12 steps to QAPI: Step 9: Prioritize quality opportunities and charter PIPs

“In God we trust; all others bring data,” said W. Edwards Deming, a global figure in statistics and management sciences. He is credited for his transformational role in quality improvement. Deming was a pioneer at transforming data into knowledge providing the basis for action. The data-driven premise of Quality Assurance Performance Improvement (QAPI) depends on data. Data, however, are not knowledge. They have to be transformed into knowledge, which is the basis for successful action. Like the rest of the world, nursing homes are drowning in data. To translate data into action, opportunities for improvement have to be identified and prioritized. This process is discussed in QAPI Step 9: Prioritize Quality Opportunities and Charter PIPs.


The Centers for Medicare & Medicaid Services (CMS) is responsible for both promulgating the QAPI regulation and providing technical assistance to nursing homes (NHs). Within a year of the promulgation of the QAPI regulation, NHs will be required to have acceptable written QAPI plans. Technical assistance is available on the CMS QAPI website and through each state’s Quality Improvement Organization (QIO). The CMS QAPI website is available to anyone.

In general, state QIO websites are available to the public, but some request registration. Telligen is the Illinois QIO. On its website, NHs can access webinar recordings and download tools and resources on their own individual timetables. State QIO websites can be accessed by quality improvement facilitators for more personalized assistance and guidance. A list of every state’s QIO is available. Accessing these sites helps NHs with the drill-down process to identify and prioritize quality opportunities and navigate the chartering of Performance Improvement Projects (PIPs).


CMS has posted tools and resources on the QAPI website to provide technical assistance for prioritizing improvements and chartering PIPs. NHs already hold routinely scheduled meetings to discuss data. Tracking data, such as falls and pressure ulcers, is already a part of they do. Seeing these incidents as opportunities instead of problems is not a common mind-set.

Deciding the opportunity area to focus improvement actions on is a function of the QAPI steering committee. Improvement opportunities present from various sources, such as when an NH’s publicly reported quality measures are vastly deficient compared with the state or national rate. The opportunity to move closer to the state or national rate also presents an opportunity to exceed those rates.

Complaints create the opportunity to improve satisfaction by improving the process. With improved processes, staff can work more efficiently, increasing job satisfaction and decreasing turnover. Data showing high risk for harm and patterns of high frequency offer improvement opportunities the steering committee can discuss and decide the priority of efforts. Data showing negative impact on resident’s psychosocial well-being, daily life choices or autonomy should be included in the steering committee’s prioritization discussion.


After a purposeful review and discussion of data sources, the steering committee charters a PIP team to focus on the area that presents the most urgent process improvement opportunity. Recognizing that deciding on the most urgent opportunity can be a challenge, CMS has provided technical assistance. One of the tools is a Brainstorming, Affinity Grouping and Multi-Voting Tool, which helps NH teams generate ideas and make decisions. This tool offers approaches and techniques for sparking creativity and facilitating team collaboration. It can be used to assist with process improvement discussions and prioritization.

Not all identified problems, complaints or issues require PIPs. The frequency, level of risk or impact on systems drives the decision for chartering PIP teams. The steering team decides whether a PIP charter is necessary based on data, a history of negative outcomes and the potential for resident harm. CMS uses the word “charter” deliberately for PIP formation. PIP charters are specific written missions to solve a specific problem. CMS has released tools providing nursing home with the technical assistance for PIPs, including a Worksheet to Create a Performance Improvement Projects to help NHs visualize the mission.

The steering team completes the Worksheet to Create a Performance Improvement Project to give the PIP team a clear understanding of the mission it is being asked to complete. The worksheets establishes the goals and scope in the overview section, which provides the PIP team with such information as the problem and the reasons the steering team decided to charter a PIP to address them. A timetable and the roles PIP team members are also defined on this tool. The steering team may select persons to invite to participate on the PIP, but certain roles should be assigned by the steering team as part of the charter. Usually, the steering team will select a leader for the PIP, but a person from the steering team must be the point of contact.

As part of the vision for the project, this tool helps the steering team proactively plan the PIP by thinking through the barriers that could block the successful completion of the mission. It also engages leadership to commit to the success of the PIP.

Leadership support is vital to the success of the mission. An NH’s leadership has to create the space for the PIP to succeed as part of the charter. The leadership supports the PIP with the time needed to participate, secures any supplies and provides the physical accommodations to complete the mission. One of the major responsibilities of the leadership is to establish the expectation that staff will work on PIPs and that co-workers will support and adjust their schedules to accommodate PIP team members.

Leadership is expected to know the status of the PIPs chartered at the NH. CMS has posted The Performance Improvement Project (PIP) Inventory tool to help. It assists NHs with tracking their PIPs. Chartered PIPs can be listed on this tracking template. Assigning a person to be responsible for updating the template at regularly scheduled intervals allows the steering team and leadership to have a means to be informed of the status of each PIP.

Once chartered, the PIP team is entrusted with the mission. Being part of a PIP is an important task that everyone working at, living in or frequenting the NH should take seriously. Whether chosen by the steering team or chosen by the PIP team itself, the PIP leader guides the team through an analysis of the data and establishes a proposed timeline for completing the mission. The Goal Setting Worksheet is another of the technical tools issued by CMS that can help PIP teams move their missions forward. This worksheet can help establish appropriate goals for Plan Do Study Act (PDSA) cycles, organizational quality measures or improvement initiative as well as PIPs. Planning is one of the keys to QAPI Step 10: Plan, Conduct and Document 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 8

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

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

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