Nursing Home Quality Improvement


Quality improvement is an ongoing strategy for assessing gaps in organizational systems and processes, and identifying opportunities for improvement. QI practice instills a quality and performance improvement culture that supports collaboration among all staff to improve clinical outcomes and quality of life as well as resident and family satisfaction by focusing on the systems that impact quality. These include staffing, communication and teamwork, leadership, compliance, financial operations, and clinical models of care. A culture of quality improvement minimizes the occurrence of healthcare acquired conditions through proactive data based strategies to reduce common geriatric syndromes such as pressure ulcers, infections, falls, avoidable hospitalizations, and inappropriate medication use.


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 proactive 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 both the processes involved in health care delivery and the outcomes for residents and staff.

QA 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 in four primary activities.

  1. Identify opportunities for improvement.
  2. Address gaps in systems or processes.
  3. Develop and implement an improvement or corrective plan.
  4. Continuously monitor effectiveness of interventions.

CMS Tools and Resources to Support Nursing Homes During QAPI Implementation

The Centers for Medicare and Medicaid Services (CMS) has developed a website with extensive resources and tools to use in the development of a QAPI program. Two primary sources of information are QAPI At a Glance which provides detailed information about the “nuts and bolts” of QAPI and the QAPI Five Elements which describes the primary organizational components for QAPI.

The QAPI Self-Assessment provides a comprehensive overview of a facility’s current implementation of QAPI. It is highly recommended that this assessment be completed every 6-12 months in order to identify areas for improvement and monitor progress. 

Basic QI methods are illustrated in the following tools:

  1. Goal Setting Worksheet  
  2. Plan-Do-Study-Act (PDSA) Cycle Template  
  3. Guidance for Root Cause Analysis (RCA) 

CMS will require that all facilities develop a comprehensive QAPI Plan for their facility that is updated on a regular basis. Instructions for developing the plan are available here.

The entire group of QAPI tools can be found at

General QI/QAPI Resources

Process Improvement Handbook: A Commitment to Ongoing Improvement Using a QAPI Framework
This manual provides a straightforward, easy-to-use approach for using basic quality improvement methods and tools in long-term care facilities. It includes a variety of tools based on QAPI principles as well as examples of their use.  

Getting Better All of the Time: Working Together for Continuous Quality Improvement: A Guide for Nursing Home Staff

This comprehensive manual developed by the Cobble Hill Health Center – Isabella Geriatric Center provides practical guidance for the development of person-centered care using a performance improvement model to guide staff in addressing the needs and preferences of residents. It includes perspectives of residents, families, direct care staff, and managers. 

Domestic Lean Goddess Series

The Domestic Lean Goddess – Getting the Kids to School on Time is a short video explaining the use of basic quality improvement tools to improve the process of getting your children to school on time each morning. It reviews the use of the PDSA Cycle (Plan-Do-Study-Act).

The Domestic Lean Goddess Clothing Processing Center – Eliminating the 7 Wastes is a short video about quality improvement methods to increase efficiency, decrease time, and improve flow using laundry day to demonstrate the elimination of waste during a process.

 Donna’s Diary

Donna’s Diary is an interactive website for nursing homes which has entries from a fictitious diary of a director of nursing (DON). The entries contain information representing realistic case studies about the challenges nursing homes face everyday. The solutions offered are based on best practices using QAPI principles and cover a variety of topics including antipsychotics, dementia, urinary tract infections, staff stability, alarms, and consistent assignment. 

Institute for Healthcare Improvement (IHI)

The Model for Improvement, developed by Associates in Process Improvement, is a simple, yet powerful tool for accelerating improvement. Learn about the fundamentals of the Model for Improvement and testing changes on a small scale using Plan-Do-Study-Act (PDSA) cycles. 

Implementing Change in Long-Term Care: A Practical Guide to Transformation

This guide was prepared by Barbara Bowers and others with a grant from the Commonwealth Fund to the Pioneer Network. While it focuses on implementing culture change (not QAPI), it is a good resource on the change process. 



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Contact Us

Nancy (Libby) Lawson, M.Ed., RN
Quality Specialist
Tel: 803-212-7500 ext. 5619