Quality Assurance and Performance Improvement (QAPI)


In accordance with 42 C.F.R. § 483.75(o), nursing homes must have a Quality Assessment and Assurance team to review and ensure standards of care. To cultivate both quality of care and quality of life in nursing homes, the Affordable Care Act § 6102 requires nursing facilities to also adopt a system to 1) continuously identify and correct deficiencies and 2) promote and sustain performance improvement. [1]

In March 2010, the Affordable Care Act allowed the Centers for Medicare and Medicaid Services (CMS) to establish Quality Assurance and Performance Improvement (QAPI) guidelines in order to continuously expand the level and scope of performance improvement in nursing homes. CMS has yet to develop any regulations regarding QAPI. However, CMS has developed the Five Elements to provide a general framework for nursing homes to implement QAPI.[2]

Affordable Care Act § 6102 (c)

The Affordable Care Act requires that all Skilled Nursing Facilities (SNF) develop QAPI programs.[3] QAPI is a data-driven proactive approach to improving the quality of life, care, and services in nursing homes. It involves members from all departments in order to identify opportunities for improvement, address discrepancies in systems, develop processes for improvement, and continuously monitor the effectiveness of interventions.

Quality Assurance

Quality Assurance (QA) is the process of meeting quality standards and assuring that care reaches an acceptable level. Typically, goals are set by the facility in order to comply with regulations. QA is a reactive approach to examine if the facility failed to meet any standards.  

Performance Improvement

Performance Improvement (PI) is a proactive and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of problems. QAPI, in combination, merges two approaches to quality of care that both aim to improve healthcare standards and quality of life.

Five Elements of QAPI

  1. Design and Scope: A QAPI program must be ongoing and comprehensive in all departments of the facility. QAPI should implement clinical care, quality of life and resident choice, aiming to provide safe and high quality clinical care while integrating autonomy and choice for residents.

  2. Governance & Leadership: A governing body is required to develop adequate QAPI efforts and seeks input from facility staff, residents, and family members. The governing body is responsible for ensuring a safe environment for residents and implementing resident centered care.

  3. Feedback, Data Systems and Monitoring: Feedback systems that actively incorporate input from staff, residents, and family will help monitor care and services. Receiving input from multiple sources helps review the facility’s performance, including tracking, investigating, and monitoring adverse events.  

  4. Performance Improvement Projects (PIPs): A PIP is a concentration on a particular area of the facility’s operation. Facilities conduct PIPs in order to examine and improve care in areas that require development.

  5. Systematic Analysis and Systemic Action: The facility should use a systematic approach to determine when in-depth analysis is needed to understand the problem, the causes, and implications. The facility should develop a procedure in order to analyze the root cause of the problem.

Developing a QAPI program will ultimately enhance the quality of life, care, and services provided to residents by not only meeting the minimum requirements, but going beyond to increase the quality of care and living in SNFs.


[1] Patient Protection and Affordable Care Act § 6102 (b)

[2] http://www.cms.gov/Medicare/Provider-Enrollment-and Certification/QAPI/Downloads/qapifiveelements.pdf

[3] http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/qapidefinition.html