12 steps to QAPI: Step 1: Leadership

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

It’s been said that “Life is 10 percent what happens to you and 90 percent how you react to it.” Many of America’s nursing homes (NHs) react after something happens. Quality Assurance Performance Improvement (QAPI) is designed to help facilities become more proactive and less reactive. QAPI is a comprehensive approach to ensuring high-quality, proactive patient-centered care using evidence-based practices to increase knowledge for planning, implementing and sustaining measurable improvement. After the regulation is promulgated, QAPI will be a Center for Medicare & Medicare Services (CMS) requirement and nursing homes will be required to submit a written QAPI plan. Helping nursing homes become more proactive and implement QAPI is what each state’s Quality Improvement Organization (QIO) is working to accomplish. 

Quality improvement is the mandate of QIOs, offering resources for acquiring the necessary knowledge and skills to build and implement a program. A unique component of QAPI is that it requires all NH staff to be active participants in quality improvement initiatives. Realizing that direct care staff are the hands-on experts on patient care and the best way to provide it, successful QAPI involves all staff in process improvements, from planning through sustainment, and QIOs can help. Each state’s QIO and contact information is listed at www.qualitynet.org in the Quality Improvement tab.


Implementation requires nursing homes to learn new concepts, engage in new practices and build a new culture. QAPI at a Glance: A Step by Step Guide to Implementing Quality Assurance and Performance Improvement (QAPI) in Your Nursing Home, is your QAPI guide. Download a copy from the CMS QAPI website, go.cms.gov/Nhqapi.

QAPI at a Glance offers 12 implementation steps. It’s not necessary to implement each step sequentially, but they all need to be addressed. Step 1—Leadership, Responsibility and Accountability—is, without exception, the first step of any initiative. Leadership commitment is the sure path to success by creating a culture to support QAPI and involve caregivers as well as provide the necessary resources. QAPI at a Glance is an implementation guidebook that suggests ways leadership can take action in the following four parts. The first part of Step 1 is to develop a steering committee, or team, to provide QAPI leadership. The following information in this article is taken from the guide.

1. Develop a steering committee charged with the overall responsibility to develop and modify the plan, review information and set priorities for performance improvement projects, or PIPs. Top leadership such as the administrator and the director of nursing must be part of this steering committee, which charters PIP teams to work on particular problems, review results and determine the next steps. The steering committee must learn and then use system thinking.

It is also important to have a medical director who is engaged in QAPI. Your quality assurance (QA) committee can be adapted to become your “steering committee” to oversee QAPI. For this to work, the QA committee may need to meet more often, include more people and establish permanent and time-limited workgroups that report to it. Nursing homes should already have established committees that have medical director involvement and meet regularly. This is an existing component of the regulation for Quality Assessment and Assurance (QAA).

The QAPI steering committee is tasked with developing and modifying the plan, reviewing information and setting priorities for PIPs. This is a culture shift for many nursing homes. After being informed of the steering committee’s duties, nursing homes recognize this for the culture shift it is but may revert to complacency for task completion. Instead of forming the QAPI steering committee and tasking its members with writing the QAPI plan, it is written by the administrator, director of nursing or someone in the nursing home’s corporate office. Reverting to the usual way of getting things done diverts effective QAPI. At best, this delays the steering committee's progress as an effective team and, at worst, prevents it. The QAPI steering committee working as an effective and engaged team sets the tone for all the other PIP teams the nursing home will charter. Establishing the QAPI steering committee as soon as possible will help the nursing home move into system thinking,

Purposeful system thinking is not usual in most nursing homes. Most nursing homes are nursing department-centric. Essentially, the role of other NH departments is viewed as support for the nursing department. System thinking invites input from both those close to the problem and those with knowledge about the impact of the problem on the individual systems.

All of the nursing home’s systems impact delivery of care to the resident. The admissions department is often the first contact and can be vital to any successful intervention by establishing the practice from the initial contact with the resident and family. The Minimum Data Set, or MDS 3.0, is a main data source for CMS. The person entering the assessment and writing each resident’s care plan is a rich resident information source and a subject matter expert on the nursing home’s quality of documentation. The billing coder has knowledge to help determine the financial impact of possible interventions. The medical director’s involvement brings a physician’s viewpoint to the discussion and can be key to making sure physician orders align with the planned intervention. Inviting input from dietary, housekeeping or environmental services also provides a unique vantage point on resident care improvements opportunities.

2. Administrators must be involved. Administrators must provide resources including equipment and training.

  • Caregivers may need time to attend team meetings during working hours, requiring others to cover their clinical duties for a period of time.
  • Equipment might include anything from additional computers, to low-cost supplies like posters to create storyboards or multiple copies of resource books or CDs.
  • Leadership may want to consider sending one or more team members to a specialized training.

Working through scheduling shortages and staffing interruptions is something NH administrators are skilled at doing. Implementing QAPI will require them to access this skill. Mastering some of the concepts, such as system thinking and strategies, may require specialized training, something that historically has been reserved for administrative leaders. Since QAPI encourages direct care staff participation, however, consider including direct care staff in specialized training. This, too, is a culture shift for nursing homes.

3. Establish a climate of open communication and respect. Leadership may wish to consider having an open-door policy to communicate with staff and caregivers, emphasizing communication across shifts and between departmental heads. Another culture change opportunity includes creating an environment where caregivers feel free to bring quality concerns forward without fear of punishment.

4. Understand your home’s current culture and how it will promote performance improvement.

  • Create an environment where caregivers feel free to bring quality concerns forward without fear of punishment.
  • Create the expectation that everyone in your nursing home is working on improving care and services.
  • Establish an environment where caregivers, residents and families feel free to speak up to identify areas that need improvement.
  • Expect and build effective teamwork among departments and caregivers.


Communication remains the most identified quality care issue and is often one of the contributing factors at the root of most quality problems. Embedding ongoing communication improvement into a nursing home’s culture is an identified leadership responsibility and key to a high-functioning team.

This first step in the QAPI implementation process alerts nursing home administrators that budget and schedule planning should include staff education and training. Training and teamwork are recurring themes at the root of each of the 12 implementations steps. Teamwork is so important that the second QAPI implementation step in QAPI at a Glance is titled “Developing a Deliberate Approach to Teamwork.”

To achieve effective and sustainable QAPI, all NH leaders are encouraged to lead by example. By being proactive, demonstrating the principles of QAPI and putting a personal face on quality issues, NH leadership teams can effectively guide their organizations through the quality cultural shift and be stronger, better care communities.

Nell Griffin, LPN, EdM, is a Healthcare Quality Improvement Facilitator in Illinois, a certified TeamSTEPPS Master trainer and an author. She can be reached at nell.griffin@comcast.net.

Stay tuned for more Steps to QAPI in the coming weeks.

Topics: Articles , Executive Leadership , Facility management , Leadership , Risk Management , Staffing