Skip to content

Qsource’s comprehensive collection of tools and resources assist care facilities in developing an effective QAPI program. These resources addressed an array of challenges through problem solving, while striving to embed QAPI principles and Performance Improvement Projects (PIP) into the work culture and daily operations of care facilities.

Care and Expertise is the Foundation of a Strong Quality Improvement Program

We assist with the development of QAPI plans for your skilled nursing facility, and work with each department to formalize a written plan that integrates process improvement tools and identifies gaps in systems that can be consistently monitored for improved results.

  • Quality Measure Review & Improvement Plan
  • Care Planning and MDS System Improvement
  • Special Focus Facility (SFF) Assistance
  • Compliance Review
nurse on tablet

Why is QAPI Crucial to Quality Healthcare?

Launching and sustaining a QAPI program opens your team up to a set of rewards that will benefit patients in a number of ways. The rewards of a QAPI program include:

  • Competencies that equip you to solve quality problems and prevent their recurrence
  • Competencies that allow you to seize opportunities to achieve new goals
  • Fulfillment for caregivers, as they become active partners in performance improvement
  • Better care and better quality of life for your residents.

Five Elements for Framing QAPI

CMS identifies five strategic elements that are basic building blocks to effective QAPI. The five elements are your strategic framework for developing, implementing, and sustaining QAPI.


Design and Scope

A QAPI program must be ongoing and comprehensive, dealing with the full range of services offered by the facility, including the full range of departments. The QAPI program should address all systems of care and management practices, and should always include clinical care, quality of life, and resident choice. It aims for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for patients.

two people

Governance and Leadership

The healthcare facility develops a culture that involves leadership seeking input from facility staff, residents, and their families and/or representatives. Adequate resources must be available for all QAPI efforts, which includes designating one or more individuals to lead QAPI efforts. Their responsibilities include setting expectations around safety, quality, rights, choice, and respect by balancing safety with resident-centered rights and choice. This ensures accountability, while creating an atmosphere where staff identify and report quality problems as well as opportunities for improvement.


Feedback, Data Systems, and Monitoring

The facility puts in place systems to monitor care and services, drawing data from multiple sources. Feedback systems actively incorporate input from staff, residents, families, and others as appropriate. This element includes using Performance Indicators to monitor a wide range of care processes and outcomes, and reviewing findings against benchmarks and/or targets the facility has established for performance. It also includes tracking, investigating, and monitoring Adverse Events that must be investigated every time they occur, and action plans implemented to prevent recurrences.


Performance Improvement Projects (PIPs)

A Performance Improvement Project (PIP) is a concentrated effort on a particular problem in one area of the facility or facility wide. It involves gathering information systematically to clarify issues or problems, and intervening for improvements. The facility conducts PIPs to examine and improve care or services in areas that the facility identifies as needing attention. Areas that need attention will vary depending on the type of facility and the unique scope of services they provide.

Magnifying Glass

Systematic Analysis and Systemic Action

The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. The facility uses a thorough and highly structured approach to determine how identified problems may be caused or exacerbated by the way care and services are organized or delivered. Additionally, facilities will be expected to develop policies and procedures and demonstrate proficiency in the use of Root Cause Analysis. Systemic Actions look comprehensively across all involved systems to prevent future events and promote sustained improvement. This element includes a focus on continual learning and continuous improvement.

Qsource is ready to implement the necessary practices to help you kickstart an effective QAPI program. With our expertise, there will be no gaps in your knowledge or shortfalls in your care.