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It's Time to Get Back to Understanding QAPI Basics

(QA) and Performance Improvement (PI).”as two separate processes. These have since been streamlined into QAPI, what the Centers for Medicare & Medicaid Services (CMS) defines as “the coordinated application of two mutually reinforcing aspects of a quality management system: Quality Assurance. In the distant past, Quality Assurance (QA) and Performance Improvement (PI) were seen QA is the process used to meet quality standards and ensure that the care and services provided reach acceptable levels. Skilled Nursing Facilities (SNFs) will often set QA thresholds to comply with federal regulations. Typically, SNFs will create standards that go beyond regulations in Quality of Life, Quality of Care, Safety, and Resident Choice. As CMS suggests, “QA is a reactive, retrospective effort to examine why a facility failed to meet certain standards/regulations.” QA activities can and do improve quality, but the activities frequently end once the threshold is met. PI (also called Quality Improvement – QI) is a proactive and continuous study of organizational systems and processes for the purpose of preventing or reducing the likelihood of problems. This is accomplished by pinpointing areas of opportunity for improvement and testing new approaches (or interventions) to fix the underlying causes of “high-risk, high-volume, problem-prone, adverse events” and persistent/systemic problems. PI in post-acute care (PAC) aims to improve processes and solidify procedures into policy.

As CMS indicates, “PI can make good quality even better.”

There are several tools that organizations can use to structure and assist with PI. A Root Cause Analysis can help to identify the major reason why a problem is occurring so that appropriate interventions can be applied to correct the issue. The 5 Why’s, in which the QAPI team defines the specific problem and determines the potential causes of the problem (i.e., Why did that occur? And then, why did THAT occur?) can help to find the “root cause” and suggest possible improvements.

Next, the Plan-Do-Study-Act (PDSA) model can be used to guide the improvements that the QAPI team has identified as top priorities. By relying on PDSA cycles, performance improvement plans (PIPs) can meet the aim of continuous and sustainable improvement. First, the team should Plan which problem to target, the intervention or approach to use, and which staff should be involved. Next, the team will Do the plan and track their observations or data for a limited period of time (e.g., days, weeks, or months). The team should then Study the data to determine whether the intervention resulted in the desired improvements. Then, the team will Act on the results by continuing the intervention, adopting a different approach, or establishing new policies and procedures based on the results. Finally, the PDSA cycle starts again with the same problem (if a new intervention will be attempted) or by initiating a new PIP. QAPI may seem like a daunting task, but there are many resources and tools available to support improvement efforts. CMS, the Agency for Healthcare Research and Quality (AHRQ), the Institute for Healthcare Improvement (IHI), and your local Quality Improvement Organization (HSAG) offer training, toolkits, and step-by-step guides to ensure success. Covenant Health Network is also always happy to provide training, coaching, or informal discussions on QAPI for managers and frontline staff.


  1. Agency for Healthcare Research and Quality.

  2. Center for Medicare & Medicaid Services. (2021). QAPI resources. Accessed from:

  3. Center for Medicare & Medicaid Services, University of Minnesota, & StratisHealth. (2012). QAPI at a glance. Accessed from:

  4. Health Services Advisory Group. (n.d.). The CMS QAPI guide: What you need to know. Accessed from:

  5. Institute for Healthcare Improvement. (2022). Quality improvement essentials toolkit. Accessed from:


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