Elements for Framing QAPI in Nursing Homes

Working to improve the quality of care delivery to nursing home residents.

Root Cause Analysis (RCA)

This term is used to describe a systematic process for identifying contributing causal factors that underlie variations in performance. It is important to note that RCA focuses primarily on systems and processes, not individual performance. This structured method of analysis is designed to get to the underlying cause of a problem – which then leads to identification of effective interventions that can be implemented in order to make improvements.

RCA helps teams understand that the most immediate or seemingly obvious reason for the problem or an event may not be the real reason that an event occurred. The RCA process leads to digging deeper and deeper – looking for the reasons behind the reasons. This process will generally lead to the identification of more than one root cause. The root cause(s) and any contributing factors can then be sorted into categories to facilitate the identification of various actions that can be taken to make improvements.


Teamwork is a core component of an effective quality improvement (QI) activity and too often it is misunderstood. You will hear and read that you should discuss a situation with “your team,” or that the opinion of “everyone on the team” is valued. The word “teamwork” may have different meanings. Many people work together without being a designated or formal “team.” The characteristics of an effective team include the following:

  • Having a clear purpose
  • Having defined roles for each team member to play
  • Having commitment to active engagement from each member

Problem Solving Model – PDSA (Plan-Do-Study-Act)

Improvement plans and problem solving plans includes identifying areas to work on through comprehensive data review. The problem solving model is a process that runs through small tests of change and then sees whether or not the change(s) made a difference in the area you are trying to improve.

PLAN - the team learns more about the problem, plans for how improvement would be measured, and plans for any changes that might be implemented.

DO - the plan is carried out, including the measures that are selected.

STUDY - the team summarizes what was learned.

ACT - the team and leadership determine what should be done next. The change can be adapted (and re-studied), adopted (perhaps expanded to other areas), or abandoned. The decision determines the next steps in the problem solving or PDSA cycle.


Communication is key to any quality improvement process. Make sure all staff, residents, and families know that their views are sought, valued, and considered in facility decision-making and process improvements by announcing and discussing QAPI in resident and family councils and other venues.

Ask staff, residents and family members to tell you about their quality concerns. Many facilities today are using some type of customer-satisfaction survey. Results should be used to identify opportunities for improvement that will proactively have an impact on all residents and their families.

Data Collection, Measurement, Analysis and Use

Teams will decide what data to monitor routinely. Some examples may include:

  • Clinical care areas e.g., pressure ulcers, falls, infections
  • Medications, e.g., those that require close monitoring, antipsychotics, narcotics
  • Resident satisfaction
  • Caregiver satisfaction
  • Results from MDS resident assessments
  • Caregiver turnover, caregiver competencies, and staffing patterns, such as permanent caregiver assignment.

The data will require systematic organization and interpretation in order to achieve meaningful reporting and action. Otherwise, it would only be a collection of unrelated, diverse data and may not be useful.

Compare this to an individual resident’s health – you must connect many pieces of information to reach a diagnosis. You also need to connect many pieces of information to learn your nursing home’s quality baseline, goals, and capabilities.

Your team should set targets for performance in the areas you are monitoring. A target is a goal, usually stated as a percentage. Your goal may be to reduce restraints to zero; if so, even one instance will be too many. In other cases, you may have both short and longer-term goals. For example, your immediate goal may be reducing unplanned re-hospitalizations by 15 percent, and then subsequently by an additional 10 percent. Think of your facility or organization as an athlete who keeps beating his or her own record.

Identifying benchmarks for performance is an essential component of using data effectively with QAPI. A benchmark is a standard of comparison. You may wish to look at your performance compared to nursing homes in your state and nationally. You may compare your nursing home to other facilities in your corporation, if applicable. But generally, because every facility is unique, the most important benchmarks are often based on your own performance.

You'll want to develop a plan for the data you collect. Determine who reviews certain data, and how often. Collecting information is not helpful unless it is actually used. Be purposeful about who should review certain data, and how often, and about interpreting the information.


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New York

Pauline Kinney, RN, MA, LNHA, RAC-CT
Senior Director, Health Care Quality Improvement
Tel: (516) 209-5402
Fax: (516) 326-0434

Maureen Valvo, RN, BSN, RAC-CT
Senior Quality Improvement Specialist
Tel: (516) 209-5308

David L. Johnson, NHA, RAC-CT
Senior Quality Improvement Specialist
Tel: (518) 320-3516

Dan Yuricic, MA
Senior Quality Improvement Specialist
Tel: (516) 209-5458

IPRO Nursing Home Team