August 13, 2025
McKnight's Long-Term Care News
Anyone with an interest in quality nursing home care should agree on one thing: The moment for Quality Assurance/Performance Improvement (QAPI) is now!
A couple of years ago, a nursing home participating in a California Association of Long Term Care Medicine (CALTCM) educational program demonstrated this with a QAPI project that led to a significant reduction in catheter-associated UTIs. Their QAPI team included CNAs, LPNs and RNs, in addition to the Director of Staff Development, Infection Preventionist, DON, medical director and administrator. A fishbone diagram emphasized the importance of the process and told the story of their success.
There are those who believe the survey process is the only means toward improving quality, while others believe it is primarily a punitive system to punish facilities for their deficiencies.
With an administration that is skeptical of regulatory requirements and a survey process that might undergo major modification, now is the perfect time to focus on QAPI.
In 2015, as Director of Nursing Homes for California’s Quality Improvement Organization, I was responsible for QAPI implementation in California’s nursing homes. As a geriatrician grounded in using experience to guide clinical decision making, I believed in the value of QAPI. But I also saw QAPI treated like many other compliance-laden requirements, hampering opportunities to demonstrate its true value.
The actual value of QAPI has been obscured by its history. QAPI was not grounded in clinical evidence-based literature, but rather grew out of quality improvement approaches in other industries. CMS’s Nursing Home QAPI Demonstration project in 2012 documented little to no evidence of positive outcomes.
Nevertheless, in my personal experience, QAPI has great value when it is properly utilized. We are at a critical moment in relation to the future of nursing homes. We need solutions, and QAPI can provide us an effective path.
Medical directors have a key role in assuring that QAPI is effectively utilized to improve the quality of care in nursing homes. PALTmed, the Post Acute and Long Term Care Medical Association, in our recently updated white paper states, “As the clinical expert and medical leader in the formal program of quality assurance, a PALTC (post-acute and long-term care) facility medical director can connect the QAPI process to improved patient outcomes.”
QAPI is not merely a form to be filled out by the assistant DON, an approach many of us have seen too often. It is an iterative process to be carried out by the entire care team, with the medical director providing the necessary guidance to ensure that the health and well-being of residents are being attended to.
QAPI is about culture, not compliance.
It’s not limited to a monthly meeting, but should be practiced every day by everyone in the facility. The use of “huddles” to address immediate issues that come up daily is an important QAPI-based tool that is known to be a best practice.
Two of my favorite QAPI tools are brainstorming and root cause analysis. All staff need to be engaged in using these tools. Housekeepers and CNAs may have greater insight into the causes of a resident’s issues than a charge nurse.
There are many opportunities to use QAPI in advancing the delivery of quality care. In previous columns, I’ve discussed the importance of appropriate staffing levels and an accurate facility assessment.
While QAPI itself is not grounded in evidence-based literature, using such literature is a fundamental part of an effective QAPI program. A recent paper shared how to use the case mix index to ensure appropriate staffing levels. Using such information in a structured QAPI process effectively promotes improved quality of nursing home care. Facilities should lean into QAPI to determine the most appropriate staffing levels.
A final note on QAPI and its place within facility governance. The nursing home governing body is accountable for QAPI under F-Tag 837. The heightened responsibilities of the governing body not only include QAPI, but also the facility assessment.
Considering that the members of the governing body often have relationships to entities with a financial stake in the facility, it is essential that the governing body is not a “rubber stamp.” It should not only represent ownership and their financial interests, but must also represent the needs of the residents and staff.
As CMS looks to improve the effectiveness of the survey process, QAPI is certainly an area that is ripe for consideration.
Michael Wasserman, MD, CMD, is a geriatrician and member of the Board of Directors for PALTmed (The Post-Acute and Long-Term Care Medical Association). The views expressed here are his own.
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.
