Using a System’s Approach to Quality & Performance Improvement

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

QI Methodology

The Learning Session walks you through proven QI methodologies focusing improvement efforts towards concrete, measurable goals, and adapting best practices to your specific setting and resident population.

Methodology for Change/Model for Improvement

What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Methodologies for change or Models for Improvement gives us the structure and tools to make changes in our work in a systematic and sustainable way

The Plan-Do-Study-Act Cycle (PDSA) Problem Solving Model

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. One PDSA cycle takes from 5 minutes to 1 week at the very most. It can quickly show an improvement team what can and cannot work for their residents

  • 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. The PDSA process allows an improvement team to test changes and stay organized so that they can decide one of three things after each test:
  • Which changes we want to implement as a better way to do things,
  • Which changes we want to keep testing to make them better, and
  • Which changes are not worth keeping?

Your team will likely do many small tests of change as you decide how to adapt and implement best practices. The PDSA Cycle is a classic, scientific method that we can apply in a very small, focused, and practical way.

QAPI (Quality Assurance & Performance Improvement)

What is QAPI?

QAPI is the coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving.

The Affordable Care Act of 2010 requires nursing homes to have an acceptable QAPI plan within a year of the promulgation of a QAPI regulation. However, a more basic reason to build care systems based on a QAPI philosophy is to ensure a systematic, comprehensive, data-driven approach to care. When nursing homes promote such an approach, the results may prevent adverse events, promote safety and quality, and reduce risks to residents and caregivers.

Although QAPI is the merger of two approaches to quality management, Quality Assurance (QA) and Performance Improvement (PI); both involve seeking and using information, but they differ in key ways:

QA is a process of meeting quality standards and assuring that care reaches an acceptable level. QA is a reactive, retrospective effort to examine why a facility failed to meet certain standards.

PI (also called Quality Improvement or QI) is a pro-active and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems. PI in nursing homes aims to improve processes involved in health care delivery and resident quality of life.

Care systems based on a QAPI philosophy is to ensure a systematic, comprehensive, data-driven approach to care. The approach may prevent adverse events, promote safety and quality, and reduce risks to residents and caregivers.QA + PI = QAPIQA and PI combine to form QAPI, a comprehensive approach to ensuring high quality care. QAPI is a data-driven, proactive approach to improving the quality of life, care, and services in nursing homes. The activities of QAPI involve members at all levels of the organization to:

  • Identify opportunities for improvement
  • Address gaps in systems or processes
  • Develop and implement an improvement or corrective plan
  • Continuously monitor effectiveness of interventions

QAPI Features

QAPI includes components that emphasize improvements that can elevate the care and experience of all residents, and improve the work environment for caregivers. With QAPI, your organization will use a systems approach to actively pursue quality, not just respond to external requirements. Look at the following list of QAPI features and assess how many you are already implementing:

  • Using data to not only identify your quality problems, but to also identify other opportunities for improvement, and then setting priorities for action
  • Building on residents’ own goals for health, quality of life, and daily activities
  • Bringing meaningful resident and family voices into setting goals and evaluating progress
  • Incorporating caregivers broadly in a shared QAPI mission
  • Developing Performance Improvement Project (PIP) teams with specific “charters”
  • Performing a Root Cause Analysis to get to the heart of the reason for a problem
  • Undertaking systemic change to eliminate problems at the source
  • Developing a feedback and monitoring system to sustain continuous improvement

QAPI and Nursing Home Quality Care Collaborative Learning

The Nursing Home Quality Care Collaborative Learning series has QI and QAPI focus for NHs to meet their QI responsibilities in ways that maximize the benefits of QAPI principles.Links below will feature more about the QAPI topic and useful tools.

Use of Data to Drive Improvement

There are many data sources to consider when working on you improvement processes. Your team will decide what data to routinely monitor after discussion of the types of data available to you, the method of collection, monitoring, analysis and usefulness for deciding next steps. Your team should set targets for improvement and measure progress in the areas you are monitoring. Identifying targets for improvement is an essential factor of using data effectively with QAPI.

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
  • 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.

Collaborative Problem Solving/Maximizing Communication and Teamwork

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 memberAwareness of what you are dealing with is the first step in addressing it. Aligning communication and teamwork systems and workflows is key to preventing avoidable healthcare acquired conditions. Effective communication and collaborative problem solving entails a team brainstorming approach:
  • What are possible causes?

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.

  • What causes can you do something about?
  • What’s the easiest to change that has a big impact?
  • What help do you need?
  • How will you know it worked?
  • Who do you need to involve?


Staff Stability/Instability

Look at the organizations existing employee hiring, retention, staffing, orientation, etc. practices and the impact on staff stability/instability. Then measure the different sources of information to determine the root cause of your facility's staff stability/instability:

Change Package

      • Provides a framework to ensure every nursing home resident receives the highest quality care by:
      • Outlines a number of specific interventions that have either proven to be successful or that expert believe will positively impact quality in nursing homes
      • Gives a menu of options from which to select specific interventions

Select a strategy to focus on, and then a change concept, and an action item – then treat that like a PDSA. One action at a time!

What is the Change Package that is part of the NNHQCC?

A change package is a menu of strategies, change concepts and specific actionable items that any nursing home can choose from to begin testing for purposes of improving quality of care. The change package is focused on the successful practices of high performing nursing homes and includes specific replicable actions being taken by high performing nursing homes.

Change Package Strategies

  • Lead with a sense of purpose: The actions of leaders, multiplied by the actions of many, shape a culture and an organization. The foundation of a learning organization rests upon: exceptional leadership; a strong mission and organizational values; and an accepting non punitive culture.
  • Recruit and retain quality staff: A quality-driven nursing home identifies and develops great talent, in whatever discipline they serve, by setting high expectations and fostering an affirming culture. It recruits and hires qualified caring staff that fits its mission, values, and culture, and then cultivates longevity through a supportive work environment. Staff members at every level feel that their primary purpose is to provide quality care to the residents
  • Connect with Residents "CELEBRATE LIVES": Treat residents as they want to be treated, remembering that your facility is their home. Foster relationships with families, and create connections with the community. Provide compassionate end of life care.
  • Nourish teamwork and communication:
  • Teamwork and communication among staff and between staff and residents is nourished by disseminating information in a complete, consistent and timely manner. Strong communication links people and build relationships between staff and residents. High-functioning teams respect one another and work interdependently towards common goals.
  • Be a continuous learning organization: A continuous learning organization: knows where it stands; knows when and how to change; uses data to drive performance; and views the organization as an interdependent system. The interdependent system is described as the combination of the people, structures, and resources that come together within an organization to make it function.
  • Provide exceptional compassionate clinical care that treats the whole person: A focus on the whole person requires staff that knows the residents well and can anticipate their needs. It also requires an engaged and competent medical and care team that effectively manages residents’ changing health conditions and avoids Healthcare-Acquired Conditions (HACs).
  • Construct solid business practices that support your purpose: A well-run nursing home excels as a business yet feels like home. It seeks ways to effectively manage the bottom line with integrity and with the resident as the focus. It runs efficient operations; invests in equipment and supplies to provide the highest quality care; and ensures that its physical and outdoor environments are comfortable and inviting.


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Contact Us

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