The QAPI (Quality Assurance & Performance Improvement) initiative and its associated Performance Improvement Plans (PIPs) may seem daunting, but to a savvy skilled nursing facility (SNF) leader, they represent opportunities.
A PIP is a concentrated effort on a particular problem that involves systematically gathering information to clarify issues or problems and intervene for improvement.

PIPs are data-driven efforts, meant to focus on high-risk, high-volume, or problem-prone areas. A team of experts comes together for a limited period of time to identify the root cause of the issue and develop a change in a system or process. The goal of the PIP is to solve a problem using a team approach and trial interventions—testing for improvement, prevention, or elimination of the issue.

An Opportunity for Improvement

Fundamentally, the problem-solving approach of a PIP is an opportunity to avoid harm or realize improvements. When the problem is prevented or decreased, residents benefit from an improved quality of life. Moreover, in proposing QAPI, the Centers for Medicare & Medicaid Services’ (CMS’) rationale was that the performance improvement efforts would save time and resources for facilities. While QAPI’s implementation regulations have been delayed, facility leaders have an opportunity to perfect how they select issues for focus in PIPs.

Every facility collects data on topics such as resident outcomes and facility performance. QAPI requirements indicate that organization leaders use a facility assessment to help identify facility-specific issues.

Other possible data sources include facility dashboards, Certification and Survey Provider Enhanced Reports (such as quality measures and survey history), legal/risk reports, employee surveys, resident satisfaction surveys, incident reports, or resident council minutes.

Categorize Data

With so much data, it can be difficult to determine which issues require a PIP and which just need a quick fix. To identify opportunities for improvement, start by categorizing data into five areas: quality of care, quality of life, care environment, regulatory requirements, and facility performance. This will help to filter the data and set priorities for action.
■ Quality of care. Think of quality-of-care areas as those that impact a resident’s health because of something staff do or don’t do that impedes outcomes. Areas that fall under this category include wounds, falls, infections, weight loss, vaccination compliance, and medication errors. When reviewing facility data, look for any area that does or can impact multiple residents.
■ Quality of life. This area pertains to the physical, mental, and psychosocial needs of residents. Issues such as abuse, neglect, misappropriation of resident property, decline in functional status, incontinence, and restraints fall under this category. If the resident council has raised any related concerns under this area, these deserve particular consideration. Several areas under this category are high-risk, such as abuse and restraint use, and thus may be good options for a PIP.
■ Care environment. The environment in which residents live is full of possible high-risk, problem-prone areas, such as alarm use, staff retention, employee health, smoking residents, staff competency, laundry, and concerns with the building and grounds. It is easy to overlook the care environment when considering PIPs, but there are several items that have the potential to impact many residents. In some cases, such as smoking and staff competency, these challenges can be high-risk.
■ Regulatory requirements. Survey deficiencies fall under this category. Consider reviewing the past three years’ worth of survey data to make note of trends, and plan to develop a PIP for areas that consistently show up.

Other regulatory areas to consider are life safety concerns, accreditation requirements, rehospitalizations, and concerns related to the state’s nurse practice act.
■ Facility performance. Many facility leaders have a dashboard that tracks several performance areas that require monitoring. This can be used to identify possible PIPs.

Other areas that fall under this category include quality measures, staff turnover rates, reimbursement, and census concerns. Another important item that falls under facility performance is near misses. Having a number of near misses that are related could benefit from a PIP in order to prevent high-risk, problem-prone areas from impacting a high volume of residents.

Implementing a PIP

Once the data have been reviewed and analyzed, the next step is to prioritize improvement efforts. Nurse leaders should review trends and select high-risk, high-volume, or problem-prone areas, considering the number of residents impacted. Rank the issues in order of severity and risk. When this phase of the process is complete, it is possible a number of PIPs will be needed; if so, keep an inventory list of PIPs.

Once the PIP areas have been identified, gather support and resource approval from the governing body. Maintaining awareness of facility performance and the priorities of executives can help the nurse leader demonstrate strategic alignment of the PIP targets they are recommending.

Form a Cross-Functional Team

Following approval, develop the PIP team. Selection should be done based the issue and what expertise is needed to unravel the issue and implement changes. Providing a cross-functional perspective is a key component of an effective PIP team; having the right members equips the team to solve the issue.

For wounds, this might include the wound nurse. If the issue is call-light response time, it might mean having a nurse assistant on the team. Remember: A PIP team role is an opportunity for staff to develop their leadership capabilities and problem-solving skills. 

Once team selection is made, a best practice is to develop a PIP charter. Articulate the problem to be solved, background information, goals, how progress will be managed, timetable, responsibilities, resources, and barriers or constraints. By defining the project’s scope at the outset, the nurse leader establishes expectations, clarifies what success looks like, and focuses efforts and resources on facility priorities.

Get to the Root of the Issue

Then, the team can come together to conduct a root-cause analysis of the issue. Define processes currently in place, and identify any gaps or opportunities for improvement. Assess where breakdowns occur. Graphical representations, like process maps or flowcharts, can be particularly helpful, as they illustrate breakdowns, unnecessary steps, or workarounds developed. Ensure the PIP team looks at all possible contributing factors before determining a plan of action.

Put Together a Plan

Once the root cause or causes have been determined, it is time to put together the plan of action. Using an improvement model such as Plan, Do, Study, Act (PDSA) can bring structure to the inquiry. The next step is to test the plan of action on a small scale before expanding it to the entire facility. This allows the team to collect data from the trial run to determine if the plan should be adopted and expanded as-is, adapted and reapplied, or abandoned and a new plan or intervention put in place. Remember that even a successful pilot does not guarantee success with broader application; the CMS Sustainability Decision Guide can help to determine whether improvements are scalable and can be maintained.

Throughout the PIP process, there are three key questions the team needs to ask: What is it they are trying to accomplish? How will they know when the change is an improvement? What change or changes can they make that will yield the desired results?

Organizing the PIP around these questions positions the team to identify and seize opportunities for improvement. Although the process can be time-consuming, it positions the facility to achieve positive results for its residents, staff, and other stakeholders.
Amy Stewart, MSN, RN, DNS-MT, is vice president of curriculum development for the American Association of Nurse Assessment Coordination. She can be reached at astewart@AAPACN.org.