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

June 6, 2014
by Nell Griffin, LPN, EdM
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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.