12 steps of QAPI: Step 3: Self-assessment

[Editor’s note: This article is the third in a series describing the 12 steps to implement Quality Assurance Performance Improvement (QAPI) in long-term care organizations.]

Instead of taking a wrecking ball to current nursing home practices, Quality Assurance Performance Improvement (QAPI) strengthens the practices that are working. Building a strong foundation for quality improvement from the ground up begins with strong leadership. Nursing home administrators and department heads may think they positively know what is or isn’t working well at their nursing home and in their departments. But a nursing home’s foundation can crumble under the weight of false positives. Completing an assessment before implementing a treatment is a best practice that has proven to better target planning resulting in desired and sustainable outcomes. The third of the 12 QAPI implementation steps is to take your QAPI "pulse" with a self-assessment.

The QAPI self-assessment is one of the tools designed to assist nursing homes with QAPI. It’s located in the appendix of the QAPI implementation guidebook, QAPI at a Glance, and can be downloaded from the Centers for Medicare & Medicaid Services (CMS) website, go.cms.gov/Nhqapi. Completing the QAPI self-assessment should be at the beginning of every nursing home's implementation process and should be reviewed periodically.

When planning a journey, it’s helpful to know where you currently are. The journey for all nursing homes is QAPI. The QAPI self-assessment tool helps nursing homes determine where they currently are with QAPI. With this tool, nursing homes can determine what QAPI components are present and intended to be used for ongoing evaluation of the journey’s progress.

State quality improvement organizations (QIOs) are helping nursing homes recognize the value of this assessment tool. Like any process or assessment tool, the QAPI self-assessment only has value when its purpose and function are understood and the tool is used. Status assessment is an evidence-based best practice. No competent healthcare provider would treat a patient without first assessing the patient’s status. A fact of life is that it’s always wise to assess the situation before acting.

QAPI at a Glance states: “To get you started we’ve developed a self-assessment tool to take your QAPI ‘pulse.’ ” It will assist you in evaluating the extent to which components of QAPI are in place within your organization and identifying areas requiring further development. It will help you determine how you really know whether QAPI is taking hold.”


The QAPI self-assessment tool is comprised of 24 statements that are the essence of QAPI. After discussing each statement, the steering committee should select the most appropriate rating: Not started, Just starting, On our way, Almost there or Doing great. There are directions on how to use the tool before beginning work on QAPI. Use it annually or semi-annually to evaluate progress. The directions also state this tool is intended to be an honest reflection of your nursing home’s progress and to direct the steering committee to areas of improvement opportunity.

Each statement has a space for the steering committee to note why the current rating was selected. For some nursing homes, it takes more than one meeting before the steering committee can define its purpose and develop its functionality. In nursing homes without a QAPI steering committee or the steering committee is in the initial state of team formation, then it’s advisable for the administrator to complete the initial QAPI self-assessment. However, if the administrator completes the initial self-assessment, this should be the only occurrence. A plan should be created for the steering committee to assume self-assessing responsibility by the next scheduled review.

The steering committee should become a deliberate team with a clear purpose, defined roles and a commitment to active engagement from each member.


The administrator should provide the training and education as needed for the QAPI steering committee to become an effective team and the QIO can help. Completing the initial QAPI self-assessment and providing training and education, aligns with the first of the 12 QAPI implementation steps: leadership responsibility and accountability.

Every one of the 24 self-assessment statements reflect at least one of the five elements CMS identified as the building blocks of QAPI and align with one or more of the 12 steps that build on QAPI principles. The five elements:

  • Element 1: Design and Scope
  • Element 2: Governance and Leadership
  • Element 3: Feedback, Data Systems and Monitoring
  • Element 4: Performance Improvement Projects (PIPs)
  • Element 5: Systematic Analysis and Systemic Action

Although it is not necessary to implement the steps in the order given, it is necessary to implement all of the 12 steps, which are:

  1. Leadership, Responsibility and Accountability
  2. Develop a Deliberate Approach to Teamwork
  3. Take your QAPI “Pulse” with a Self-Assessment
  4. Identify You Organization’s Guiding Principles
  5. Develop Your QAPI Plan
  6. Conduct a QAPI Awareness Campaign
  7. Develop a Strategy for Collecting & Using QAPI Data
  8. Identify Your Gaps and Opportunities
  9. Prioritize Quality Opportunities and Charter Performance Improvement Projects (PIPs)
  10. Plan, Conduct and Document PIPs
  11. Get to the “Root” of the Problem
  12. Take Systemic Action

For example, the 11th of the 24 self-assessment statements is: Leadership can clearly describe, to someone unfamiliar with the organization, our approach to QAPI and give accurate and up-to-date examples of how the facility is using QAPI to improve quality and safety of resident care. For example, the administrator can clearly describe the current performance improvement initiatives, or projects, and how the work is guided by caregivers involved in the topic as well as input from residents and families.

This statement reflects components of all five of the elements and aligns with several of the steps, including Step 1. The selected rating would depend on the context and applied interpretation of the statement. Because each statement is subjective, QIO facilitators are encouraging nursing homes to write notes detailing the reason for the selected rating at that time. There is a note section for each statement on the QAPI Self-Assessment.

Completing the QAPI self-assessment is a way to evaluate current processes and identify the components that are already in place. This is also a tool nursing homes can use to evaluate their ongoing QAPI progress and sustainment. Nursing homes can contact their state’s QIO for assistance or questions about completing the QAPI Self-Assessment. To locate your state’s QIO, go to www.qualitynet.org and click on the Quality Improvement tab. Every nursing home should complete the self-assessment and let its state QIO know this step in the QAPI process is finished.

QAPI is about strengthening the processes that are working and correcting the processes that aren’t by using data and evidence- based strategies. But more than just correcting and strengthening, QAPI requires nursing homes to sustain the improvements. Sustaining the improvements requires ongoing monitoring, evaluating and assessing. The function of the QAPI self-assessment tool is for nursing home to use to monitor, evaluate and assess their ongoing QAPI progress.

Nell Griffin, LPN, EdM, is a Healthcare Quality Improvement Facilitator, a certified TeamSTEPPS Master Trainer and author. She can be reached at nell.griffin@compcast.net.

Read about the other steps:

12 steps to QAPI: Step 1: Leadership

12 steps to QAPI: Step 2: Teamwork

Topics: Articles , Executive Leadership , Leadership , Regulatory Compliance