It's Not Too Early to Prepare for QAPI

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By Jane M. Niemi, MSN, RN, NHA, Senior HealthCare Specialist

With a QAPI regulation in process and the subsequent date for submission of a facility QAPI plan to CMS a year after promulgation of the regulation pending, preparing for Quality Assurance and Performance Improvement (QAPI) may seem like an initiative too far away to be of immediate concern. However, by beginning your preparations for QAPI now, you can also positively position your organization in ways that will have an immediate effect on performance.

State of Quality Regulations for the Industry

QAPI, part of the Affordable Care Act Section 6102 (c), establishes standards for a program in nursing homes that will add the component of ongoing organization-wide performance improvement to existing quality standards. The law also requires CMS to provide technical assistance to nursing homes for meeting these new program standards.

Currently, nursing homes follow Quality Assessment and Assurance (QAA) 43 CFR, Part 483.75 (o) that requires identifying and correcting quality issues. QAPI will shift the focus to organization-wide involvement in continuous improvement activities that are data-driven. The bolded words in this last sentence emphasize key terms senior level operators need to begin to understand to prepare for the new standards. QAPI puts attention on the best practices and methods necessary for implementing and sustaining a comprehensive and effective performance management system.

CMS has provided Five Elements of QAPI:

Element 1: Design and Scope

Element 2: Governance and Leadership

Element 3: Feedback, Data Systems and Monitoring

Element 4: Performance Improvement Projects (PIPs)

Element 5: Systematic Analysis and Systemic Action

The Process of QAPI Standards Development

In a June 2012 Memorandum (S&C:12-38-NH), CMS relayed they were in the process of drafting a new QAPI regulation and that nursing homes will be expected to submit their QAPI plans to CMS one year after promulgation of this regulation.  The new regulation will be in addition to the current QAA regulation at F520. 

Beginning in September 2011, CMS in collaboration with the University of Minnesota and Stratis Health launched a small two year QAPI demonstration project in four states (CA, FL, MA, and MN). The goal of the demonstration is to learn the kinds of support nursing homes need to implement QAPI and to test different types of tools and technical assistance.  At this time, ongoing refinement of tools for nursing homes continues and CMS plans to have materials available to nursing homes later in 2012 to assist in preparing for the national roll-out of the initiative and future QAPI regulations.  The CMS QAPI website will provide information on the national launch and resources to assist with implementation of the program with helpful links such as “Resources for Quality Improvement” and “Advancing Excellence in America's Nursing Homes Campaign,”      

What We Currently Know

Interpreting early QAPI information provides us some insight on the meaning of the key elements and how they will need to be supported in the nursing home environment.

Let's look at the first element, for example. It is stated that the facility's written QAPI plan for design and scope of the program should include the areas of clinical quality, quality of life, resident choice and care transitions. QAPI puts attention on the best practices and methods necessary for implementing and sustaining a comprehensive and effective performance management system. These areas are far reaching and encompass most functions within a nursing home environment.

Another important element of QAPI outlined by CMS is that the governing body and/or administration of the nursing home develops and leads the program with input from staff, residents, and their families.  By pairing a culture of safety and resident-centered choice, leadership would ensure a “just” environment that promotes accountability of all staff members through facility-wide participation and education.  Success will require a top-down approach that empowers individuals to act within a known set of standards of processes. Owners and administrators bear the responsibility of creating and tooling all persons appropriately to promote a quality guided culture.

QAPI also intends to ensure systems are in place to monitor care and services. The systems should include multiple data sources to monitor a wide range of care processes and to track improvement compared to goals and benchmark groups.  Feedback from staff, residents and families, are an important part of this system.  This element of continuous feedback, data systems and monitoring also involves implementing performance improvement techniques to determine causal factors, such as Root Cause Analysis, in order to prevent recurrences. 

CMS identified care transitions as an important area to be addressed in the design and scope of the nursing home's program. Implementing  systems to monitor your nursing home's rehospitalization rates compared to  internal targets and external benchmark groups, as well as implementing processes  for identifying  and mitigating risk factors for those residents found to be “at risk” of rehospitalization are vital in addressing this focus area.

Early Preparations for QAPI

As we await the final standards, providers can begin by taking some initial steps to create an environment open and ready for QAPI deployment. The systematic approach will require strong leadership, governance, systems, and tools to deliver the results intended for QAPI, so “early and often” are good rules to apply to preparation effort.

In addition to incorporating the Five Elements of QAPI and ongoing review and utilization of materials available on the QAPI site, consider the following:

1.     Ensure that the governing body/administration of the nursing home truly develops and leads the program.

Do not delegate the development of QAPI. Nursing home executive administration and/or governing bodies need to take center stage and lead the program. Many can be involved in carrying out daily activities to support the initiative, but QAPI requires a culture shift for many organizations, which can only be implemented through demonstrated commitment and consistent leadership dedicated to continuous improvement within the standards.

2.     Adopt a systems approach based on an organization-wide commitment to safety and quality.

Positioning yourself for success with QAPI involves implementing processes that assure the accuracy of your MDS data and the various outcome areas derived from the Resident Assessment Instrument. Areas such as CMS' Quality Measures, Medicare PPS reimbursement, rehospitalization rates, and resident risk assessment and care planning need to be based on audited, accurate data. 

Implementing methods that allow standard health survey and complaint survey deficiency areas to be readily analyzed and trended over time would also help to position your home for QAPI.  Ensuring the deficient areas are effectively addressed within the QAPI program promotes a comprehensive and proactive approach.

3.     Begin assessment of adequate staff and resources for those accountable for implementing the necessary processes.

Staffing patterns also play a key role when assessing facility level outcomes. Utilizing tools for analyzing staffing according to resident acuity, monitoring staffing levels and structure (i.e. consistent assignments), competencies, and staff satisfaction and retention, and then tracking performance in these areas would provide data for this important operational area that impacts the quality of care and quality of life of your residents.


The entire premise of healthcare reform is to improve quality and curb the trend of “out of control” costs. The issuance and adoption of QAPI for nursing homes will set this segment of care on the right path to achieve these goals. As the initial studies are completed, we will have more insight into the recommendations and processes needed to realize the intended results. Until then, initial actions can begin the shift in approach for many making the planning and deployment of plans easier and effective.


CMS QAPI website,  “Five Elements of QAPI “, and informational content.

CMS Memorandum- Ref: S&C: 12-38-NH. June 29, 2012

Medicare and Medicaid Requirements for Long-Term Care Facilities. Regulations: 42 CFR Part 483 (o), subpart B, F520.

Patient Protection and Affordable Care Act (“PPACA”): Section 6102 (c)

Stratis Health website, Stratis Health Leads National Demonstration Project to Improve Care in Nursing Homes. Accessed 10-4-2012.