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Embracing QAPI: Part 2: define your organization and the principles that guide your mission.

Instead of taking a wrecking ball to current nursing home (NH) practices, Quality Assurance Performance Improvement (QAPI) strengthens the practices that are working.


Building a strong foundation for quality improvement from the ground up begins with strong leadership. NH administrators and department heads may think they definitively know what is or isn't working well at their facilities and in their departments, but a home's foundation can crumble under the weight of false positives Completing an assessment before implementing a treatment is a best practice that has proven to better target planning, resulting in desired and sustainable outcomes. The third of the 12 QAPI implementation steps is "Take your QAPI 'Pulse' with a Self-Assessment."


The QAPI self-assessment is designed to assist facilities in implementing QAPI. It's located in the appendix of the QAPI implementation guidebook, QAPI at a Glance, and can be downloaded from the Centers for Medicare & Medicaid Services (CMS) website ( Homes should complete the QAPI self-assessment at the outset the implementation process and review it periodically.

The QAPI self-assessment tool helps facilities determine where they stand with the QAPI process--what QAPI components are present and intended for use in ongoing evaluation of the journey's progress.

Indeed, QAPI at a Glance states: "To get you started we've developed a self-assessment tool to take your QAPI 'pulse.'" It will assist you in evaluating the extent to which components of QAPI are in place within your organization and identifying areas requiring further development. It will help you determine how you really know whether QAPI is taking hold."

As with any process or assessment tool, the QAPI self-assessment only has value when its purpose and function are understood and the tool is used. Status assessment is an evidence-based best practice. State quality improvement organizations (QIOs) are helping facilities recognize the value of the self-assessment tool. Locate the QIO in your state at www.


The essence of QAPI is found in the 24 statements of the self-assessment tool. After discussing each statement, the steering committee should select the most applicable rating related to where the facility stands regarding it: Not started, Just starting, On our way, Almost there or Doing great. The assessment provides a space for the steering committee to note which rating it selected.

Consult the directions on how to use the tool before beginning work on QAPI. Use it annually or semi-annually to evaluate progress. This assessment is intended to be an honest reflection of a home's progress and to direct the steering committee to areas where improvements can be made.

At some facilities, the steering committee must meet more than once to define its purpose and develop its functionality. In homes without a QAPI steering committee or where the steering committee is just being formed, the administrator can complete the initial QAPI self-assessment. The administrator, however, only should complete the initial self-assessment once. A plan should be created for the steering committee to assume self-assessing responsibility by the next scheduled review.

The steering committee should become a deliberate team with a clear purpose, defined roles and members committed to active engagement.


The administrator should train and educate the QAPI steering committee on becoming an effective team, and the QIO can help. Completing the initial QAPI self-assessment and providing training and education aligns with the first of the 12 QAPI implementation steps: Leadership Responsibility and Accountability (for more information on that step, visit article/12-steps-qapi-step-1-leadership).

Every one of the 24 self-assessment statements reflects at least one of the five elements that CMS identified as the building blocks of QAPI, and each aligns with one or more of the 12 steps that build on QAPI principles. The five elements:

* Design and Scope;

* Governance and Leadership;

* Feedback, Data Systems and Monitoring;

* Performance Improvement Projects (PIPs); and

* Systematic Analysis and Systemic Action.

For example, the 11th of the 24 self-assessment statements is: "Leadership can clearly describe, to someone unfamiliar with the organization, our approach to QAPI and give accurate and up-to-date examples of how the facility is using QAPI to improve quality and safety of resident care. For example, the administrator can clearly describe the current performance improvement initiatives, or projects, and how the work is guided by caregivers involved in the topic as well as input from residents and families."

This statement reflects components of all five of the elements and aligns with several of the steps, including Step 1. Which rating the committee selects will depend on the context and applied interpretation of the statement. Because each statement is subjective, QIO facilitators are encouraging homes to write notes in the area provided to detail the reason a particular rating was selected.


In addition to providing a way to evaluate current processes and identify the components that already are in place, the assessment tool also enables facilities to evaluate their ongoing QAPI progress and sustainment. Homes should let their state QIOs know when they have complete the self-assessment.


An organization's mission, vision, purpose and guiding principles make up its foundation. The vision moves the mission forward, the purpose is the reason for the organization's existence and the principles make up the code of conduct that drives the actions of those in and affiliated with the organization.

When people understand their role within an organization, they feel connected to it, feel a sense of belonging and feel empowered. And empowered staff members tend to be happier, long-term employees.

In long-term care facilities, NH leadership may not incorporate the home's mission, vision, purpose and guiding principles into their own daily professional lives or into the functions of the staff members they manage. Most employees are aware that these standards exist, but they don't know what the standards are. Instead, in a home, direct care staff members define their roles by the tasks they are required to complete for any individual shift.

QAPI will incorporate the mission, vision, purpose and guiding principles into the daily professional behaviors of all NH employees. That's why each home needs to ensure it has identified its mission, vision, purpose and guiding principles as part of QAPI.

Facilities can use "A Guide to Develop Purpose, Guiding Principles and Scope for QAPI" to formalize the purpose, guiding principles and scope for QAPI in their care communities into a written document. Step-by-step instructions are located in the appendix of this CMS-endorsed, downloadable tool. Visit cms. gov/Medicare/Provider-Enrollment-and-Certification/ QAPI/Downloads/QAPIPurpose.pdf to download it.


The tool for QAPI Step 4 is divided into six parts and includes examples. The first step is to locate or develop the vision statement. The tool includes an example of a vision statement.

QAPI encourages each home to use an all-inclusive process, rather than just involving leadership, to create the vision statement as well as the mission statement and principles. The vision statement is a written picture of the organization's future and is intended to inspire and connect all staff. Because most employees don't know their employer's vision, the intent of the vision statement often goes unrealized. QAPI recognizes this gap and bridges it with a foundation that involves all staff members in steps from planning to implementation.

For many facilities, developing the vision statement embodies a culture shift. That's because the statement represents the strategic plan for the future of person-centered care, focusing on the individual needs and preferences of both staff and residents. So the focus shifts from the staffs schedule to meeting the resident's individualized needs, including the staffs input.


The second part of QAPI Step 4 is to locate or develop your organization's mission statement--a description of the home's purpose. It is the framework for formulating strategies, defines the overall goal and outlines how decisions are made.

As does the vision statement, the mission statement reflects the facility's path to meeting each individual's care needs. The example of the mission statement provided in the guide demonstrates how the mission statement builds on the vision. Input from the staff as well as leadership is key to developing a mission statement that truly reflects person-centered care and provides a written picture of the home's reason for doing what it does every day.


Describing how the vision and mission will support QAPI is the third part of QAPI Step 4. Develop a purpose statement, which is a written declaration of what a home intends to accomplish through QAPI. This statement is the connecting path to the vision and mission statement. It speaks to how the vision and mission will be accomplished.

CMS also provides an example of a purpose statement in the aforementioned guide tool. As with the mission and vision statement, staff input is vital to the viability and usefulness of a home's purpose statement.


The fourth part of the stairway leading to the development of the purpose and scope for QAPI is to establish guiding principles. The facility's principles are the moral rules or beliefs that influence the staffs actions by helping them know what is right and what is wrong. These principles explain why and how a home does what it does by detailing its QAPI philosophy. This part of QAPI Step 4 also includes examples of several guiding principles.

As with all the other parts of developing this portion of the QAPI process, this one requires staff input. It is the foundation of the facility's culture and directs the actions of every person working in it. Staff input is critical to the strength of this foundation and compliance with the expected behaviors and actions.


Parts five and six of QAPI Step 4 are to define the scope of QAPI in your organization and then assemble the document. The scope speaks to the types of care and services provided and the effect on the home's clinical care, quality of life, resident choices and care transitions. In these final two parts, the facility describes how QAPI will be used for the ongoing assessing, monitoring and improving of performance for the identified care and services. After completing parts one through five and receiving input from staff, residents and family, the documents are assembled in preparation for writing the QAPI plan.

Editor's note: This is the second article of a series offering advice on successfully implementing Quality Assurance Performance Improvement in your organization.

Nell Griffin, LPN, EdM, is a Healthcare Quality Improvement Facilitator, a certified TeamSTEPPS Master trainer and author. She can be reached at nell.griffin@
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Title Annotation:POLICY MATTERS
Author:Griffin, Nell
Publication:Long-Term Living
Date:Apr 1, 2014
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