12 steps to QAPI: Step 4: Guiding principles

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

“Where there is no vision, the people perish: but he that keeps the law, happy is he.” This Bible quote is applicable to any organizational structure.

An organization’s mission, vision, purpose and guiding principles are its foundation. The vision moves the mission forward. The purpose is the reason for the organization’s existence. The principles are the code of conduct that drives the actions of those in and affiliated with the organization. Keeping the law makes those involved happy when they understand the mission, vision and principles, because they have the power of knowledge, which means understanding their roles. Understanding your role means feeling connected. Feeling connected fosters a person’s belief that this is where he or she belongs, which empowers the person. Empowered staff are happy and tend to remain with that employer.

The same is true of nursing homes (NHs). They have missions, visions, purposes and guiding principles. Most employees know their organization has a mission, vision, purpose and guiding principles, but most employees don’t know what they are. In an NH, direct care staff define their roles by the tasks they are required to complete for that shift. NH leadership will be aware that it has a mission, vision, purpose and guiding principles but may not incorporate them into their daily professional lives or into the functions of the staff they manage. Often these are items on paper but not reflected or lived in the professional lives of the NH employees.

Incorporating the mission, vision, purpose and guiding principles into the daily professional behaviors of all nursing home employees is what Quality Assurance Performance Improvement (QAPI) will do. Each nursing home needs to identify its mission, vision, purpose and guiding principles for QAPI. This is the fourth QAPI implementation step: Identify your organization’s guiding principles.

The national goal for each NH is to improve care for individuals, improve health for populations and reduce costs. Each of the nation’s NHs can accomplish this by implementing QAPI. The Centers for Medicare & Medicaid Services (CMS) has provided tools and resources to help nursing homes accomplish this in QAPI at a Glance, A Step by Step Guide to Implementing Quality Assurance and Performance Improvement (QAPI) in Your Nursing Home. A copy of QAPI at a Glance can be downloaded from the CMS QAPI website.

Quality improvement facilitators at each state’s quality improvement organization (QIO) have been urging NH leaders to implement QAPI now. According to the QAPI website, CMS launched the QAPI prototype program in a small number of nursing homes in September 2011. This launch combined with feedback from providers, consumers and stakeholders was used to establish these QAPI tools and resources. QAPI at a Glance is a resource to help NHs embed QAPI principles into their daily care and services.

“A Guide to Develop Purpose, Guiding Principles and Scope for QAPI” is one of the downloadable tools located in the guide’s appendix. NHs are encouraged to use this CMS-endorsed tool to establish the purpose, guiding principles and scope for QAPI in their care communities. Like the QAPI plan, this is a written document. The guide provides step-by-step instructions for articulating the purpose, guiding principles and scope for their organizations.


The tool for QAPI Step 4 is divided into six steps and includes examples. The first step is to locate or develop the vision statement. The vision statement is a written picture of your organization’s future intended to inspire and connect all staff. Since most employees don’t know their NH’s vision, this intent of the vision statement is often not realized. QAPI recognizes this gap and bridges it with a foundation that involves all staff from planning to implementation.

For many NHs, developing the vision statement embodies a culture shift. The vision statement represents the strategic plan for the future of person-centered care focusing on the individual needs and preferences of both staff and residents. The trend is shifting from the staff’s schedule to meeting the resident’s individualized needs and including the staff’s input in the verbal picture of what the NH will look like in the future. An example of a vision statement is included in this tool. Rather than just leadership creating the vision statement, QAPI encourages each NH to use an all-inclusive process when creating the vision, mission and principles statements.


The second step is to locate or develop your organization’s mission statement. The mission statement describes the NH’s purpose. It is the framework for formulating strategies. It defines the overall goal and outlines how decisions are made. Like the vision statement, the mission statement reflects the NH’s path to meeting each individual’s care needs. The example of the mission statement demonstrates how the mission statement builds on the vision. Input from the staff as well as leadership is key to developing a mission statement that truly reflects person-centered care and provides a written picture of the NH’s reason for doing what it does every day.


Describing how the vision and mission will support QAPI is the third step. Develop a purpose statement, which is a written declaration of what an NH intends to accomplish through QAPI. This statement is the connecting path to the vision and mission statement. It speaks to how the vision and mission will be accomplished.

CMS also provides an example of a purpose statement in this guide tool.  As with the mission and vision statement, staff input is vital to the viability and usefulness of an NH’s purpose statement.


The fourth step of the stairway leading to the development of the purpose, guiding principles and scope for QAPI is to establish guiding principles. The NH’s principles are the moral rules or beliefs that influence the staff’s actions by helping them know what is right and what is wrong. These principles explain why and how an NH does what it does by detailing its QAPI philosophy. This step also includes examples of several guiding principles.

As with all the other steps for developing this portion of the QAPI process, an NH’s guiding principles need to have staff input. This is the foundation of the NH’s culture and directs the actions of every person working in it. Staff input is critical to the strength of this foundation and compliance with the expected behaviors and actions.


Steps five and six are to define the scope of QAPI in your organization and then assemble the document. The scope speaks to the types of care and services provided and the impact on the NH’s clinical care, quality of life, resident choices and care transitions. In these final two steps, the NH describes how QAPI will be used for the ongoing assessing, monitoring and improving of performance for the identified care and services. After completing steps one through five and receiving input from staff, residents and family, the documents are assembled in preparation for writing the QAPI plan.


In addition to QAPI at a Glance, QIO facilitators are available to support nursing homes throughout the QAPI process. Each state has a QIO that can be located on Quality Net.

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 Steps 1 through 3

12 steps to QAPI: Step 1: Leadership

12 steps to QAPI: Step 2: Teamwork

12 steps of QAPI: Step 3: Self-assessment

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