guide will help your team address
the important elements of QAPI, and develop a formal QAPI plan.
With concrete examples and actionable steps in a logical
progression, the guide will walk you step by step through the
creation of your plan.

Goal-Setting Worksheet (QAPI at a Glance, page 37)

This worksheet will help your Performance Improvement Project (PIP)
teams develop SMART performance improvement goals. Effective
goals are specific, measurable, attainable, relevant and time-bound.

The CMS QAPI Guide: What You Need to Know Page 4 of 21

 Q A PDSA Model for Improvement
P I
The success of QAPI and the Performance Improvement Project (PIP) teams at your facility will depend on everyone’s
knowledge of the Plan-Do-Study-Act (PDSA) model for improvement. While there are several different improvement
methodologies, PDSA is a simple model that is easy to follow.

To begin, make observations in the system that has been targeted for improvement. Targeted areas could be
anything – staff performance, actual processes or service delivery, documentation, staffing, organizational culture,
or any other aspect of care or services where the outcomes are not meeting facility expectations or standards.

As a PIP team, answer these questions:

1. What are we trying to accomplish?
2. How will we know that a change is an improvement?
3. What changes can we make that will result in improvement?

From there, follow these easy steps, and remember to document your team’s process and decision-making.

•ACT on the basis of •PLAN to improve

your findings. performance.
Continue with the •What area(s) are not
change, make further as strong as you
changes, or stop? would like? What can
• you do about it?
ACT PLAN
- What changes are - Objective
to be made? - Predictions
- Next cycle? - Plan to carry out
the cycle (who, what,
where, when)

STUDY DO
- Analyze data -Carry out the plan
- Compare results - Document
to predictions observations
- Summarize what - Record data
was learned

•STUDY the results. •DO carry out your

•Step back and look plan.
at the big picture. •Document what you
Has there been see when the plan is
improvement? carried out.

The CMS QAPI Guide: What You Need to Know Page 5 of 21

 Q A Root Cause Analysis
P I
What is Root Cause Analysis?
Just as you would pull a weed out of your garden by its root (to ensure that it doesn’t grow back), getting to the
“root” cause of a systems issue is important to prevent the problem from returning. There are many formalized
root cause analysis tools; this handout includes a sample of tools that are easy to use.
Cause and Effect (Fishbone) Diagram
▪ The Cause-and-Effect (Fishbone) diagram starts with the problem at the head of the fish.
▪ Under each general category of
the Fishbone, answer the
question, “Why?” for the
identified problem.
▪ Once the Fishbone diagram is
completed, discuss the various
causes to determine the root of
the problem - or the real reasons
why the problem exists. It is from
this discussion that the focus for
the improvement plan begins.

Five Whys
The Five Whys tool aids in the identification of the root cause of a problem. Begin by identifying a specific problem,
and ask why this is occurring. Continue to ask “Why?” to identify causes until the underlying cause is determined.
Each “Why?” should build from the previous answer. There is nothing magical about the number five; sometimes a
root cause may be reached after asking “Why?” just a few times; at other times, deeper questioning is needed.
STEPS:
The problem: __________________________________________________________________.
▪ Define a problem; be
Why does this occur?
specific.
▪ Ask why this problem 1. Why is that?
occurs, and list the
reasons in Box 1.
2.
▪ Select one of the Why is that?

reasons from Box 1

3. Why is that?
and ask, “Why does
this occur?” List the
reasons in Box 2. 4.
Why is that?
▪ Continue this process
of questioning until
5.
you have uncovered
the root cause of the
identified problem. If
there are no identifiable answers or solutions, address a different reason.
The CMS QAPI Guide: What You Need to Know Page 6 of 21
 Q A Frequently Asked Questions
P I
Q: Aren’t we already meeting the requirements of QAPI?
A: Nursing homes are currently required to have a Quality Assessment and Assurance (QAA)
program through the regulatory requirement of F-520.1 While this federal regulation does
require certain elements of quality improvement (for example, having a committee structure,
holding regular meetings, identifying root causes, developing action plans, engaging in
continuous improvement, etc.), the use of a formal improvement model and ongoing
accountability is not specified. According to information on the CMS website:
“This provision provides a rule but not the details as to the means and
methods taken to implement the QAA regulations. CMS is now reinforcing
the critical importance of how nursing facilities establish and maintain
accountability for QAPI processes in order to sustain quality of care and
quality of life for nursing home residents.”2
Thus, with QAPI, nursing homes are being asked to incorporate a standardized process for
ongoing performance improvement, and to develop a written plan to ensure accountability and
sustainability for their improvement efforts.

Q: When will the QAPI regulations be issued?

A: According to the Section 6102 of the Affordable Care Act (ACA), nursing homes will have one
year from the date on which the regulations are promulgated to submit their plan to meet
these standards and details as to how the quality assessment and assurance activities will be
coordinated with the plan.3

Q: Will surveyors have access to our QAPI documentation?

A: Until the regulations are promulgated, this remains unclear.

1 Centers for Medicare & Medicaid Services (CMS), State Operations Manual Appendix PP. Available at: http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
2 CMS, Nursing Home Quality Assurance & Program Improvement. Available at: http://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/SurveyCertificationGenInfo/Downloads/nhqapibackground.pdf
3 CMS, http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/qapisection6102ac.pdf

The CMS QAPI Guide: What You Need to Know Page 7 of 21

 Q A QAPI Step 1: Leadership
P I Responsibility & Accountability
The facility leadership (i.e. medical director, administrator, director of nursing and other key managers) is
responsible for “setting the tone” to help staff identify how to meet the organization’s mission, vision, guiding
principles, standards, and expectations. Without strong leadership, change efforts often fail or are not sustainable.

Action Steps
1. Develop a steering committee, which is a team that will provide QAPI leadership.
2. Provide resources for QAPI, including equipment and training.
3. Establish a climate of open communication and respect.
4. Understand your home’s current culture and how it will promote performance improvement.

Probing Questions for Team Discussion

1. Who is on our QAPI Steering Committee?
2. Is our Medical Director involved in QAPI?
3. How can we provide needed resources for QAPI?
4. Is our climate open, respecting and “just” (fair)? What does our climate look like?
5. How can QAPI blend with our existing QA efforts?

Surpassing the Hurdles

1. What barriers do you anticipate with these action steps?
2. What additional information does your team need?
3. What additional resources would be helpful?
4. What structures can you create to help ensure your success with this step?

CHECKLIST
Who is Date
Action Step
Responsible? Completed

Develop a steering committee.

Provide resources for QAPI, including equipment and training.

Establish a climate of open communication and respect.

Articulate your home’s current culture, and how it will promote performance
improvement.

The CMS QAPI Guide: What You Need to Know Page 8 of 21

 Q A QAPI Step 2: Develop a Deliberate
P I Approach to Teamwork
QAPI at a Glance states that QAPI relies on teamwork in several ways. Do teams at your organization have a clear
purpose? Do teams have defined roles for each team member to play? Do teams have commitment and active
engagement from each member?

Action Steps
1. Assess the “effectiveness” of teamwork in your organization.
2. Discuss how Performance Improvement Project (PIP) teams will work to address QAPI goals.
3. Determine how direct care staff and residents and families can be involved in PIPs.
4. Identify any communication structures that need to be implemented or enhanced.

Probing Questions for Team Discussion

1. How can residents and families be involved in our QAPI efforts?
2. Do we have effective teamwork? How do we know? What does it look like?
3. How does leadership support the development of effective teams?
4. Do we have effective communication in our facility? How do we know?
5. Do team members support one another?

Surpassing the Hurdles

1. What barriers do you anticipate with these action steps?
2. What additional information does your team need?
3. What additional resources would be helpful?
4. What structures can you create to help ensure your success with this step?

CHECKLIST
Action Step Who is Date
responsible? completed

Assess the “effectiveness” of teamwork in your organization.

Discuss how Performance Improvement Project (PIP) teams will work to

address QAPI goals.

Determine how direct care staff, residents and families can be involved in
PIPs.

Identify any communication structures that need to be implemented or

enhanced.

The CMS QAPI Guide: What You Need to Know Page 9 of 21

 Q A QAPI Step 3: Take Your QAPI
P I “Pulse” with a Self-Assessment
Assessing your facility’s current practice is a necessary part of implementing QAPI. Since facilities are already
required to have quality assessment and assurance committees, take the time now to find out to what degree you
have already mastered the concepts of QAPI.

Action Steps
1. Determine a date and time for completing the Self-Assessment Tool.
2. Assemble the right people to complete the Self-Assessment Tool
3. Complete the QAPI Self-Assessment Tool, recording your answers for future comparison.
4. Determine a date for the next Self-Assessment Tool review.

Probing Questions for Team Discussion

1. Who should be involved in this assessment of our current practices?
2. What is our timeline for completing it?

Surpassing the Hurdles

1. What barriers do you anticipate with these action steps?
2. What additional information does your team need?
3. What additional resources would be helpful?
4. What structures can you create to help ensure your success with this step?

CHECKLIST
Who is
Action Step Date completed
responsible?

Determine a date and time for completing the Self-Assessment Tool.

Assemble the right people to complete the Self-Assessment Tool.

Complete the QAPI Self-Assessment Tool, recording your answers for future
comparison.

Determine a date for the next Self-Assessment Tool review.

The CMS QAPI Guide: What You Need to Know Page 10 of 21

 Q A QAPI Step 4: Identify Your
P I Organization’s Guiding Principles
Is the care provided by your facility tied to your organization’s fundamental purpose or philosophy? How do you
determine programmatic priorities? Taking time to articulate the purpose, the guiding principles and the scope of
QAPI will help you integrate these efforts into your organization.

Action Steps
1. Locate or develop your organization’s vision statement.
2. Locate or develop your organization’s mission statement.
3. Develop a purpose statement for QAPI.
4. Establish guiding principles
5. Define the scope of QAPI in your organization.
6. Assemble the document.

Probing Questions for Team Discussion

1. What beliefs do we have about our facility’s purpose and philosophy?
2. What beliefs do we have about our approach to QA and PI?
3. What is our mission and vision statement?
4. What are some of the ways in which we expect care to be provided?

Surpassing the Hurdles

1. What barriers do you anticipate with these action steps?
2. What additional information does your team need?
3. What additional resources would be helpful?
4. What structures can you create to help ensure your success with this step?

CHECKLIST
Who is
Action Step Date completed
responsible?

Locate or develop your organization’s vision statement.

Locate or develop your organization’s mission statement.

Develop a purpose statement for QAPI.

Establish guiding principles.

Define the scope of QAPI in your organization.

Assemble the document.

The CMS QAPI Guide: What You Need to Know Page 11 of 21

 Q A QAPI Step 5:
P I Develop Your QAPI Plan
A QAPI plan should be a living, breathing document that you revisit periodically to ensure that it evolves as
your facility grows in its capacity to effectively implement QAPI. This is the main document that will support
your QAPI implementation.

Action Steps
1. Determine date(s) and time(s) for writing the QAPI plan.
2. Print copies of the Guide for Developing a QAPI plan (QAPI at a Glance, page 34) for all team
members.
3. Work toward writing the QAPI plan until it is complete.
4. Determine a future date for reviewing the QAPI plan.

Probing Questions for Team Discussion

1. What goals do we have for how QAPI will work?
2. How will QAPI be integrated into leadership’s accountability?
3. How will we strive to use data and performance improvement teams?
4. How will direct-care staff be involved in QAPI and PIPs?

Surpassing the Hurdles

1. What barriers do you anticipate with these action steps?
2. What additional information does your team need?
3. What additional resources would be helpful?
4. What structures can you create to help ensure your success with this step?

CHECKLIST
Who is
Action Step Date completed
responsible?

Determine date(s) and time(s) for writing the QAPI plan.

Print copies of the Guide for Developing a QAPI plan for all team members.

Work toward writing the QAPI plan until it is complete.

Determine a future date for reviewing the QAPI plan.

The CMS QAPI Guide: What You Need to Know Page 12 of 21

 Q A QAPI Step 6: Conduct a
P I QAPI Awareness Campaign
Taking time to create a deliberate communication plan about QAPI will help ensure that everyone in your
organization is familiar with the plan, the goals and their roles and expectations in the process.

Action Steps
1. Inform everyone (staff, residents, families, consultants, ancillary service providers, etc.) about
QAPI and your organization’s QAPI plan.
2. Provide training and education on QAPI for all caregivers.
3. Develop a strategy for communicating with all caregivers.
4. Develop a strategy for communicating with residents and families.

Probing Questions for Team Discussion

1. How will we inform staff about QAPI?
2. How much education and training will be needed?
3. How will we engage residents and families in QAPI efforts?

Surpassing the Hurdles

1. What barriers do you anticipate with these action steps?
2. What additional information does your team need?
3. What additional resources would be helpful?
4. What structures can you create to help ensure your success with this step?

CHECKLIST
Who is
Action Step Date completed
responsible?

Inform everyone (staff, residents, families, consultants, ancillary service

providers, etc.) about QAPI and your organization’s QAPI plan.

Provide training and education on QAPI for all caregivers.

Develop a strategy for communicating with all caregivers.

Develop a strategy for communicating with residents and families.

The CMS QAPI Guide: What You Need to Know Page 13 of 21

 Q A QAPI Step 7: Develop a Strategy
P I for Collecting & Using Data
Effective use of data will ensure help ensure that decisions are made based on fact, and not on an assumption of
the truth. Just as a physician needs “data” about a patient in order to diagnose a condition, QAPI teams and
Performance Improvement Project (PIP) teams will need data to ensure they are targeting the right areas.

Action Steps
1. Determine what data to monitor routinely.
2. Set targets for performance in the areas you are monitoring.
3. Identify benchmarks for performance.
4. Develop a data collection plan, including who will collect which data, who will review it, the
frequency of collection and reporting, etc.

Probing Questions for Team Discussion

1. What data does our facility routinely monitor? How are these data displayed and used?
2. What benchmarks will we use when assessing our performance?
3. How can we better make use of the data we have? Do we track and trend our progress over
time?
4. How are data shared with others in the organization? Staff? Residents/families? The
Board or corporate office?

Surpassing the Hurdles

1. What barriers do you anticipate with these action steps?
2. What additional information does your team need?
3. What additional resources would be helpful?
4. What structures can you create to help ensure your success with this step?

CHECKLIST
Who is
Action Step Date completed
responsible?

Determine what data to monitor routinely.

Set targets for performance in the areas you are monitoring.

Identify benchmarks for performance.

Develop a data collection plan, including who will collect which data, who
will review it, the frequency of collection and reporting, etc.

The CMS QAPI Guide: What You Need to Know Page 14 of 21

 Q A QAPI Step 8: Identify Your
P I Gaps and Opportunities
Whether you are reviewing data from the Minimum Data Set (MDS) or quality measure reports, data from
satisfaction surveys or consultant reports, or any other data source, be sure you are identifying any trends in the
data you review. Use this time to observe for any areas where processes are breaking down.

Action Steps
1. Review information to determine if gaps or patterns exist in your systems of care, or if
opportunities exist to make improvements.
2. Discuss any emerging themes with residents and caregivers.
3. Notice what things your organization is doing well in this identified area.
4. Set priorities for improvement.

Probing Questions for Team Discussion

1. When reviewing your data, what stands out?
2. How strong is your organizational capacity for assessing facility systems (i.e., policies, protocols,
actual care delivery, etc.)?
3. What are some areas of strength and weakness?
4. What opportunities do you see?

Surpassing the Hurdles

1. What barriers do you anticipate with these action steps?
2. What additional information does your team need?
3. What additional resources would be helpful?
4. What structures can you create to help ensure your success with this step?

CHECKLIST
Who is
Action Step Date completed
responsible?

Review information to determine if gaps or patterns exist in your systems of

care, or if opportunities exist to make improvements.

Discuss any emerging themes with residents and caregivers.

Notice what things your organization is doing well in this identified area.

Set priorities for improvement.

The CMS QAPI Guide: What You Need to Know Page 15 of 21

 Q A QAPI Step 9: Prioritize
P I Opportunities & Charter PIPs
Be sure you are choosing areas that you consider important (for example, areas of high risk, frequent occurrence, or
areas that are known problems). Remember that not all identified problems require Performance Improvement
Projects (PIPs), but for those that do, the projects need to be structured, or “chartered.”

Action Steps
1. Prioritize opportunities for more intensive improvement work.
2. Consider which problems will become the focus of a PIP.
3. Charter PIP teams, by selecting a leader and defining the mission.
4. The PIP team should develop a timeline and indicate budget needs.
5. The PIP team should use the Goal Setting Worksheet to establish appropriate goals.

Probing Questions for Team Discussion

1. How will organizational priorities be determined?
2. Who will be responsible for monitoring the overall progress of our PIPs?
3. What education is needed for PIP teams?

Surpassing the Hurdles

1. What barriers do you anticipate with these action steps?
2. What additional information does your team need?
3. What additional resources would be helpful?
4. What structures can you create to help ensure your success with this step?

CHECKLIST
Who is
Action Step Date completed
responsible?

Prioritize opportunities for more intensive improvement work.

Consider which problems will become the focus of a PIP.

Charter PIP teams, by selecting a leader and defining the mission.

The PIP team should develop a timeline and indicate budget needs.

The PIP team should use the Goal Setting Worksheet to establish
appropriate goals.

The CMS QAPI Guide: What You Need to Know Page 16 of 21

 Q A QAPI Step 10: Plan, Conduct
P I and Document PIPs
For those areas that require Performance Improvement Projects (PIPs), PIP teams should use a methodic or
standardized process for making improvements. PDSA is one well-known model, but there are others that may also
work for your organization. The important point is to use a strategic methodology, and not a haphazard, “throw it at
the wall and see if it sticks” approach.

Action Steps
1. Determine what information is needed for the PIP.
2. Determine a timeline and communicate it to the Steering Committee.
3. Identify and request any needed supplies or equipment.
4. Select or create measurement tools.
5. Prepare and present results.
6. Use a problem-solving model (e.g., PDSA).
7. Report results to the Steering Committee

Probing Questions for Team Discussion

1. According to our data, what area(s) do we need to work on?
2. Who should be involved? What is the timeline?
3. What resources are needed?
4. What ideas can we test?

Surpassing the Hurdles

1. What barriers do you anticipate with these action steps?
2. What additional information does your team need?
3. What additional resources would be helpful?
4. What structures can you create to help ensure your success with this step?

CHECKLIST
Who is
Action Step Date completed
responsible?

Determine what information is needed for the PIP.

Determine a timeline and communicate it to the Steering Committee.

Identify and request any needed supplies or equipment.

Select or create measurement tools.

Prepare and present results.

Use a problem-solving model (e.g., PDSA).

Report results to the Steering Committee.

The CMS QAPI Guide: What You Need to Know Page 17 of 21

 Q A QAPI Step 11: Get to the
P I “Root” of the Problem
Prevent recurring problems by ensuring that all possible root causes have been identified and addressed.
Remember to use systematic tools, such as the Cause & Effect Diagram, or the “Five Whys” to dig down below the
surface.

Action Steps
1. Using a methodical approach, determine all potential root cause(s) underlying the performance
issue(s).
2. Determine which factors are controllable.
3. Ensure that the PSDA cycles address the root cause(s).

Probing Questions for Team Discussion

1. What are the obvious and less obvious reason(s) the problem surfaced?
2. What is at the root of those factors?
3. What systems and processes are involved (not people)?

Surpassing the Hurdles

1. What barriers do you anticipate with these action steps?
2. What additional information does your team need?
3. What additional resources would be helpful?
4. What structures can you create to help ensure your success with this step?

CHECKLIST
Who is
Action Step Date completed
responsible?

Using a methodical approach, determine all potential root cause(s)

underlying the performance issue(s).

Determine which factors are controllable.

Ensure that that the PSDA cycles address the root cause(s).

The CMS QAPI Guide: What You Need to Know Page 18 of 21

 Q A QAPI Step 12:
P I Take Systemic Action
Just as pulling a weed at the ground level will not prevent it from growing back, “weak” interventions such as staff
education, new policies, or reminders often do not prevent the recurrence of the original problem. Whenever
possible, use strong interventions, such as simplifying a process or making physical or environmental changes, in
order to “hardwire” the change into the existing system.

Action Steps
1. Implement changes or corrective actions that will result in improvement or reduce the chance of
the event recurring.
2. Target the root cause(s) with strong interventions.
3. Pilot test large-scale changes (through PDSA cycles) prior to launching the changes facility-wide.

Probing Questions for Team Discussion

1. How strong are the interventions?
2. Do the selected interventions address systems issues, or do they address individual
performance?
3. Is what we’re doing working? How do we know?
4. What are our next steps?

Surpassing the Hurdles

1. What barriers do you anticipate with these action steps?
2. What additional information does your team need?
3. What additional resources would be helpful?
4. What structures can you create to help ensure your success with this step?

CHECKLIST
Who is
Action Step Date completed
responsible?

Implement changes or corrective actions that will result in improvement or

reduce the chance of the event recurring.

Target the root cause(s) with strong interventions

Pilot test large-scale changes (through PDSA cycles) prior to launching the
changes facility-wide.

The CMS QAPI Guide: What You Need to Know Page 19 of 21

 Q A Suggestions for
P I Implementing QAPI Steps
The following strategies were excerpted from the National Nursing Home Quality Care Change Package.

STEP 1: Leadership Responsibility and Accountability

▪ Institute an “open-door” policy for all levels of leadership to establish presence and consistent availability for
staff.
▪ Provide training and gain staff, resident and family member commitment for your QAPI initiatives.
▪ Routinely spend time in all neighborhoods and during all shifts.
▪ Talk directly to staff and residents. Establish a practice to ask how they are doing, what they need in order to do
their best work and provide excellent care, and how you can help reduce frustrations that prevent them from
doing their best work.
▪ Commit to following through on issues brought to you—keep that commitment
▪ Set the example and pitch in.
▪ Recognize and honor staff and resident opinions. Demonstrate your sincere appreciation.
▪ Credit others for their contributions that positively affect your performance.
▪ Ensure necessary equipment is readily available and in good working order.
▪ Involve all staff in changes and improvement to increase the feeling of ownership and accountability.
▪ Build leadership skills through training, support and coaching to help staff be effective.
▪ Openly admit your unintentional errors so people are less afraid to admit theirs.
▪ As a leader, uphold high expectations of the organizations. If you see an issue, take action and set the tone for
high expectations.

STEP 2: Develop a Deliberate Approach to Teamwork

▪ Set the expectation for leaders and staff to look for and share ideas for ways to grow and innovate.
▪ Build trust with and between your staff (do what you say you are going to do) Celebrate successes—it’s the little
things that matter.
▪ Establish the use of learning circles and huddles to foster relationships and create an opportunity for all to be
heard.
▪ Remove boundaries between departments (hold neighborhood meetings that all disciplines attend, use
interdisciplinary teams for problem-solving, etc.)
▪ Use templates or methods for consistency and to support shared expectations of process (agendas, minutes
and a place to share information with the team.
▪ Encourage and reward staff for supporting each other.
▪ Expect that the medical director/providers listen to nurses, aides and other staff, and actively seek their
suggestions, assessments and recommendations.
▪ Encourage the medical director and physicians to keep track of opportunities for improvements, and bring those
to leadership (and the QAPI Steering Committee).

STEP 3: Take your QAPI “Pulse” with a Self-Assessment

STEP 4: Identify Your Organization’s Guiding Principles
▪ Use an inclusive process to establish, review, and reaffirm your mission. Involve staff, residents and families.
▪ Ensure values are considered core to the facility and those who live and work there.
▪ Translate the mission into action.
The CMS QAPI Guide: What You Need to Know Page 20 of 21
STEP 5: Develop Your QAPI Plan
STEP 6: Conduct a QAPI Awareness Campaign
▪ Share the mission, vision and guiding principles with all staff.
▪ Include the mission, vision and guiding principles in orientation for new staff.
▪ Develop communication plans that use multiple approaches (email, verbal, newsletters, etc.) throughout the
facility and across all shifts.
▪ Hold neighborhood meetings.
▪ Openly and transparently share your performance data with staff, board, residents and families.
▪ Set up a scoreboard for staff that monitors progress toward important goals. Example: days at zero pressure
ulcers. Post progress in common areas such as halls, staff room, etc.

STEP 7: Develop a Strategy for Collecting & Using QAPI Data

STEP 8: Identify Your Gaps and Opportunities
▪ Measure important indicators of care that are relevant and meaningful to the residents that you serve.
▪ Guide and empower staff to solve problems. For example: Leaders should respond to problems that are raised—
not by proposing a solution but instead by asking the team to investigate and determine what they believe would
work best.
▪ Hold short stand-up meetings with managers and staff for each shift to identify concerns, resources, needs, etc.
▪ Establish the nursing home as a learning organization in which all staff identifies areas for improvements.
▪ Discuss processes and systems to identify areas for improvement regularly—in meetings as well as everyday
interactions.
▪ Empower residents to get involved in identifying areas of improvement.

STEP 9: Prioritize Quality Opportunities and Charter Performance Improvement Projects (PIPs)
▪ Get everyone involved in setting goals: residents, staff, family members, and Board members.
▪ If practices are not making sense or are frustrating to staff, residents or family, do not settle for “this is just the
way it has to be”-challenge and sort out what you have control over, and look for ways to address improvements.

STEP 10: Plan, Conduct and Document PIPs

▪ Identify and support a change agent for each improvement project—i.e., a cheerleader and/or key facilitator of
change in your facility.
▪ Use an action plan template that defines who and when, to establish timelines and accountability.
▪ Seek creative ideas from multiple sources within and outside the organization in order to foster innovation.
▪ Create a safe environment to test changes, to try new ways to meet resident needs.
▪ Include “all voices” that have a stake in what is being discussed. Use methods that encourage open and honest
communication, especially to get at concerns.

STEP 11: Get to the “Root” of the Problem

▪ Use the root cause analysis (RCA) process to look at systems rather than individuals when something breaks
down.

STEP 12: Take Systemic Action

▪ Before initiating a change in the organization, meet with any staff and residents that will be impacted by the
change in order to gain their support, buy-in and feedback.

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