This is the fourth column in the series of five addressing how QIS methods can be used in a QAPI system, by showing the parallels between QIS methods and the Five Elements of QAPI. (See

By breaking down Element 4: Performance Improvement Projects (PIPs), the parallels between QAPI and the QIS process are clearly apparent.

The Centers for Medicare & Medicaid Services (CMS) calls a PIP “a concentrated effort on a particular problem in one area of the facility or facilitywide; it involves gathering information systematically to clarify issues or problems and intervening for improvements.”

Recognizing that the QIS was designed for surveyors to determine compliance with regulations rather than intervene to improve performance, conducting a PIP is not, per se, a part of QIS. However, when providers use QIS methods for QAPI, the tools available in stage 2 of QIS can be applied to “gathering information systematically to clarify issues or problems.” In fact, QIS is designed in two stages in order to concentrate effort on a particular problem.

Providers can use stage 1 of QIS to identify a problem area and then concentrate their efforts in stage 2 on clarifying the issues for that problem. The stage 2 protocols can be used as an adjunct in the process of root cause analysis, an essential step in PIPs, to complement other tools that examine care and service delivery systems.

Sometimes, with the combined stage 1 and stage 2 information, “intervening for improvements” is apparent to staff. But for the most part, a PIP carries the QIS process a step further with respect to determining and executing an intervention, with subsequent evaluation for measured improvement.

Element 4 is based on the premise that problems generally result from system breakdowns. Interventions, therefore, need to address how to change the system so it is not susceptible to failures. This is why PIPs are not universal; rather they are targeted to concerns in a specific organization and for specific services.

As CMS says about Element 4, “The facility conducts PIPs to examine and improve care or services in areas that the facility identifies as needing attention,” areas that will vary “depending on the type of facility and the unique scope of services they provide.”

For this reason, stage 1 of the QIS process is an ideal starting point for identifying which quality issue to concentrate on and then start gathering data on it. The Quality of Care and Life Indicators (QCLIs), which are rigorously defined in QIS based on resident, family, and staff interviews, as well as observations and chart reviews for both short- and long-term residents, enable staff to identify “care or services in areas…needing attention.” Based on stage 1, areas can be prioritized for PIPs.

Thus, when used by facilities for QAPI, QIS processes provide a solid basis for Element 4, requiring expansion with respect to development of interventions, measuring results, and implementing improvements facilitywide.

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).