Andy Kramer, MDThis is the second column in a series of five addressing how QIS methods can be used in a Quality Assurance and Performance Improvement (QAPI) system by showing the parallels between QIS methods and the five elements of QAPI.

To better understand the QAPI regulation that will be enacted this year, go to According to the QAPI at a Glance document, Element 2 of the five elements is Governance and Leadership: “The governing body and/or administration of the nursing home develops and leads a QAPI program that involves leadership working with input from facility staff, as well as from residents and their families and/or representatives.

“This includes designating one or more persons to be accountable for QAPI [and] developing leadership and facilitywide training on QAPI … They are responsible for establishing policies to sustain the QAPI program despite changes in personnel and turnover.

“The governing body and executive leadership are also responsible for setting priorities for the QAPI program and … setting expectations around safety, quality, rights, choice, and respect by balancing both a culture of safety and a culture of resident-centered rights and choice.”

This element stresses how QAPI is about creating a balanced organizational culture that permeates from leadership to every level of staff. This must start with the QAPI program being completely supported by the top leaders in the organization, through both interactions with staff and adequate resource planning.

Part of this leadership is to ensure that all of the participants in the delivery of services are contributors to the QAPI program.

This column has previously described guidelines from providers that have successfully used the QIS methods: Select a leader to guide the implementation effort; involve staff at all levels and in all disciplines; and use QIS every day and make it part of a daily routine, as in continuous quality improvement.

These methods lead to a system that derives much of the Stage 1 information from a wide range of sources involving residents, their families, and staff members.

There are two reasons that the QIS methods help to establish a system that is sustainable “despite changes in personnel and turnover.”

First, the QIS methods are embodied in standard procedures for assessment and investigation. A primary objective of QIS is that these processes are used the same way no matter who is conducting them, leading to consistency across staff changes.

Second, because so many staff members are involved in using the QIS methods rather than one or two individuals, the impact of personnel changes does not have to affect the collective knowledge of the system.

A fundamental aspect of the QIS methodology is to identify opportunities for improving care in cases of unacceptable levels of performance, up through above-average levels of performance. This can help guide a leader in “setting priorities” for a QAPI program.

Overall, the balance of resident safety and resident-centered care embodied in QIS methods can assist leadership in setting expectations for performance and improvement, thereby fulfilling this element of QAPI.

Andy Kramer, MD, is a long term care researcher and professor of medicine who was instrumental in the design and development of the Quality Indicator Survey (QIS).