12 steps to QAPI: Step 2: Teamwork

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

Teamwork is a familiar word in professional industries, and healthcare is no exception. Hospitals, nursing homes, outpatient caregivers and home care providers all rely on some form of teamwork for their care delivery system. Quality Assurance Performance Improvement, QAPI, challenges the activities that nursing homes historically have labeled as teamwork.

QAPI at a Glance is a QAPI implementation resource that nursing homes can download from the Centers for Medicare & Medicaid Services (CMS) QAPI website, go.cms.gov/Nhqapi, at no cost. The states' quality improvement organizations (QIO) are local resources nursing homes can access. QIOs are contracted with CMS and will provide onsite assistance and information to nursing homes also at no cost. QAPI at a Glance lists 12 action steps for nursing homes to use while implementing QAPI. Quality improvement facilitators can assist nursing homes implement these steps.

QIO facilitators may emphasize to nursing home leaders the importance of role modeling the behaviors that define successful QAPI but, ultimately, the leaders actually must do the work. Among the CMS-endorsed tools and resources QIOs can recommend to nursing homes is the downloadable National Nursing Home Quality Care Collaborative Change Package. The Change Package presents concepts and strategies from the effective practices and experiences of high-performing nursing homes in five states.

QIOs can help nursing homes reap the benefits of the Change Package as well as QAPI at a Glance by facilitating leadership engagement and higher-functioning teams. Both documents are rich sources of strategies for effective leadership and effective teamwork in nursing homes.

In Step 1 of the 12 QAPI implementation steps, which details leadership responsibilities and accountability, nursing home leaders are tasked with providing resources including equipment and training. QAPI at a Glance states: “Leadership may want to consider sending one or more team members to a specialized training.” Team-building falls in the category of specialized training that nursing home leaders may want to consider.


Teamwork is a core component of QAPI. Leadership is expected to build effective teams among the departments and caregivers. QAPI at a Glance notes that the characteristics of an effective team should include a clear purpose, defined roles for each team member to play and a commitment to active engagement from each member.

Leadership guidance through the team-building process presupposes that nursing home leaders have the necessary skills, training and time, which may not be the case. Therefore, facilitating teamwork may fall in the category of specialized training.


For many nursing homes, staff and leadership's definition of their roles and purposes might not be the same. Many direct-care staff are task-oriented and not patient-centered. Staff get residents up as scheduled, get them to scheduled meals, get them to planned activities, get scheduled showers done and get residents to take medications as scheduled. Establishing a clear purpose and defining roles for each team member is a foundation component of teamwork that all nursing homes should embrace. Do not assume that staff members know their purpose and role or see themselves as working in teams. Defining both the purpose and the role of the team with input from those who actually do the work is a deliberate approach to teamwork. Discussing the purpose with the staff members who will perform the role confirms agreement and teach back confirms understanding.

For task-oriented direct-care staff, recognizing a team structure in their work day can be challenging. Residents are placed in a preset schedule within the nursing home structure, and direct-care staff are responsible for getting a resident from point A to point B. Certified nursing assistants (CNAs) are assigned a hall or group of residents and are responsible maintaining schedules. Nurses are assigned a hall or group of patients to whom they must administer medication within a preset time frame. Most nursing home nurses and CNAs would define their role and purpose as consisting of these tasks. They likely would challenge anything that pulls them away for these tasks. After all, not passing medication on time, getting a resident to a scheduled event or completing an assigned and scheduled care activity are reasons why nurses and CNAs are reprimanded. But how does this align with patient-centered care, resident choice or resident autonomy? This is where the purpose and roles as defined by the direct-care staff and leadership can differ.

Leadership defines the staff members’ roles around the expectations of CMS, whereas staff members define their purposes and roles around the task they must complete. Building resident-centered care into the care structure of a nursing home is a leadership role, but input from the caregivers is critical. Before defining the purpose and role of new teams, assess the current teamwork environment.


Step 2 of the 12 implementation steps outline how QAPI relies on teamwork:

  • Task-oriented teams may be specially formed to examine  a particular problem, and their work may be limited and focused.
  • Performance improvement project (PIP) teams are formed for longer-term work on an issue.
  • When chartering a PIP, give careful consideration to its purpose and type of members needed to achieve that purpose.
  • Family members and residents may be team members, although for confidentiality reasons, they may not review certain data or information that identifies individuals.
  • PIP teams need to plan for sufficient communications—including face-to-face meetings to get to know each other and plan the work. The team also should plan how each team member will review information that emerges from the PIP.
  • Leadership needs to convey that being a PIP team member is an important part of the job—not something to put aside if other things come up. It must also support this idea through action and resources to enable staff members to complete daily assignments, provide clinical care and also participate on QAPI teams.


Creating a culture to sustain the all-staff-included and teamwork component of QAPI may be seen as a challenge for nursing homes struggling with staffing issues. More effective teamwork, however, will improve both care delivery and staff retention. A clear sense of purpose, clearly defined roles and a commitment to active engagement characterize an effective team—these also are reasons for engaged staff to choose to stay and not seek employment elsewhere. Developing a deliberate approach to teamwork positively impacts staff and demonstrates leadership responsibility and accountability. The state’s QIO facilitators can help accomplish this at no cost to the nursing home. A list of state QIOs can be found at www.qualitynet.org under the Quality Improvement tab.

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

Read the other steps:
12 steps to QAPI: Step 1: Leadership

Topics: Articles , Clinical , Executive Leadership , Leadership , Regulatory Compliance