How to overcome QAPI challenges

Share this content:
Richard Royer
Richard Royer

Quality has been a longtime focus in nursing home care, but the effectiveness of quality-focused initiatives is often questioned. The purpose of adding performance improvement to existing quality assurance requirements – and a primary goal of QAPI – is to achieve excellence in nursing home care. While it is easy to get on board with this goal, nursing homes have a tremendous amount of work to do to make the vision a reality.

To improve quality of care in nursing homes – and quality of life for residents – the Centers for Medicare & Medicaid Services is expanding quality provisions by pairing quality assurance with performance improvement. This means that nursing homes must establish processes that enable them to identify the root cause of certain issues with the goal of diminishing future potential problems. Right now this is difficult since nursing facilities are often understaffed and lacking in resources.

When done right, QAPI involves systemic change at every level within a facility. Change of this magnitude requires time for planning, training, evaluating progress and more. Since it is a sizable undertaking, and teams are learning as they go, every nursing home should expect to face challenges as they plan and implement their QAPI program. As a provider, you must know what to expect and how best to address the challenges for minimal disruption and maximum impact.

Lack of precedent

One of the many things that makes QAPI compliance challenging is that there is a lack of significant precedent. Because QAPI is new, many teams do not know where to begin when building a QAPI program. Even after taking the first few required steps, (identifying a QAPI team and drafting a QAPI plan) there are still many questions that need to be answered in regards to how to set priorities and execute plans.

A common question for nursing homes is: Which performance improvement projects will deliver the best returns? To address challenges that stem from a lack of precedent, nursing homes should consider working with a consultant that has demonstrated a proven ability to design and implement QAPI programs. Experts in this area can provide resources and valuable guidance to teams that are struggling with the current lack of precedent but strive for improving quality of care.

Culture adjustment

The adoption and support of a QAPI plan should involve asking questions about the nursing home's processes and culture.  For example:

  • Does it encourage an emphasis on safety?
  • Does it promote performance management?

QAPI teams should use performance data to help answer these questions. As opportunities for improvement are identified, the entire facility needs to make adjustments and be willing to adopt new processes. This is not always easy, because of the resistance to change that is so natural. However, a willingness to change and improve is part of the commitment to quality improvement that every nursing home must agree to under QAPI. Creating a culture to support QAPI efforts begins with strong leadership and vision. From there, QAPI teams should encourage the active participation of every caregiver and employee.

Staff training

Nursing homes must take time to evaluate their staff and provide QAPI training where needed. Telling staff they need to make adjustments and adopt new ways of doing their job is one thing, but training them to make necessary changes leads to solid, lasting improvements. It can also increase quality improvement buy-in. A steering committee that oversees all planning and priorities, as well as an actively engaged medical director should work to lead training efforts.


Nursing homes have numerous responsibilities and it can be difficult to prioritize new initiatives when dealing with the urgency of day to day issues. Nursing homes that struggle to prioritize QAPI because of too many competing priorities should consider seeking support from a third party that can take on time-consuming planning and strategy development.

Benefits and payoffs

While there are a healthy number of challenges to overcome, the benefits of a successful QAPI program are plentiful. For example, following QAPI guidelines and generating ongoing improvement means less stress when it is time for surveyors to inspect facilities. Every nursing home wants to avoid citations, and a well-oiled QAPI program makes that possible. Of course, along with fewer citations come more opportunities to achieve a coveted five-star rating.

Another benefit of a successful QAPI program is the potential for fewer hospitalizations among residents. By improving care, nursing homes can reduce the need for acute care among residents. Not only is this good for residents, but it allows nursing homes to keep more care in-house, which means more reimbursements and financial benefits. Quality improvement also has a positive impact on staff. Optimizing care delivery can make life easier for direct care staff, and executing strategic QAPI plans can reduce turnover for those teams.

These benefits are just the tip of the iceberg. A successful QAPI program will lead to many other benefits for nursing homes, their staff and residents.

Ongoing progress

One of the most important things for nursing homes to recognize is that simply writing a QAPI plan does not lead to long-term quality improvement. The plan itself is important, but the actions taken to carry out the plan will determine how successful QAPI is ultimately.

QAPI is a permanent change to how care is delivered. Nursing homes that are not comfortable in their ability and knowledge of how to make that complete change should seek support from a quality improvement partner, so they can transform their facility and achieve ongoing success.

QAPI: More than a Plan

Every nursing home that receives federal funding must establish a QAPI program, but compliance with CMS requirements should not be the only reason for pursuing a QAPI program.

Implementing a program can significantly transform the quality of care and services a nursing home provides. This is the real reason nursing homes need to be focused on improving quality. It is also the reason facilities need to be sure they are not just ticking the QAPI box – but taking all the steps to ensure the vision becomes a reality.

Richard A. Royer, MBA, has been the CEO of Primaris since 2001. He can be reached at