12 steps to QAPI: Step 8: Identify your gaps and opportunities

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

When Congress passed the Affordable Care Act (ACA) in March 2010, the Centers for Medicare & Medicaid Services (CMS)  was tasked with the responsibility of establishing and implementing a Quality Assurance Performance Improvement (QAPI) program for nursing homes (NHs), including development of standards through regulation. Although the final regulation remains pending, CMS has provided NHs with tools and resources for implementing and sustaining QAPI. In addition to quality improvement organizations (QIOs), NHs can access various resources to assist with their quality improvement efforts and QAPI implementation.

The tool kits, advice and best practices that can be found on these websites enable NHs to build on the previous QAPI implementation steps to remedy and gaps that remain. It’s also an opportunity for NHs to submit data, compare their data with those of other facilities and become aware of industry trends.


The eighth step in QAPI implementation urges NHs to identify gaps in their programs and take advantage of the resources and opportunities available. There is no shortage of data sources. Each NH must choose its data sources and use this information to uncover process gaps or patterns in care systems that are or could be quality concerns and problems. Seeking and identifying improvement opportunities is a best practice for meeting QAPI. All process improvement opportunities, monitoring of improvements and sustainment activities are driven by data. Therefore, each NH has to review its data consistently and needs a process for doing so. Certain areas require constant data review and monitoring, such as falls, physical restraints, pressure ulcers and antipsychotic use. Directly connected with the monitoring of these data are improvement opportunities as well as activities such as exercise, hydration, nutrition, REM (rapid eye movement) sleep and elimination.

Advancing Excellence in America’s Nursing Homes is a free, CMS-endorsed website created to support nursing home improvement. The website posts accessible tools, resources and information. It is also a data source.

NHs can select from nine identified quality goals (four organizational goals and five clinical outcome goals) for improvement. The organizational goals are consistent assignment, hospitalizations, person-centered care and staff retention. The clinical outcome goals are infections, medications, mobility, pain and pressure ulcers.

Each goal has seven steps to help NHs reap the most benefits. A spreadsheet has been created for each goal to help NHs collect and monitor the data to discover trends. NHs are expected to enter monthly data on the spreadsheet and submit data to the Advancing Excellence website. One organizational goal and one clinical outcome goal must be selected to complete the registration process.

By submitting monthly data for their selected goals, NHs will benefit from data collection and process improvements. In addition, each NH will have a timely snapshot of its quality improvements.


CMS-created tools and resources for QAPI can be accessed and downloaded on the CMS QAPI website. In addition to developing standards through regulation, CMS also provides technical assistance for NHs to develop best practices for meeting the standards. One of the best practice resources is the National Nursing Home Quality Care Collaborative Change Package. The Change Package provides successful strategies, concepts and action steps collected from high-performing NHs in five states.

QIOs are another free resource for technical assistance. Don’t wait for the final regulation implementing QAPI or until you are actively working on process improvements. A best practice that is already a stated standard is ongoing data-driven process improvement.

NHs can contact their state’s QIO for assistance. Along with QIOs, literature review, and evidenced-based tools and resources, the Change Package is intended to provide technical assistance for implementing the best practices to meet the QAPI regulation when it is issued.

The NH quality improvement facilitators at the Illinois QIO, Telligen, recorded a webinar series on the 12 QAPI Action Steps. Each of the four recorded webinars in the series is about 20 minutes.

One of the tools on the CMS QIO website is the Process Tool Framework. This tool lists the five QAPI elements (the building blocks of QAPI), and the tools and resources that align with each in one document. These elements are explained in QAPI at a Glance. Since QAPI implementation includes all staff, copies of this guidebook can be placed in common and community areas throughout the facility. The guidebook breaks QAPI into 12 Action Steps. Every step involves continuing education, teamwork and using data to Identify Your Gaps and Opportunities.


Much evidence supports the benefits of each of these daily activities for optimal health. The benefits and necessity of sleep for healing and health maintenance have always been known in healthcare. Care plans don’t always address sleep, however. Nutrition and perhaps hydration and even elimination will be care planned, but not sleep. Care processes for the treatment and prevention of residents at high risk for pressure ulcers will likely include repositioning every two hours even during the night. This is a common care practice.

Evidence now supports the need for NHs to conduct a root cause analysis to determine the true reason for interrupting and preventing residents from achieving REM sleep. Repositioning to relieve pressure is vital. But perhaps a pressure-relieving mattress, different incontinence products and/or different hydration processes are worth investigating so residents can receive the healing and restorative benefits of REM sleep. Since healing occurs during REM sleep and many NHs have pressure ulcer rates higher than the state and national average, collecting and reviewing data on resident sleep could help with efforts to provide person-centered care, as well as improve and heal pressure ulcers.


Other data sources for consideration are complaints, surveys and any necessary plans of correction, staff turnover data and hospitalization, to name a few. The spreadsheets on Advancing Excellence for each goal are designed to track and trend the collected data, allowing patterns to be seen. The Minimum Data Set (MDS) is a primary data source for compiling the Certification and Survey Provider Enhanced Report, commonly referred to as the Casper Report.

Lower-scoring quality measures (QMs) on this report are opportunities for improvement that should be high priority. Reviewing and comparing your facility’s QMs with those of other facilities that have a similar census is a way to identify gaps and areas of improvement opportunities.

Examining the care process for the identified QM from leadership to direct care staff to the resident will reveal the gaps. Resources such as the Change Package, QAPI at a Glance and multiple tools on the CMS QAPI website were created to provide NHs with technical assistance for implementing and sustaining best practices.

A component of best practices in addition to reviewing and monitoring data is using the data to improve. This will be a focus of the next article on QAPI Action Step 9: Prioritize Quality Opportunities and Charter PIPs.

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 7

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

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

Topics: Articles , Clinical , Leadership , Medicare/Medicaid , Regulatory Compliance