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12 steps to QAPI: Step 12: Take systemic action

September 2, 2014
by Nell Griffin, LPN, EdM
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Nell Griffin, LPN, EdM

Quality Assurance Performance Improvement (QAPI) is data driven. The data available to nursing homes (NHs) to drive their process improvements can come from many sources, but data is needed to make improvements in systems and processes. The 12th, and final, QAPI step is Take Systemic Action. Typically, NHs react to data. The process currently used by NHs is to review data and improve systems as the data indicate a change is needed.

Complaints, surveys, lower quality measures compared with the nation, the state or other peers, or an NH’s own internal numbers for events such as falls or turnover, are examples of data that a facility steering team can use to drive system improvements. Data revealing events with negative outcomes, missed targets or near misses indicate that systemic improvements are needed and that the steering team should consider chartering a performance improvement project team (PIP) to uncover the reasons for the problem by conducting a root cause analysis. Before systemic action can be taken, the root cause has to be identified, as discussed in Step 11.


After identifying the root causes, sustainable corrective actions become the goal. Changes that correct the root cause are the most effective and the most sustainable improvements. Strong corrective actions are those that involve physical changes, force functions or constraints, and simplify the process.

Intermediate actions are those that are somewhat dependent on staff competencies and abilities with accompanying tools to support and assist. Intermediate actions such as decreasing workload, initiating checklists, executing enhanced documentation and communication processes and implementing enhanced or modified software are intended to and likely will improve existing processes.

Weaker actions are those that rely on staff to remember training or policies. Weaker actions include double checks, warning labels or training and education only. These actions likely will enforce existing processes but may be more difficult to sustain. There may be times when each type of action is appropriate.


An objective of QAPI is to be proactive. Adverse events and near misses should always trigger a systematic review, but the goal is to have systems designed to decease the probability of a negative outcome. The “Guidance for Performing Failure Mode and Effects Analysis with Performance Improvement Projects” is a resource designed to support proactive systematic evaluation. The Failure Mode and Effects Analysis (FMEA) is a structured way NHs can identify and then address potential problems and their likely impact on the system before an adverse event occurs. The goal for any healthcare process is to meet each resident’s healthcare needs by delivering consistent, effective, high-quality, cost-efficient, person-centered care to the right person at the right time. The FMEA tool is intended to help nursing homes achieve this goal.

The FMEA tool can be used when evaluating a new process or system, or one that has existed for a while. It can be used by the Steering Team as well as within departments to guide the team through the following seven-step process.

  1. Select a process to analyze.
  2. Charter and select a team facilitator and team members.
  3. Describe the process.
  4. Identify what could go wrong during each step of the process.
  5. Pick which problem to work on eliminating.
  6. Design and implement changes to reduce or prevent problems.
  7. Measure the success of process changes.

To illustrate, few NHs have a systematic process to enhance the quality of residents’ sleep. Although rest and sleep are a major part of the treatment plan for a person with any condition, rest and sleep are rarely included in resident care plans or treatment plans. Because NH populations are comprised of people who often each have several comorbid conditions, improving resident sleep supports person-centered care.

The Midwest Best is a consortium of seven quality improvement organizations (QIOs). On May 6, this consortium sponsored a downloadable webinar titled “A Solution to Preventing Falls and Providing Quality Sleep.” Speaker Sue Ann Guilderman presented the Restorative Sleep Vitality Program. Included in the handouts is “The Restorative Sleep Vitality Program Checklist,” which identifies the top 10 sleep disturbances and interventions that can be implemented.

Detailing the process to enhance a resident’s quality of sleep by addressing these sleep disturbances will involve every department and every system in the nursing home. The FMEA is a tool designed to allow NHs to be proactive and identify potential obstacles and barriers to the consistent successful practice of a process or procedure. By analyzing the impact of NH’s current practices in every department on resident’s sleep, the team will likely uncover improvement opportunities in the systems within each department.

From the 5 Elements (see Step 3) to the 12 Action Steps , QAPI is anchored in system improvement. All the tools and resources are designed and intended to help NHs improve their systems. Process improvement must be a priority. It requires a change in how daily activities are viewed. Looking for improvement opportunities in every event, problem or process needs to be encouraged and practiced. Administrators, director of nursing, department heads and other leaders have a huge impact on the NH culture and staff’s overall mindset.




Nice article. Health care in general has been slow to implement effective root cause analysis and it is good to see the advantages brought out in the article.