12 steps to QAPI: Step 5: Develop your QAPI plan

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

As people, we plan for everything we do in life. A plan is a project or a scheme. It’s the extent of an idea in writing, in the spoken word or in thought. Even when a person declares that he or she will do nothing all day, that’s a plan.

In humans, planning begins with the most basic accomplishments from infancy. As soon as a child realizes something as simple as how to make his or her parent’s smile, on a subconscious level that child begins planning the next occasion to experience that pleasing outcome. When a toddler begins to pull up on furniture, the environment is prepared for the unplanned falls and tumbles the toddler will experience. Parents plan for toddlers to fall while navigating the wonders of ambulation. This analogy spotlights the fifth step of the 12 Quality Assurance Performance Improvement (QAPI) implementation steps—Develop Your QAPI Plan.

Healthcare is founded and dependent on the completion of prerequisites, which requires planning to be integrated into every healthcare component. Physicians examine before prescribing treatment. Nurses assess before administering care. Physical and occupational therapists evaluate before determining a therapeutic course of action.

The same is true for nursing homes (NHs). The prerequisite for writing the QAPI plan is to develop a vision, mission, purpose, guiding principles and scope of QAPI. Articulating these prerequisites provide the foundation to help NHs integrate these components into the staff’s behaviors and into the written QAPI plan, which guides the quality efforts and supports QAPI implementation.


One of the fundamentals of QAPI is to gather staff, resident and family input on all aspects of care and care processes from planning through sustainment. NHs that revert to complacency and have leadership write the plan without this input are delaying the embedding of this concept. NH leadership tends to focus on meeting the requirements of the regulation, while staff, family and residents focus on the practicalities of day-to-day tasks. Their input increases compliance by bridging the chasm between the idea and the reality. With all-inclusive input, the written plan is more likely to be known, accepted and practiced by all, meeting the requirements of the QAPI regulation.

Writing the QAPI plan is a function of the QAPI Steering Committee. As stated in Step 1, this Steering Committee must learn to use system thinking. Representatives from direct care staff, residents and family, should actively work with leadership on this steering committee.

The implementation guide, QAPI at a Glance, states: “The written QAPI plan guides the nursing home’s quality efforts and serves as the main document to support implementation of QAPI.  The plan describes guiding principles that will be used in QAPI as well as the scope QAPI will have based on the unique characteristics and services of the nursing home.”

NH organizations and corporations may have a QAPI plan for the collective. To meet the essences of QAPI, however, each NH must have a plan that works for its unique services and residents.  In the appendix of QAPI at a Glance the Centers for Medicare & Medicaid Services (CMS) has included a “Guide for Developing a QAPI Plan.”

Like all the CMS-provided tools, this downloadable guide is intended to lead NHs through their performance improvement efforts and the writing of their QAPI plan


There are nine sections in the “Guide for Developing a QAPI Plan.” This tool builds on the prequel, the “Guide to Develop Purpose, Guiding Principles and Scope for QAPI.” The written plan details how the NH will achieve the purpose, guiding principles and scope identified in that prequel tool. Here’s is an overview of the nine sections to refer to when developing your plan:

  • Section I. Set QAPI goals for your organization. A Goal Setting Worksheet is included in the tools located in the appendix of QAPI at a Glance to help NHs specific, measurable, actionable, relevant and time-bound goals.
  • Section II. Scope describes how QAPI will be integrated into all of the NH’s care and services. This section describes an NH’s plan for data-driven person-centered care while infusing QAPI in clinical care, quality of life and resident choice. Element 1 of the 5 Elements  of QAPI is at the foundation of this section of the written plan.
  • Section III. Guidelines for Governance and Leadership relates to the first of the 12 QAPI implementation steps (Leadership Responsibility and Accountability) and the second of the five QAPI elements. This part of the written plan details how leadership will provide resources, education and the time for staff to participate in QAPI and how all staff, services, departments, as well as residents and family will participate in the planning, implementing and sustaining of QAPI. The NH’s plan for team building and communicating between meetings and within the organizational structure is also detailed in this part of the plan.
  • Section IV. Feedback data systems and monitoring is the third the five QAPI elements and the portion of the plan that outlines the overall system for monitoring the care and services provided. Here is where the sources of data are identified, the process for collecting and analyzing data, the process for sharing data with performance improvement project teams and the frequency of information dissemination.
  • Section V. This section of the written plan, provides guidelines foraligning performance improvement projects (PIPs) with the fourth QAPI elements. This section that details the overall plan for chartering PIPs.
  • Section VI. Systematic analysis and systemic action addresses the fifth QAP element, where nursing homes document their plan to become proficient at root cause analysis, proactivity and sustaining improvements.
  • Section VII. Communications is the part of the written plan that outlines the audience, frequency and format for sharing information.
  • Section VIII. The evaluation portion of the written plan describes the process for assessing QAPI on an ongoing basis. NHs can state the frequency of the reviewing and updating of the QAPI Self-Assessment tool to document how QAPI will evaluated.
  • Section IX. The final section in establishing a plan determines the dating, scheduling and documentation of how revisions will be tracked and updated in the written plan.

All NHs will be required to write and submit a QAPI plan to Medicare. Quality Improvement organizations (QIOs) are providing NHs with tools and resources as well as webinars to assist them with this part of QAPI. Telligen, the Medicare-contracted QIO for Illinois, has presented several QAPI webinars. Every state has a QIO that is ready and willing to assist nursing homes. A list of state QIOs is  available. In addition to being a requirement, the written plan can be an instrument for to assist in “Conducting a QAPI Awareness Campaign”—the sixth QAPI step.

Read Steps 1 through 4

12 steps to QAPI: Step 1: Leadership

12 steps to QAPI: Step 2: Teamwork

12 steps of QAPI: Step 3: Self-assessment

12 steps to QAPI: Step 4: Guiding principles


Topics: Articles , Executive Leadership , Leadership , Regulatory Compliance