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Embracing QAPI: part 5: select the areas for improvement, charter PIPS and improve care practices in your organization.

"In God we trust; all others bring data," said W. Edwards Denting, a global figure in statistics and management sciences. He is credited for his transformational role in quality improvement. Deming was a pioneer at transforming data into knowledge providing the basis for action. The data-driven premise of Quality Assurance Performance Improvement (QAPI) depends on data. Data, however, are not knowledge. They have to be transformed into knowledge, which is the basis for successful action. Like the rest of the world, nursing homes (NHs) are drowning in data. To translate data into action, opportunities for improvement have to be identified and prioritized. This process is discussed in QAPI Step 9: Prioritize Quality Opportunities and Charter PIPs.


The Centers for Medicare & Medicaid Services (CMS) is responsible for both promulgating the QAPI regulation and providing technical assistance to NHs. Within a year of the promulgation of the QAPI regulation, NHs will be required to have acceptable written QAPI plans. Accessing these sites helps NHs with the drilldown process to identify and prioritize quality opportunities and navigate the chartering of Performance Improvement Projects (PIPs).


NHs already hold routinely scheduled meetings to discuss data. Tracking data, such as falls and pressure ulcers, is already a part of what they do. Seeing these incidents as opportunities instead of problems is not a common mindset.

Deciding the area on which to focus improvement actions on is a function of the QAPI Steering Team. Improvement opportunities arise from various sources, such as when an NH's publicly reported quality measures are vastly deficient compared with the state or national rate. The chance to move closer to the state or national rate also presents an opportunity to exceed those rates.

Complaints create the chance to improve satisfaction by improving the process. With improved processes, staff can work more efficiently, increasing job satisfaction and decreasing turnover. Data showing high risk for harm and patterns of high frequency offer improvement opportunities the Steering Team can discuss and decide the priority of efforts. Data showing negative impact on residents' psychosocial well-being, daily life choices or autonomy should be included in the prioritization discussion.


After a purposeful review and discussion of data sources, the Steering Team charters a PIP team to focus on the area that presents the most urgent process improvement opportunity. One of the tools CMS provides is a Brainstorming, Affinity Grouping and Multi-Voting Tool, which helps NH teams collaborate, generate ideas and make decisions about process improvement and priorities.

Not all identified problems, complaints or issues require PIPs. The frequency, level of risk or impact on systems drives the decision for chartering PIP teams. The Steering Team decides whether a PIP charter is necessary based on data, a history of negative outcomes and the potential for resident harm. CMS uses the word "charter" deliberately for PIP formation. PIP charters are specific written missions to solve a specific problem. CMS has released tools, including a Worksheet to Create a Performance Improvement Project, to help NHs visualize the mission.

The worksheet establishes the goals and scope in the overview section, which provides the PIP team with information such as the problem and the reasons the steering team decided to charter a PIP to address them. A timetable and the roles PIP team members are also defined on this tool. The Steering Team may select persons to invite to participate on the PIP, but certain roles should be assigned as part of the charter. Usually, the Steering Team will select a leader for the PIP, but a member of the Steering Team must be the point of contact.

As part of the vision for the project, this tool helps the Steering Team proactively plan the PIP by thinking through the barriers that could block the successful completion of the mission. It also engages leadership to commit to the success of the PIP.

Leadership support is vital to the success of the mission. An NH's leadership has to create the space for the PIP to succeed as part of the charter. The leadership supports the PIP with the time needed to participate, secures any supplies and provides the physical accommodations to complete the mission. One of the major responsibilities of the leadership is to establish the expectation that staff will work on PIPs and that co-workers will support and adjust their schedules to accommodate PIP team members.

Leadership is expected to know the status of the PIPs chartered at the NH. CMS has posted the Performance Improvement Project (PIP) Inventory online tool to help. It assists NHs with tracking their PIPs. List chartered PIPs on this tracking template. Assigning a person to be responsible for updating the template at regularly scheduled intervals allows the Steering Team and leadership to have a means to be informed of the status of each PIP.

Once chartered, the PIP team is entrusted with the mission. Being part of a PIP is an important task that everyone working at, living in or frequenting the NH should take seriously. Whether chosen by the Steering Team or by the PIP team itself, the PIP leader guides the team through an analysis of the data and establishes a proposed timeline for completing the mission. The Goal-Setting Worksheet, located in the appendix of

QAPI at a Glance, is another of the technical tools issued by CMS that can help PIP teams move their missions forward. This worksheet helps establish appropriate goals for Plan Do Study Act (PDSA) cycles, organizational quality measures or improvement initiative as well as PIPs. Planning is one of the keys to QAPI.


QAPI is comprised of structured processes and consistent practicing of evidenced-based practices intended to reduce variations in care practices among staff, which have proven to be contributing factors in errors, adverse events and deficiencies. Planning is an integral part of a structured process. Testing the process, before folding it into the care system, increases the probability of successful integration.


For process improvements to be data-driven, data have to be understood and used. Data identify the improvement opportunities. One of the roles of the QAPI Steering Team is to decide what data sources to use. Team members discuss and interpret the data's meaning and regularly review them. When the data indicate that an NH is performing below state, national or its own expectations in any measured area, the Steering Team may decide to charter a PIP team, which is designed to learn more about a specific area and determine what will improve the performance.

The Steering Team charters a PIP and provides a clearly defined scope and focus to its team members. CMS offers a Worksheet to Create a Performance Improvement Project Charter, which provides the PIP team with directions by defining team members' roles, responsibilities, goals, scope and timing.


The goal of the Steering Team when chartering the PIP is the overall goal. The PIP team establishes small goals to move the team forward and meet the overall goal. One of the PIP team's first goals is to schedule meetings. Doing so can be challenging when the team members work different shifts and different times. NHs must maintain a high-functioning staffing level 24/7.


QIOs monitor official, unofficial public and private data sources for trends to proactively engage healthcare providers as early as possible. The goal is to interrupt patterns indicating negative outcomes. As an example, pressure ulcer prevention remains a focus of CMS and QIOs. Each Medicare-certified NH's quality measures are posted on Nursing Home Compare on the Medicare website (www.medicare/gov/nursinghomecompare), which is updated regularly. The national percent of long-stay, high-risk residents with pressure ulcers is 6.1, while the state percentage in Illinois, for example, is 6.6 percent. The pressure ulcer rate for Illinois is slightly higher than the national rate, but history has shown that pressure ulcer rates tend to increase, meaning that residents continue to develop pressure ulcers while in the care of healthcare professionals.

Some pressure ulcers are unavoidable due to multiple debilitating medical conditions that negatively impact nutrition and mobility. These occur in the sickest of residents and are not the norm. Other pressure ulcers are avoidable. Whenever a resident develops a pressure ulcer, a root cause analysis (RCA) should be conducted to determine if it was avoidable. Every NH should have a process for selecting events or issues to undergo an RCA. The development of a pressure ulcer should always be one of those events.

An RCA is a systematic process to determine the underlying causes or true causes of a problem for the purpose of correcting it. When one resident develops a pressure ulcer, an RCA should be done to learn more. When more than one resident develops a pressure ulcer, however, this could indicate a problem with the current pressure ulcer prevention process, suggesting that a PIP could be chartered to focus more attention on the problem. The best pressure ulcer prevention practices include regular skin assessments, redistributing pressure and maintaining the residents nutrition. Avoidable pressure ulcers occur when skin assessments aren't completed on a scheduled, regular and frequent basis; residents aren't turned to redistribute pressure regularly and frequently; or staff are not aware of a resident's nutritional intake changes.


CMS has provided a downloadable tool to assist NHs--the Guidance for Performing Root Cause Analysis (RCA) with Performance Improvement Projects (PIPs). This tool outlines a seven-step process for a PIP team. Conducting an RCA is the initial part of the process to reveal the root of the problem.

The Steering Team selects one of its members to fill liaison roles that are not necessarily involved in the routine duties of the PIP team. The Steering Team can select a leader and members for the PIP team, but the PIP leader is often empowered to select team members.

Once chartered, the PIP team can begin the seven-step process outlined in the RCA guidance. Identifying the contributing factors and analyzing them will lead to the identification of the underlying process gaps at the root of the problem. The PIP team can then design changes that address the true roots of the problem. The goal is to create strong, corrective actions that improve the process and do not allow errors or omissions to occur.

When the PIP team decides on a corrective action for an identified root cause, the team should test the action to increase the likelihood that the action will both correct the problem and be sustained. The team should complete the QAPI Plan Do Study Act (PDSA) cycles to test the ideas or actions it chooses to correct an identified root cause.

The PDSA cycle template can be used to test any idea or action. With practice, this template will help NH staff become proficient at running PDSA cycles. With each cycle, a little more knowledge is gained until the team agrees whether the idea or action will be an improvement and whether it should implemented. CMS expects NH staff to become proficient in using systematic methods and has provided tools for documenting every step from conception to completion.

The danger of implementing a solution without identifying the root of the problem can negatively impact the entire NH system. Because identifying the root cause is a critical part of improvement processes, NHs are guided through a more detailed process in Step 11: Getting to the "root" of the problem.

Editor's note: This is the fifth article in 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
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Title Annotation:POLICY MATTERS; Quality Assurance Performance Improvement; Performance Improvement Projects
Author:Griffin, Nell
Publication:Long-Term Living
Geographic Code:1USA
Date:Aug 1, 2014
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