The Role of the Medical Director in QAPI in LTC

PALTmed (Post-Acute and Long-Term Care Medical Association) advocates that medical directors  lead the way in setting the standard for appropriate clinical care practices to improve quality within post-acute and long-term care (PALTC) facilities. Medical directors may fulfill the leadership role in collaboration with the interdisciplinary team in facility quality assurance and performance improvement (QAPI) programs in the following ways:

Participate as an active member of the facility’s Quality Assessment and Assurance (QA&A) Committee, which implements the Quality Assessment/Performance Improvement (QAPI) program.  

• Meet with the QA&A Committee at least quarterly, if not monthly.
• Review facility quality data through the QAPI program at a frequency that ensures adequate knowledge of clinical improvements needed and/or in progress.
• Analyze QAPI issues using strategies such as Root Cause Analysis and Plan-Do-Study-Act (PDSA) methodology.
• Reconcile concerns of clinical quality involving the medical staff, including having a mechanism to evaluate situations where the medical director is the attending physician.
• Personally participate in and take a leadership role in QA&A efforts. In unusual instances where a designee is filling in for the medical director, the medical director should ensure that the designee (not another required member of the QA&A Committee such as the director of nursing) possesses knowledge of the facility’s policies and procedures,  practices, assessment, and priorities so that the designee may fully participate and add value to the QAPI program comparable to that of the medical director.

Uphold the standard of appropriate care practices within facility QAPI programs, including medication regimen review (MRR), infection prevention and control (IPC), and other clinical issues as identified in the annual facility assessment, survey findings, and other quality improvement efforts. 

• Promote adherence to the facility policy on response time and comprehensive, documented rationale for responses to pharmacist MRRs.
• Ensure that medical care and prescribing are consistent with current standards of practice for medication use, including psychotropics and antimicrobials.
• Ensure adequate management and documentation on the use of psychotropic medications, including accurate clinical indications, appropriate gradual dose reductions, non-pharmacological interventions, monitoring for adverse effects, safe medication tapering, obtaining informed consent, and appropriate use of medications administered on a p.r.n. basis.
• Implement a facility process to evaluate each resident’s medical condition and medications during key events, such as admission or readmission to the facility or other transitions, significant changes in clinical condition, and when concerns are raised by the MRR.
• Ensure that new medications ordered as emergency measures are reevaluated once the emergency is resolved.
• Collaborate with the facility to provide feedback and data to prescribers through the facility’s IPC program, and promote compliance with IPC and antimicrobial stewardship programs, such as avoiding unnecessary antibiotics for asymptomatic bacteriuria.
• Review facility assessment data to guide competent clinical care based on facility case mix and individual resident needs.
• Pursue medical education that enhances the skills necessary to provide oversight of QAPI programs in PALTC, including understanding current standards for MRR, appropriate use of psychotropic and non-psychotropic medications, IPC, medical errors, patient monitoring, medically necessary treatments, and care planning. 

Share updated processes, guidelines, standards of care, and QAPI issues with other facility medical providers through regular written and/or verbal communications.

Background

Since the first published Institute of Medicine (IOM) study in 1986, quality of care in nursing homes has had a federal regulatory focus. The 1986 IOM study, entitled Improving the Quality of Care in Nursing Homes (Institute of Medicine (US) Committee on Nursing Home Regulation. Improving the Quality of Care in Nursing Homes. (Washington DC: National Academies Press (US); 1986.), spawned the Omnibus Budget Reconciliation Act (OBRA) ’87, a federal law that reformed nursing home regulations. In July 1995, the OBRA enforcement regulations became effective and created changes to the long-term care industry focused on improving quality of life and quality of care. Included in these regulations were provisions for oversight of clinical care by a physician designated as the facility medical director. 

In 2022, the National Academies of Sciences, Engineering, and Medicine (NASEM) report highlighted the lack of information on characteristics and expertise of medical directors, including characteristics tied to quality (Travers JL, et al. 2022 NASEM Quality of Nursing Home Report: Moving Recommendations to Action, J Am Geriatr Soc. 2023 Feb; 71(2):318-321. doi: 10.1111/jgs.18274.). The NASEM report pointed out the potentially negative impact of infrequent medical visits and lack of medical director and attending clinician involvement on nursing home quality, and recommended the establishment of education and competency requirements for medical directors in areas pertinent to nursing home quality. 

QAPI amounts to much more than a provision in federal statute or regulation. Per the Centers for Medicare & Medicaid Services (CMS), QAPI represents an ongoing, organized method of doing business to achieve optimal results, involving all levels of an organization. (QAPI Description and Background | CMS). The CMS State Operations Manual (SOM) Guidance to Surveyors for Long Term Care Facilities provides guidance for interpreting nursing home federal regulations, referencing medical director oversight and responsibility roles in QA&A in long-term care facilities. 

Since 2024, CMS has designated skilled nursing facility medical directors as “managing employees,” with reporting requirements for public disclosure by participating skilled nursing facilities (r12393PI.pdf). Federal guidance does not explicitly delineate the extent, methods, or authority of medical directors. PALTmed interprets the medical director’s broad federal mandate for overall coordination of medical care to extend to oversight of all relevant areas of clinical care within the facility. 

State Operations Manual (SOM), Guidance to Surveyors for Long Term Care Facilities

Nursing facilities must designate a physician to serve as medical director, and the medical director is responsible for the implementation of resident care policies and overall coordination of medical care per federal regulations (Title 42, CFR §483.70(g)). Appendix PP of the SOM provides guidance to surveyors on the federal regulations grouped by F tag number for citing deficiencies. Several of the F tags regarding the role of medical directors and the provision of quality in nursing homes are summarized in Table 1. (Medicare State Operations Manual; SOM - Appendix PP) Medical director participation may expand beyond the formal QAPI program to include additional activities aimed at improving resident care. For example, the medical director may review incident reports related to patient care or employee injuries to assess for trends and opportunities to improve quality. A focus on designated clinical areas such as nutrition and hydration, functional decline, or falls may be conducted by establishing separate QAPI programs or Performance Improvement Projects (PIPs) to review these specific issues. The medical director also may provide education to families, medical providers, consultants, and facility staff.

PALTmed, the medical specialty society representing the community of medical directors, physicians, nurse practitioners, physician assistants, and other practitioners working across the PALTC continuum, has long advocated that the SOM reflect a stronger leadership role for the medical director.   The revisions to the SOM implemented in April 2025 explicitly outline a more prominent role than ever for medical directors.

Medical directors should help set the standard of appropriate clinical care practices to improve quality within PALTC communities and should play a key role in developing and implementing resident care policies that affect clinical care. In collaboration with the director of nursing, administrator, medical staff, and other facility leaders, medical directors should assist the facility in establishing systems to review and provide appropriate feedback on the quality of clinical care, participate in the facility’s QA&A processes, and help the facility establish a safe and caring environment for providing medical care.

Additionally, medical directors should provide oversight and review of attending physician services, including ensuring oversight by another clinician to assess the medical director’s performance as an attending physician. Performance reviews should be conducted as part of the QA&A process and may include evaluation of physician behavior in the facility, timely visits, appropriate antimicrobial prescribing, responsiveness to facility MRR, and timely and adequate response to resident changes in condition. Effective review necessitates open communication with other clinicians, facility staff, and leadership.

QAPI necessitates that PALTC medical directors identify appropriate areas for review and data for collection, review and analyze collected information, help develop useful care quality indicators, guide the facility’s development and implementation of resident care policies and coordination of medical care, make recommendations to the administrator and director of nursing to help improve care and operational issues related to clinical care, and participate in problem-solving. The work of PALTmed (under the previous names of AMDA – The Society for PALTC Medicine or the American Medical Directors Association) is referenced repeatedly within the SOM and recognized as a reputable source of clinical guidelines and medical guidance.

Medical Director QAPI Skills

QAPI is the coordinated application of two mutually reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving (QAPI Description and Background | CMS). The Five Elements of QAPI per CMS are (1) Design and Scope, (2) Governance and Leadership, (3) Feedback, Data Systems, and Monitoring, (4) Performance Improvement Projects, and (5) Systematic Analysis and Systemic Action (qapifiveelements.pdf.)

To participate in QAPI, medical directors require strong communication and leadership skills, access to performance indicators, and the time and authority to participate in performance improvement. Medical directors who are active in the QAPI process assist the facility with analyzing data and interpreting results, and should practice the skills fundamental to QAPI such as Root Cause Analysis and the iterative Plan-Do-Study-Act (PDSA) methodology. 

PALTmed, Medicare Quality Improvement Organizations (QIOs), and other organizations provide resources and education for medical directors seeking to strengthen QAPI skills. The PALTmed Core Curriculum on Medical Direction includes learning modules on regulations, surveys, leadership, organizational structure, documentation, the Resident Assessment Instrument, quality management, IPC, antibiotic stewardship, quality improvement, risk management, systems theory, and problem solving.  Completion of the Core Curriculum is a step toward certification as a Certified Medical Director or towards a Fellow of PALTmed designation for eligible medical directors and clinicians through PALTmed. 

Tools for Assessing Quality in PALTC

Federal regulations associated with F Tag 867 (QAPI/QA&A Improvement Activities) require data collection, monitoring, and feedback to generate improved outcomes through QAPI programs.  Such assessment allows for identification of gaps and necessary interventions to improve resident outcomes. Medical directors may consider utilizing the following tools for data monitoring.

The Minimum Data Set (MDS): The MDS ensures that facilities implement standardized assessment for care management in nursing homes (Minimum Data Set (MDS) 3.0 for Nursing Homes and Swing Bed Providers | CMS). On a quarterly frequency, the MDS reports assessments that include each resident’s cognitive patterns, mood, behavior, routines, gait and falls, pain, activities of daily living (ADLs), diagnoses, symptoms, swallowing and weight loss, oral and dental status, pressure ulcers, restraints, and preference to return to the community. The data that drive facility quality measures and indicators are often derived from the MDS. 

The Facility Assessment: The facility must conduct and document a facility-wide assessment to determine what resources are necessary to competently care for its residents (42 CFR§483.71), and the medical director must be actively involved in this process. The assessment is reviewed and updated at least annually and whenever there is, or the facility plans for, any change that would require a substantial modification. The facility assessment must address or include the following: resident population and care needs, facility resources and services, and risk/hazard assessment.  

Quality Indicators: CMS maintains databases of quality indicators that facilities should provide to medical directors for monitoring quality data. The Nursing Home Quality Initiative (NHQI) website provides information and resources about the MDS, Care Compare, payment, quality measures, and survey and certification information for providers. This website provides information about quality measures that are shown on the Care Compare website, which allows consumers, providers, states, and researchers to compare information on nursing homes using a 5-star rating. Survey indicators and results such as components in the Quality Indicator Survey (QIS) uses an automated process that guides surveyors through a structured investigation intended to allow surveyors to systematically and objectively review all regulatory areas and subsequently focus on selected areas for further review. CMS survey data evaluate facility data and performance and compare an individual facility’s performance with other facilities in the state and nationally, along with comparing the facility’s current and past performance.

Internal facility reports. Monitoring systems may be developed internally by the facility or a corporate entity. Dashboards, for instance, have been developed to provide an overview of clinical issues such as falls and incidence of acquired pressure ulcers or may be administrative (for example, MRR response time or nurse turnover). 

Conclusion

Medical directors have an essential role in promoting QAPI within PALTC. As the clinical expert and medical leader in the formal program of quality assurance, a PALTC medical director has the opportunity to connect the QAPI process to improved patient outcomes. Independent of the regulatory requirement, education and engagement of staff, residents, and other stakeholders for quality assurance is fundamental to maintaining and improving quality of care. PALTmed continues to develop tools, guidelines, and official statements to assist members with improving and maintaining quality and participating in QAPI in PALTC facilities. The engagement of a committed medical director significantly and positively impacts facility culture and professionalism, which in turn directly influences the quality of all services provided.

Table 1. Sample of F Tags referring to the role of medical directors in QAPI

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IMPORTANT UPDATE: This resource supersedes C11 – The Role of the Medical Director in Quality Assurance & Performance Improvement (QAPI) in Long-Term Care, originally published in March 2011.