1. Allen, Nancy E. BSN, RNC

Article Content

Just like the song sung by the purple dinosaur, Barney, an effective Quality Assurance Performance Improvement (QAPI) program never ends. As a consultant, surveyor, and Office of Inspector General monitor who has traveled extensively assessing adherence to regulations and the quality of patient care, there are commonalities where organizations "miss it."


One of the most vulnerable areas is the QAPI program that, if not done correctly, can leave an organization, staff, and patients at risk for poor outcomes. Depending on the size of an organization, a QAPI program can become quite complex. However, it is important to keep it simple, break it down in assigned tasks so all can understand and participate.


The Medicare Conditions of Participation mandate the QAPI focuses on high risk, high volume, problem-prone areas and considers the impacts of the incidence, prevalence, and severity of the problems Allen, (2021). With this information one should not be blindsided by serious deficiencies in a survey, audit, or daily operations.


Consider the following steps of a basic QAPI program (CMS QAPI Tools)


1. Develop a QAPI Committee.


2. Determine what data to collect based on requirements of state, federal regulations, and/or accreditation standards pertinent to one's organization.


3. Use lists and templates for process consistency.


4. Create a calendar for when data are to be collected/analyzed and by whom. Examples include infections, complaints, incidents, and patient chart audits.


5. As an organization grows, consider delegating management of tasks. Examples are an infection control preventionist (i.e., pandemic response) or a safety liaison for emergency management.


6. Create committees for areas such as compliance and ethics.


7. Include all personnel in QAPI including aides and clerical staff.


8. Develop compliant audit tools. Self and peer reviews are effective methods to achieve compliance.


9. Educate staff how to use review tools so it is understood what is expected of their documentation.


10. Hold staff accountable for set expectations.



There are two parts of QAPI to be understood.


1. Quality Assurance refers to a retrospective look at the care that has been given to patients and operations over a period of time. Where organizations often "miss it" is that data are collected but that is where it ends, or an action plan is created and not evaluated to see if goals were achieved.


2. Performance Improvement-To improve performance of an organization a Performance Improvement Plan (PIP) should be implemented to correct any identified problem(s) to prevent recurrence. At minimum, the following should be included in the PIP:


* Issue identified/Date


* Action plan and who is responsible for correction


* The percentage goal and date to evaluate the progress.



This process is repeated until the identified issue(s) have been corrected. Even after the problem is corrected, audit tools should capture any relapse of noncompliance. The PIP is then repeated as needed to maintain correction and compliance with the required regulations and/or standards.


By implementing these (The Agency for Healthcare Research and Quality) tried and proven recommendations, a QAPI program becomes effective and minimizes the risks to the organization, staff, and vulnerable patients. This in turn creates the full circle for perpetual improvement and compliance as reflected in the Barney song, "It goes on and on, my friend."




Allen N. E. (2021). Survivor! 10 Practical Steps to Survey Survival. Solutions for Care. [Context Link]




The Agency for Healthcare Research and Quality.