Waiting is hard. The questions, the anticipation, and the uncertainties can be frustrating, even exhausting. Long term care facility leaders and teams know this from experience. They have been waiting for months to learn what the regulatory requirements regarding Quality Assessment and Performance Improvement (QAPI) will be, only to hear as late as last month that the final regulations are still in the works.
Still, many facilities and organizations are moving forward with QAPI initiatives.
While these groups are unsure about the final regs, they are confident about their ability to implement QAPI. Some even see a little déjà vu in QAPI, as they see it reflected in many of their current quality improvement efforts. At the same time, those involved in the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) National Quality Award program see a parallel between the steps involved in the program and the five elements of QAPI. Whatever their approach, they make it clear quality assurance and performance improvement already are a priority.

Unraveling The QAPI Mystery

Clearly, it doesn’t require a crystal ball to prepare for QAPI. As Ruta Kadonoff, vice president of quality and regulatory affairs for AHCA, says, “What is happening in nursing homes is modeled after what has been in place in other settings and follows the basic concepts of quality assurance—ensuring that you are in compliance with requirements about care and have systems in place to address failures as they arise.”
To help facilities prepare for QAPI, the Centers for Medicare & Medicaid Services (CMS) recently released “QAPI at a Glance.” The document provides insights into the program and guidance on how facilities can prepare. For example, it clarifies the difference between quality assurance and performance improvement (see table, below). It emphasizes that QAPI involves team members “at all levels of the organization to: identify opportunities for improvement, address gaps in systems or processes, develop and implement an improvement or corrective plan, and continuously monitor effectiveness of interventions.”
The CMS document stresses the rewards facilities will reap from QAPI, including competencies that will equip them to solve quality problems and prevent their recurrence; competencies that will allow facilities to seize opportunities to achieve new goals; fulfillment for caregivers, who are able to become active partners in performance improvement; and, ultimately, better care and quality of life for residents.

Not A New Concept

QAPI isn’t entirely new, CMS stresses. It uses the existing Quality Assessment and Assurance regulation and guidance as a foundation. “QAPI at a Glance” reinforced the idea that many facilities already are implementing quality assurance and performance improvement in many ways, including creating systems to provide care and achieve compliance, investigating problems and attempting to prevent their recurrence, tracking and reporting adverse events, benchmarking and comparing quality with other homes, investigating complaints, seeking resident and caregiver feedback, and setting targets for quality.
If a facility is performing some of the following tasks, it already is well on the way to QAPI:
■ Using data not only to identify quality problems but also to uncover other opportunities for improvement, then setting priorities for action;
■ Building on residents’ own goals for health, quality of life, and daily activities;
■ Bringing meaningful resident and family voices into goal setting and progress evaluation;
■ Incorporating caregivers broadly in a shared QAPI mission;
■ Performing root-cause analyses to address problems;
■ Developing Performance Improvement Project (PIP) teams with specific “charters;”
■ Making systemic changes to eliminate problems at the source; and
■ Developing feedback/monitoring systems to sustain improvement.
“QAPI at a Glance” discusses the five elements of QAPI—design and scope, governance and leadership, feedback/data systems and monitoring, performance improvement projects, and systematic analysis and systemic action.
It also offers several steps to effective QAPI implementation that addresses issues such as putting a personal face on quality issues, developing a deliberate approach to teamwork, conducting a self-assessment, identifying guiding principles, and conducting a QAPI awareness campaign.

Baldrige Criteria, QAPI Go Hand In Hand

“Both QAPI and the AHCA/NCAL [National] Quality Award program are systematic processes to address quality. Both focus on leadership and responding to staff and customers. Both have a focus on performance improvement in a team-based context and on demonstrating results. They parallel each other pretty completely,” says Kadonoff, adding, “We believe that the criteria of the award program, which helps organizations do better as a mission-driven organization providing services, is aligned with the goals of QAPI.”
The National Quality Award program is based on the core values and criteria of the Baldrige Performance Excellence Program, which promotes a sustainable business model based on the core values of delivering a consistently positive customer experience, valuing and empowering the workforce, thinking and acting ethically, and thinking and acting strategically.
Senior Baldrige Examiner Christopher Quality Assurance vs. Performance ImprovementLaxton, CAE, agrees that award program participants are well on their way to QAPI success. He says that anyone who has been through a Baldrige process or cycle is extremely well prepared to implement QAPI. “Both take a systems approach to organizational performance,” he says.
Laxton, executive director of AMDA—Dedicated to Long Term Care Medicine, says that Baldrige participants have already answered many of the questions QAPI will ask of them and that they already have undertaken PIPs as part of the award pursuit. “They already have been required to demonstrate cycles of learning and outcomes from those. These are the goals of QAPI,” he says.
Laxton actually lined up elements of the Malcolm Baldrige Performance Excellence Program and QAPI and found several specific commonalities. For example, Baldrige begins (as does the AHCA/NCAL National Quality Award Program) with an organization profile, which is similar to the self-assessment outlined in “QAPI at a Glance.” Both of these sections, he says, address “how your leaders lead, how you manage your processes, data, etc. The questions posed are intended to cause the organization to think more deeply and precisely about what they do.”

 Christopher LaxtonWhile it is useful to compare what a facility has done for the Quality Award Program to what QAPI will require of them, Laxton advises, “Don’t get too hung up on one framework over another. All point to better patient care.”
He suggests focusing on how the initiatives support each other and will help the facility move through the QAPI elements. “Begin with the end in mind—in this case, better patient care.”

Based on his experiences with the Baldrige criteria, Laxton says he is “100 percent confident that facilities can do this well. There isn’t a single organization that can’t do performance improvement of some sort. They need to be committed and embrace it from the top down.
“Even small organizations with as few as 25 employees have been award winners because they embraced a systematic approach to performance improvement and excellence.”
He says he’s seen facilities of all sizes do this and show results that are extraordinary—not just in terms of patient outcomes but in reduced readmission rates well below national averages and financial strength well above. “It’s all about sustainability and making sure each organization is doing as well as it can to care for its patients and keep the organization moving forward.”

Don’t Let QAPI Make You Queasy

Jeri Reinhardt, RN, director of quality at Benedictine Health System in Minnesota, talks about how she and others are preparing for QAPI, despite the uncertainties about the regs. She says, “People are uncertain about the final regs and what the guidance to surveyors will be, and that creates unease. But we’ve been using quality assurance and performance improvement practices for years. We also have a facility in the QAPI pilot project. We currently use QI [quality improvement] in everything we do. We have already completed the self-assessment for the organization. Now we’re waiting for the regulations.”
Uncertainties about the regs haven’t kept others from implementing QAPI.
“We started doing this several months ago. When you really dig into this concept, it’s performance improvement—analyzing processes and systems and improving them in a proactive way—that is a game changer,” says Matthew Wayne, MD, CMD, chief medical officer for CommuniCare Health Services in Ohio. “We saw it as an opportunity. Using the five elements of QAPI, we started by determining what metrics we wanted to track as an organization and move the needle to improve quality.”

 Golden LivingCenter, Oakmont, Pa.The devil is in the details, and “every single step needs definitions and clarity,” Wayne says. For example, he and his team spent time determining specifically how they would collect and review data.
“We took time to teach people how to analyze information and conduct a root-cause analysis. This is a key step, because if you don’t understand data analysis, you can miss problems or see problems that don’t exist,” he says.
“I feel good about what we’ve accomplished in the past several months,” says Wayne of his foray into QAPI. However, he stresses, “We could not have achieved this without buy-in from the top down. We work together with the interdisciplinary team each month. It’s important enough for us all to be there, and our success is due to that commitment.”
Ed McMahon, PhD, national director of quality for Golden Living, says, “We started our real focus on QAPI over two years ago. We knew it was coming, and we knew it made sense. We had gotten into the Baldrige criteria before that, so it was an easy adaption for us.”
Ed McMahon
McMahon realized the need for widespread communication throughout QAPI’s implementation, so he published a QI newsletter to help everyone prepare and to get them on the same page.
“We would look at a different tool and at a different Baldrige core value every month and talk about how these would be included in the QAPI process,” he says.

The Team Challenge

“One challenge will be to get organizations to buy in to this as a team approach. Getting the whole team involved will promote actual quality assurance and performance improvement, instead of it just being another regulation,” says Karyn Leible, RN, MD, CMD, chief medical officer for Jewish Senior Life of Rochester, N.Y.
Kadonoff agrees. She says, “This isn’t something that lives in the nursing department. It’s not the responsibility of one small committee, but something that involves the entire team.” Toward the end, leadership needs to embed QAPI in all aspects of the system, Kadonoff says.
“QAPI doesn’t have to be something additional or different. The team needs to work together and identify where there are missing pieces.”
In getting team members on board, says Leible, “You have to take the language of QAPI and put it into a context that CNAs [certified nurse assistants] and others can understand. You need to relate the steps in terms of things that they can relate to.” She adds, “It is important to emphasize that most of this isn’t much different from what they’re doing already.”
Explaining root-cause analysis and tools such as fishbone diagrams is more effective when team members can see them in action, Leible says. “Once I was trying to figure out why a patient was falling, so I started doing a fishbone diagram. The staff saw what I was doing and started throwing out ideas. Before long, we had some good solutions, and the staff did it.”
When staff understand how effective this process can be, people do participate, she says. “This is an opportunity for the team to get involved, dig deep, and generate ideas.”
Maintaining momentum may be a challenge, especially when there is staff turnover. “When there is turnover, people don’t always see the results of QAPI,” says Leible. However, this will be less of a problem for facilities that have embraced culture change. “If you have a culture where everyone has an equal voice, you will have a leg up. People will feel comfortable speaking up and being heard,” she says.
“If you get past the language, it makes sense to look at the processes you have and the tasks you perform every day. Then you can identify areas of concern and address QAPI in a proactive way.”
Karyn Leible
Leible stresses that how much the team understands and buys into QAPI will depend in part on “how you present the tools. You need to do this and do it well. AMDA is working to develop a program for the team that presents a case study and uses QAPI tools to devise solutions to the problem. We will see more programs and materials such as this to help people get more comfortable using the tools,” she says.
Creating a culture where quality improvement focuses on processes rather than individual blame is more likely to result in positive, lasting change. Wayne says, “When the pressure ulcer rate is too high, let’s look at our process and not jump to blame CNAs for not turning patients frequently enough. When you eliminate the blame, you make it easier for people to be accountable for outcomes.” At the same time, he says, “Once the team is convinced that they won’t be blamed, it is easier for them to own problems and address them.”

When Leaders Love QAPI

Of course, no QAPI program will work if leadership doesn’t embrace it. “Leaders need to take ownership and help remove obstacles,” says Baldrige examiner Laxton.
One important role for leaders is to keep QAPI moving as their facilities work through the five elements. “If they get stuck on an element, leaders need to intervene to keep up the momentum.”
The leadership also needs to get everyone on the same page.
“Leaders need to talk about QAPI in the same way with everyone in the facility. They need to make sure that, as a team, everyone is speaking the same language,” says Laxton.
They also need to ensure that everyone has appropriate access to data, not just for information purposes but to enable everyone to contribute to the collective knowledge.
While leaders need to make sure that everyone is interpreting data objectively, Laxton stresses that they shouldn’t take the passion out of quality improvement. “It’s the passion that gets people up in the morning. You don’t want to minimize that.”
 Golden LivingCenter, Waynesburg, Pa.
He adds, “It’s easy to get data heavy with QI and to get overly analytical. Don’t dial this down, but make sure everyone understands that QI isn’t personal or about pointing fingers.”
Be positive up front about the purpose of QAPI, he says, and “that lets you maintain the passion while addressing the quality.”
Leaders have to “create a culture of transparency,” says Stacey Rose, vice president of quality management at Sava Senior Care Consulting in Atlanta.
“They have to make it clear that it is okay to identify a problem or bring an error to light. Leaders need to help everyone understand that they can help prevent adverse events from happening if they identify and address problems promptly and effectively.”
Finally, says Laxton, leaders need to practice and encourage patience. “QAPI, like any performance improvement [program], takes time. You can’t rush it. To do it right, give it time.”
He observes that going through a full Baldrige cycle takes three to five years, and facilities can expect a similar time frame from QAPI.
Laxton also notes that many practitioners are “high-touch” and that they may feel that asking them to get into data doesn’t fit their personality. However, he says, “Collecting and applying good data is the quickest way to make improvements. Leaders can use the clear effectiveness of good data to push past any resistance to collecting it.”

Size Doesn’t Matter

Even smaller facilities with limited resources can be QAPI-ready. They can start by looking at the five elements and how they relate to the current quality indicators they’re using, and they can try to simplify things instead of recreating the wheel.
Additionally, they can look at the QAPI requirements and determine if the facility is meeting them with the current standards they’re using. If they are doing some type of quality improvement already—and most are—they simply may need to fill in some gaps, change the language to coincide with QAPI terminology, and implement some QAPI-specific tools.
It may be challenging to get the board, employees, residents, and others to understand what QAPI is, compared with what they’re doing now. However, it is worth the effort to conduct training programs and have ongoing conversations about QAPI. With QAPI’s focus, more players than ever will be involved in quality initiatives, and this means more viewpoints, opinions, and input. The key is a lot of communication and the ability to dig into details and track trends. And, ultimately, staff will need to make decisions as a team.
Creating a culture of quality improvement and teamwork takes time, but it is essential to make QAPI successful. Facility teams can’t operate in silos.

Filling a Toolbox That Builds Quality

As much as mechanics have a variety of tools in their toolboxes, facilities need to build a collection of tools for QAPI. “Tools are only effective if they are used in the appropriate circumstances,” says Wayne. Facilities need to use tools that help them conduct effective root-cause analyses and choose areas for improvement based on the highest priority.
“They don’t teach root-cause analysis in school. So we need a structured way of looking at opportunities for improvement and identifying breaks in the system,” says Lisa Zeis, vice president of operational services for The Waters Senior Living in Bloomington, Minn. “There are lots of tools that help with this.” One useful tool for root-cause analysis is the fishbone diagram. This tool, which resembles a fish skeleton, helps categorize the many possible causes of a problem in an organized way.
 Lisa Zeis
Four main steps are involved in creating a fishbone diagram. The “head” of the fish is the problem being analyzed. The larger “bones” closest to the head represent the most likely causes and the ones that have the greatest impact, while the smaller “bones” further from the head represent those having a smaller impact. The completed diagram helps the team identify what problems, or components of the process, they need to focus their attention on to effect positive change.
Another popular tool is the “Five Whys Tool,” which starts with an effective problem statement that describes the current condition or issue. The team asks “why” to the problem statement and then asks why to the answer to that, then why to the answer to that, and so on. Like the fishbone diagram, this tool is designed to fix the system and not just remove the symptoms.
Also useful for root-cause analysis is a Pareto Analysis, which employs the 80/20 rule, that is, 20 percent of causes generate 80 percent of results. A Pareto Analysis helps the team prioritize the changes most likely to improve a situation or process. “This tool helps you see where you will get the biggest bang for your buck,” says McMahon.

More Helpful Tools

A flowchart is another useful tool. A diagram that represents a process, the flowchart shows steps as boxes and their order via connecting arrows. This tool can help the team diagram a solution to a specific problem.
“Flow diagramming can help you look at your current process and identify where there is a potential breakdown, ” Leible says. To help ensure that everyone interprets data consistently across the board, a run chart can be helpful. This is a graph that shows data in a time sequence and enables the team to identify trends and detect outliers.
“How data are presented makes a difference. You don’t want to chase numbers,” says Leible.
When you identify an issue, you need to try to stratify what is causing it by identifying the most common reason for it, says Wayne. “This will help you decide where to prioritize your efforts.” However, he cautions, “You need to help the team to analyze the data properly. Only then can you choose and apply the appropriate tool.” He says that sometimes the team can spend time ineffectively if they don’t understand what the data are telling them.
“If the only tool you have is a hammer, every problem looks like a nail,” says Reinhardt, who stresses the importance of having and using proven tools in a consistent, effective manner. “We have a toolbox that includes several items. No one tool will work in every situation.” It is important to have tools that are part of a systematic problem-solving process.
She says, “If you really want to understand what is going on and determine root causes, you have to understand causal factors and come up with a plan to do something different and not just train people one more time or repeat another inservice. Then you need to make sure that whatever plan you implemented did what you intended it to do.”
Benedictine has a “cheat sheet” for staff with tools they can use and where they can go for training on their use.
“There are so many tools, people may be overwhelmed at first,” says Zeis. She says that facilities have good resources in the form of state Quality Improvement Organizations, state health care associations, and other organizations. These resources, says Zeis, can help facilities put tools into place.
 Matthew Wayne
McMahon is confident that team members will have little problem adapting to the use of various tools.
“If you give them tools that enable better outcomes, they will jump on them because they want to do the right thing for their residents,” he says.

Cloudy Crystal Ball

As much as facilities would like to have a QAPI crystal ball, they can’t predict how the regulations are being written.
“We had expected to see more rules by now, but we are likely to see some firmer regulatory guidance soon about what QAPI will look like from a reporting standpoint,” says Laxton. However, he suggests, “Don’t get caught up on second-guessing the rulemaking. QAPI is a journey, and every organization should be engaged on this at some level.”
McMahon says that whenever a new regulation is promulgated, people panic.
“They don’t know how surveyors will interpret them. They wonder about surveyor training. And they will stress until they have a survey showing that they are doing the right things. After that, they will become less fearful and more confident.”
Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.