12 steps to QAPI: Step 7: Collecting and using data

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

Quality Assurance Performance Improvement (QAPI) is driven by teamwork, ongoing education and data. QAPI at a Glance is the Centers for Medicare & Medicaid Services’ (CMS') implementation guidebook. According to QAPI at a Glance, “QAPI is a data-driven, proactive approach to improving the quality of life, care and services in nursing homes. The activities of QAPI involve members at all levels of the organization to: identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor effectiveness or interventions.” When implemented, each of the 12 QAPI action steps moves a nursing home (NH) closer to the self-sustaining approach to improving safety and quality that CMS expects.


The first action step invokes leadership commitment to providing the resources and time to plan, implement, monitor and sustain QAPI. The second and third steps charge NHs with developing a deliberate approach to teamwork and taking their QAPI pulse by conducting a self-assessment. Identifying your organization’s guiding principles and developing a written QAPI plan guided NHs through action steps four and five. The sixth QAPI action step discusses purposeful information dissemination to the two NH audiences that are directly affected by the care delivery systems: the staff and the residents and their families. Communication is the focus of the sixth step. Thoughtful planning for each audience helps the NH to create communications that are appropriate and effective. This is a time investment with high returns for the future. Effective communication is a major part of QAPI and the seventh QAPI Action Step: Develop a Strategy for Collecting and Using QAPI Data.


Each NH’s QAPI strategies are driven by data. Teams decide the data sources and what data to monitor. Many of the electronic medical record (EMR) vendors have designed their products to meet this need. The EMR products designed for NHs collect data to help meet this QAPI action, step but the team must study and connect the data to give it meaning. CMS requires NHs to electronically transmit certain submissions. All NHs are not fully electronic, but all have some electronic systems in place for these submission that can only be completed electronically.

Copious data sources are available and myriad amounts of data. Data without context is meaningless, however. Each NH chooses on its data sources. The main data source for CMS is the Minimum Data Set (MDS). CMS requires an MDS to be completed annually and for specific events and/or changes in resident medical status.

The medical community is shifting to person-centered care, which is resident-specific. It promotes autonomy and helps each resident achieve and sustain the best physical, mental and psychosocial level that is practical for him or her. Instead of a predetermined course of the same routine care for all, the care has to be individualized and designed to meet the identified needs of each individual resident. CMS updated the MDS from 2.0 to 3.0 to capture the resident’s voice. It focuses on the resident’s clinical assessment to screen for conditions and syndromes. The aim of the MDS 3.0 is to increase the accuracy of this assessment by obtaining information directly from the resident. There is a large body of research confirming that even residents with moderate to significant cognitive impairment can accurately and reliably answer simple interview questions about how they feel and what they want.

Respecting the resident is vital for high-quality care and high-quality life. Asking the resident directly about his or her preferences and feelings, is one of the most direct ways to convey respect and practice person-centered care. NH leadership that permits the MDS coordinator to only review the medical record and talk to the nursing staff to respond to the resident questions on the MDS may be missing this essential data component and the true essence of person-centered care. MDS 3.0 is the data source for the NH’s quality measures which are publicly reported on CMS’s Medicare Compare.

Medicare Compare data can be used for benchmarking, which is a standard of comparison that can help with goal setting. Looking at the state and national rates for quality measures allows NHs to compare themselves with other NHs in the state and nation. Consumers to do the same.

Another comparison source that can be used for benchmarking is Advancing Excellence, which is an NH resource endorsed by CMS. Every NH should register on the website and select a minimum of two goals—a process and a clinical goal—for improvement. The NH’s designee then submits its data on this website monthly. Advancing Excellence offers the benefit of being self-reporting without the time lag of Medicare Compare data. NHs can then compare themselves against others that selected the same improvement goals. 


Involving residents and family in the improvement process is a foundational tenet of QAPI. Residents and family bring the care receiver’s perspective on the problems that the team has identified for monitoring based on the data. This involvement helps residents and family maintain the person-centered care focus. To get input from family and residents, NHs can host small group discussion meetings and perhaps arrange to meet with the resident council.


Access to data is not a problem for most NHs, but using it consistently to drive improvements is. Quality improvement organizations (QIOs) provide resources, tools and webinars to assist NHs master this fundamental QAPI requirement. To help learn to use data to drive their improvements, Telligen, the Illinois QIO, has posted several tools, resources and webinar recordings. Each state’s QIO can be located on the Quality Net website. Many, if not all, QIOs will have information to assist NHs with all phases of QAPI implementation, monitoring and sustainment processes, including how to use data to drive their process improvements. 

Teamwork is a recurring theme in QAPI and an integral component of this seventh action step. Deciding what data to track and monitor is a team decision. When deciding what data to routinely monitor, teams should look at areas such as clinical quality measures and process, medications, satisfaction and state survey results, complaints, MDS assessments and care planning processes from creation of the care plan to bedside application, as well as data impacting the business and administrative processes. All identified problems should be addressed and proactively managed by the various NH teams. A proactive way to manage identified problems is to charter a performance improvement project (PIP) team.

PIPs won’t be needed for all problems. When the team decides a problem needs more detailed attention, however, a PIP should be chartered to uncover the root causes and find solutions. A PIP team should be a multidisciplinary team with input from residents and family as appropriate and necessary.  Chartering PIPs is included in the recommended processes for several of the QAPI action steps, including Step 8: Identify Your Gaps and Opportunities, which will be the focus of the next article in this series.

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 6:

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

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

12 steps to QAPI: Step 6: Conduct a QAPI Awareness Campaign

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