The 12 steps of QAPI: Step 10: Plan, conduct and document PIPs

Quality Assurance Performance Improvement (QAPI) is comprised of structured processes and consistent practicing of evidenced-based practices intended to reduce variations in care practices among staff, which have proven to be contributing factors in errors, adverse events and deficiencies. Planning is an integral part of a structured process. Testing the process before folding it into the care system increases the probability of successful integration.

As with all the 12 QAPI steps, the Centers for Medicare & Medicaid Services (CMS) has provided technical assistance to help nursing homes (NHs) accomplish this step. The CMS website devoted to QAPI offers downloadable tools and resources for NHs and quality improvement organizations (QIOs) to use. Telligen, for instance, is the QIO for Illinois, Iowa and now Colorado. Its QIO website has webinars, resources and tools available at no cost. QIOs are contracted with CMS and offer free technical assistance. The webinars are recorded tutorials on QAPI and process improvement methodology.


For process improvements to be data driven, data has to be understood and used. Data identify the improvement opportunities. One of the roles of the QAPI Steering Team is to decide what data sources to use. Team members discuss and interpret the data’s meaning and regularly review them. When the data indicate that an NH is performing below state, national or its own expectations in any measured area, the Steering Team may decide to charter a Performance Improvement Project (PIP) team, which is designed to learn more about a specific area and determine what will improve the performance.

The Steering Team charters a PIP and provides a clearly defined scope and focus to its team members. CMS offers a Worksheet to Create a Performance Improvement Project Charter, which provides the PIP team with directions by defining team members’ roles, responsibilities, goals, scope and timing. QAPI Step 9, as well as Step 10, in QAPI at a Glance, has guidelines for NHs in this phase of the QAPI implementation process.


The Goal-Setting Worksheet, located in the appendix of QAPI at a Glance, is useful for the Steering Team to set  goals for the PIP team being chartered and as it moves forward. The goal of the Steering Team when chartering the PIP is the overall goal. The PIP team establishes small goals to move the team forward and meet the overall goal.

One of the PIP team’s first goals is to schedule meetings. Doing so can be challenging when the team members work different shifts and different times. NHs must maintain a high-functioning staffing level 24/7. NHs are finding it more manageable for PIP teams to function when the leadership openly supports this effort by staffing to accommodate PIP activities and establishing the expectation that staff will actively participate on PIP teams.


QIOs monitor official, unofficial public and private data sources for trends to proactively engage healthcare providers as early as possible. The goal is to interrupt patterns indicating negative outcomes. As an example, pressure ulcer prevention remains a focus of CMS and QIOs. Each Medicare-certified NH’s quality measures are posted on Nursing Home Compare on the Medicare website, which is updated regularly. The national percent of long-stay, high-risk residents with pressure ulcers is 6.1, while the the state percentage in Illinois is 6.6 percent. The pressure ulcer rate for Illinois is slightly higher than the national rate, but history has shown that pressure ulcer rates tend to increase, meaning that residents continue to develop pressure ulcers while in the care of healthcare professionals.

Some pressure ulcers are unavoidable due to multiple debilitating medical conditions which negatively impact nutrition and mobility. These occur in the sickest of residents and are not the norm. Other pressure ulcers are avoidable. Whenever a resident develops a pressure ulcer, a root cause analysis (RCA) should be conducted to determine if it was avoidable. Every NH should have a process for selecting events or issues to undergo an RCA. The development of a pressure ulcer should always be one of those events.

An RCA is a systematic process to determine the underlying causes or true causes of a problem for the purpose of correcting it. When one resident develops a pressure ulcer, an RCA should be done to learn more. When more than one resident develops a pressure ulcer, however, this could indicate a problem with the current pressure ulcer prevention process, indicating that a PIP could be chartered to focus more attention on the problem. The best pressure ulcer prevention practices include regular skin assessments, redistributing pressure and maintaining the resident’s nutrition. Avoidable pressure ulcers occur when skin assessments aren’t completed on a scheduled, regular and frequent basis; residents aren’t turned to redistribute pressure regularly and frequently; or when staff aren’t aware of a resident’s nutritional intake changes.


CMS has provided a tool to assist nursing homes, the Guidance for Performing Root Cause Analysis (RCA) with Performance Improvement Projects (PIPs). This tool outlines a seven-step process for a PIP team.  Conducting an RCA is the initial part of the process to reveal the root of the problem. The Steering Team can use the Worksheet to Create a Performance Improvement Project Charter to inform the PIP team what its being tasked to do. The Steering Team selects one of its members to fill liaison roles, like the sponsor and director, that are not necessarily involved in the routine duties of the PIP team. The Steering Team can select a leader and members for the PIP team, but the PIP leader is often empowered to select team members.

Once chartered, the PIP team can begin the seven-step process outlined in the RCA guidance.  Identifying the contributing factors and analyzing them will lead to the identification of the underlying process gaps at the root of the problem. The PIP team can then design changes that address the true roots of the problem. The goal is to create strong, corrective actions that improve the process and do not allow errors or omissions to occur. When the PIP team decides on a corrective action for an identified root cause, the team should test the action to increase the likelihood that the action will both correct the problem and be sustained. The team should complete Plan Do Study Act (PDSA) cycles to test the ideas or actions it chooses to correct an identified root cause.

The PDSA cycle template can be used to test any idea or action. With practice, this template will help NH  staff become proficient at running PDSA cycles. With each cycle, a little more knowledge is gained until the team agrees whether the idea or action will be an improvement and whether it should implemented. CMS expects NH staff to become proficient in using systematic methods and has provided tools for documenting every step from conception to completion.

The danger of implementing a solution without identifying the root of the problem can negatively impact the entire NH system. Because identifying the root cause is a critical part of improvement processes, NHs are guided through a more detailed process in Step 11: Getting to the “root” of the problem.

Nell Griffin, LPN, EdM, is a Healthcare Quality Improvement Facilitator, a certified TeamSTEPPS Master trainer and author. She can be reached at

Read Steps 1 through 9

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

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

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