I know QA, but what Is QAPI?

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Teresa Remy
Teresa Remy

Nobody likes change. If we all had a dollar every time we heard someone in our workplace say “but this is the way we've always done it” we'd all be independently wealthy. The Centers for Medicare & Medicaid Services recently rolled out new Requirements of Participation that describe in detail the Nursing Home Quality Assurance and Performance Improvement guidelines, better known as QAPI, also known as - change.  


As a skilled nursing center consultant, I visit facilities all over the country and field daily questions about QAPI – chief among them is “I know QA, is this QAPI really any different?” 

I get it. I've been a nurse, nursing home administrator, regional director of operations, vice president of operations and quality, and a state surveyor. With 35 years of experience in long-term care, I know QA inside and out. Many times over the years, I have been frustrated with changing regulations and interpretive guidelines, especially when the changes seemed unrealistic, which was often. I have even asked myself “who is writing these rules and interpretive guidelines?” (Which of course is just a step away from, but this is the way we've always done it, and so maybe not worth a dollar, but at least fifty cents.)

It works!

CMS developed QAPI using research and pilot projects to create an evidenced-based guideline structure for the perfect ‘recipe' for effective, long-term QA. QAPI-F Tags 865, 866, 867, and 868 is an RoP that works — they got it right this time! 

CMS defines QAPI as the coordinated application of two mutually-reinforcing aspects of a quality management system, and states, “QAPI is critical to our national goals to improve care for individuals and improve health for populations….” The QAPI process builds on traditional QA models as a living, breathing process that works more efficiently and permanently than traditional QA. Implemented as CMS outlines, QAPI will give an organization the framework to fix concerns and problems long term by identifying gaps in processes via Root Cause Analysis, which gets to the heart of the problem rather than ‘patching' the issue.

Long-term success

QAPI identifies the creation of an event timeline as a key component to RCA. Many centers struggle to identify root causes via RCA because they rush to conclusions without deliberating on timeline data, which leads to a solution that only works in the short term because the underlying gaps in the process and other contributing factors have not been addressed (and will likely occur again). The approach outlined in QAPI requires documentation and discussion among the entire team of a chronological sequence of events leading to the incident (harmful or non-harmful). This approach teaches teams how to critically analyze a timeline of factual events before determining causal factors, which comes later in the process. The team becomes able to identify factual inconsistencies in the processes that led up to the incident. As QAPI outlines, it is critical to create this timeline before rushing to the RCA, or proposing solutions.

Implementing QAPI is beneficial to the entire organization, especially residents, but can be rewarding for administrators (no more concerns keeping you awake at night), and even fun (yes, fun!) for staff. Teams may find this process serves as a team-building method that strengthens the group at all levels of service, and across all disciplines.

There so much more to QAPI! Stay tuned for a series of future articles in which I will discuss how to begin effectively implementing QAPI as part of a standard QA process.

Teresa Remy, DSc, MHA, LNHA, BSN, RN, RAC-CT, CDP, QCP, has nearly 35 years of experience working in healthcare and is the Director of Clinical Services at LeaderStat. Her areas of expertise include the entire continuum of care from acute care to every aspect of post-acute care such as sub-acute, skilled nursing, residential care/assisted living, home care, hospice/ palliative care and private duty. 


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