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12 steps to QAPI: Step 1: Leadership

January 30, 2014
by Nell Griffin, LPN, EdM
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Nell Griffin, LPN, EdM

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

It’s been said that “Life is 10 percent what happens to you and 90 percent how you react to it.” Many of America’s nursing homes (NHs) react after something happens. Quality Assurance Performance Improvement (QAPI) is designed to help facilities become more proactive and less reactive. QAPI is a comprehensive approach to ensuring high-quality, proactive patient-centered care using evidence-based practices to increase knowledge for planning, implementing and sustaining measurable improvement. After the regulation is promulgated, QAPI will be a Center for Medicare & Medicare Services (CMS) requirement and nursing homes will be required to submit a written QAPI plan. Helping nursing homes become more proactive and implement QAPI is what each state’s Quality Improvement Organization (QIO) is working to accomplish. 

Quality improvement is the mandate of QIOs, offering resources for acquiring the necessary knowledge and skills to build and implement a program. A unique component of QAPI is that it requires all NH staff to be active participants in quality improvement initiatives. Realizing that direct care staff are the hands-on experts on patient care and the best way to provide it, successful QAPI involves all staff in process improvements, from planning through sustainment, and QIOs can help. Each state’s QIO and contact information is listed at www.qualitynet.org in the Quality Improvement tab.


Implementation requires nursing homes to learn new concepts, engage in new practices and build a new culture. QAPI at a Glance: A Step by Step Guide to Implementing Quality Assurance and Performance Improvement (QAPI) in Your Nursing Home, is your QAPI guide. Download a copy from the CMS QAPI website, go.cms.gov/Nhqapi.

QAPI at a Glance offers 12 implementation steps. It’s not necessary to implement each step sequentially, but they all need to be addressed. Step 1—Leadership, Responsibility and Accountability—is, without exception, the first step of any initiative. Leadership commitment is the sure path to success by creating a culture to support QAPI and involve caregivers as well as provide the necessary resources. QAPI at a Glance is an implementation guidebook that suggests ways leadership can take action in the following four parts. The first part of Step 1 is to develop a steering committee, or team, to provide QAPI leadership. The following information in this article is taken from the guide.

1. Develop a steering committee charged with the overall responsibility to develop and modify the plan, review information and set priorities for performance improvement projects, or PIPs. Top leadership such as the administrator and the director of nursing must be part of this steering committee, which charters PIP teams to work on particular problems, review results and determine the next steps. The steering committee must learn and then use system thinking.

It is also important to have a medical director who is engaged in QAPI. Your quality assurance (QA) committee can be adapted to become your “steering committee” to oversee QAPI. For this to work, the QA committee may need to meet more often, include more people and establish permanent and time-limited workgroups that report to it. Nursing homes should already have established committees that have medical director involvement and meet regularly. This is an existing component of the regulation for Quality Assessment and Assurance (QAA).

The QAPI steering committee is tasked with developing and modifying the plan, reviewing information and setting priorities for PIPs. This is a culture shift for many nursing homes. After being informed of the steering committee’s duties, nursing homes recognize this for the culture shift it is but may revert to complacency for task completion. Instead of forming the QAPI steering committee and tasking its members with writing the QAPI plan, it is written by the administrator, director of nursing or someone in the nursing home’s corporate office. Reverting to the usual way of getting things done diverts effective QAPI. At best, this delays the steering committee's progress as an effective team and, at worst, prevents it. The QAPI steering committee working as an effective and engaged team sets the tone for all the other PIP teams the nursing home will charter. Establishing the QAPI steering committee as soon as possible will help the nursing home move into system thinking,

Purposeful system thinking is not usual in most nursing homes. Most nursing homes are nursing department-centric. Essentially, the role of other NH departments is viewed as support for the nursing department. System thinking invites input from both those close to the problem and those with knowledge about the impact of the problem on the individual systems.