By the time this column is published, the new survey and certification rule, including the Quality Assurance & Performance Improvement (QAPI) regulation, may already be published in the Federal Register. This new QAPI regulation represents a major transformation of the nursing center Quality Assessment & Assurance (QAA) regulation along the path that all health care providers are now moving on to improve health care effectiveness.

The QAPI regulation (§483.75) would, according to the Centers for Medicare & Medicaid Services (CMS), “require that a facility develop, implement, and maintain an effective, comprehensive, data-driven QAPI program, reflected in its QAPI plan, that focuses on systems of care, outcomes, and services for residents and staff.”

Where do you start in meeting the requirements for this extensive regulation?

Just like in Deming’s PDSA cycles (plan, do, study, act) that underlie all specific QAPI activities, in its regulation CMS is specific that you begin your QAPI program with a comprehensive QAPI plan: “We propose in new §483.75(a)(2) that the facility must submit the QAPI plan to the state agency or federal surveyor, as the agent of the secretary, at the first annual recertification survey that occurs at least one year after the effective date of these regulations.”

Thus, the QAPI plan is where surveyors will begin to evaluate compliance with this regulation, and, equally important, a successful QAPI program requires that you invest in developing a plan that is designed around the specific needs, people, and processes in your building. A less formal quality assurance process will no longer suffice, even if you have had successes in the past finding and fixing selected quality problems.

Rather, CMS is seeking a more proactive, systematic, and comprehensive approach that goes beyond previous QAA: “While our proposal retains the existing QAA requirements at §483.75(o), these requirements alone do not conform to the current health care industry standards that proactively design quality improvement into each program at the outset, monitor data (indicators, measures, and reports of staff/residents/families), determine root causes of problems, design and use performance improvement projects (PIPs) to promote continuous improvement, develop and implement plans that effect system improvement, and monitor the success of this systematic approach to improving quality.”

To be successful in your QAPI efforts, it is essential that you conduct the QAPI processes yourself based on your residents’ concerns, your organizational structure and staff, your operating systems, and the current challenges that you face. Ensuring quality and improving performance only works if your organization owns it.

It’s no secret that even the perfect plan that contains all of the QAPI elements is of little value if you put it on a shelf and don’t use it. To be effective in health care today, we have to elevate QAPI on par with all other essential services that we provide to our residents.

So after developing your plan, I encourage you to systematize your approach to following and documenting each step. Think of your QAPI plan as a living document that helps you in meeting the dynamic challenges that all of our industry is facing today.