Quality Assurance and Performance Improvement

This Root Cause Analysis (RCA) template will allow facilities to use as a tool to identify and work through the process of doing a RCA.

CMS has added the February 2014 OIG report on Adverse Events in SNFs as well as a listing of Potentially Preventable Adverse Events, the Adverse Drug Event Trigger Tool, Acronyms Related to Adverse Events & a comment they will add more tools and resources.

This study from the Department of Health and Human Services found an estimated 22 percent of Medicare beneficiaries experienced temporary harm events during their skilled nursing facility stays, with 59 percent of these events being preventable.

Appendix PP of the CMS State Operations Manual offers day-to-day operating instructions, policies and procedures as a guide to surveyors of long-term care facilities.

Care Compare has detailed information about Medicare and Medicaid-certified nursing homes. This is a government site.

In this module 2 of TMF's monthly CMD training series, medical directors will understand the importance of implementing a successful infection prevention and control program (IPC) in the nursing home setting and how to integrate IPC into their Quality Assurance Performance Improvement (QAPI) program.

By the end of this module, medical directors will have a solid understanding of quality management and how to implement a strong Quality Assurance Performance Improvement (QAPI) program. They will learn how to structure effective quality initiatives, such as QAPI meetings, so they can identify deficiencies and sustain continuous quality improvement.

This change package is intended for nursing homes participating in the National Nursing Home Quality Care Collaborative led by the Centers for Medicare & Medicaid Services (CMS) and the Medicare Quality Innovation Network Quality Improvement Organizations (QIN-QIOs), to improve care for the millions of nursing home residents across the country.

This video shows how to eliminate the seven wastes: Waiting, Overproduction, Rework, Motion, Processing, Inventory and Transportation. Nursing home staff can view this video to better understand how to make process improvements within their organization.

This video shows how applying the four steps of the Plan-Do-Study-Act (PDSA) cycle pinpoints the root cause of a problem and provides a method for achieving improvement, even in a domestic situation. Nursing home staff can view this video to better understand how to use the PDSA cycle to help improve processes within their organization.

Use this Fishbone Diagram to help your organization conduct a Root Cause Analysis (RCA). Note that there are three different versions of this tool, please pick the version that works best for your facility.

Use this Fishbone Diagram to help your organization conduct a Root Cause Analysis (RCA). Note that there are three different versions of this tool, please pick the version that works best for your facility.

Use this Fishbone Diagram to help your organization conduct a Root Cause Analysis (RCA). Note that there are three different versions of this tool, please pick the version that works best for your facility.

This tool provides information on the five elements of a Quality Assessment and Performance Improvement (QAPI) program that nursing facilities can use to adhere to QAPI practices.

Learn more about the Five-Star Quality Rating System that the Centers for Medicare & Medicaid Services (CMS) created to help consumers compare nursing homes more easily.

Learn more about the Five-Star Quality Rating System that the Centers for Medicare & Medicaid Services (CMS) created to help consumers compare nursing homes more easily.

This Quality Assurance and Performance Improvement tool provides step-by-step directions for developing a QAPI plan for your organization.

This Quality Assurance and Performance Improvement (QAPI) tool can be used to establish the purpose, guiding principles and scope for QAPI in your organization.

These instructions will assist you in developing a dashboard, which can be helpful way to monitor the progress of Quality Assurance and Performance Improvement (QAPI) in your organization by tracking key performance indicators.

This Healthcare Management Forum article focuses on the important role that leadership plays in enabling the conditions for high-quality long-term care.

Learn how to turn your SMART goals into SMARTIE goals and ensure you meet the specific needs of the populations you serve.

The user's manual covers the Centers for Medicare & Medicaid Services MDS 3.0 quality measures. Scroll to the bottom of the page to access the full user's manual.

This Texas Health and Human Services website provides links and resources for MDS completion. It also includes links to other state’s MDS websites.

Find the current version of the RAI Manual in the Download section of the CMS webpage.

How can your nursing home team benefit from using the Quality Assurance Performance Improvement (QAPI) process? Listen to this TMF Quality Innovation Network webinar recording from Sept. 12, 2024, to learn about tools and resources you and your team can use to help guide you through the QAPI process.

In this recorded webinar on Feb. 29, 2024, TMF QIN-QIO specialists provide a Quality Assurance Performance Improvement (QAPI) refresher with a focus on reducing hospital readmissions. Learn the tried-and-true QAPI principles of collecting and analyzing data, determining goals and objectives, and implementation and monitoring.

In this June 27, 2023, recording, TMF QIN-QIO specialists present a Quality Assurance Performance Improvement (QAPI) scenario that focuses on COVID-19 bivalent vaccination rates and highlights the importance of ensuring you have the best members at the table to maximize effectiveness.

In this May 2, 2023, recording, TMF Quality Innovation Network-Quality Improvement Organization (QIN-QIO) specialists provide ways that everyone in your facility can use Quality Assurance Performance Improvement (QAPI) activities for continuous improvement daily, including a scenario on improving COVID-19 bivalent vaccination rates.

In this April 4, 2023, recording,TMF Quality Innovation Network-Quality Improvement Organization (QIN-QIO) specialists demonstrate how Quality Assurance Performance Improvement (QAPI) principles result in better infection control, including increased COVID-19 bivalent vaccine rates.

In this July 11, 2023, recording, TMF QIN-QIO specialists provide tools and explain how to complete a root cause analysis (RCA) and align QAPI goals with your RCA.

In this Aug. 9, 2022, recording of the Quality Assurance Performance Improvement (QAPI) series, the TMF QIN-QIO reviews continuous improvement tools that help nursing homes identify the source problem and potential solutions affecting COVID-19 booster acceptance. We discuss tools such as root cause analysis (RCA), the Five Whys Tool, and a fishbone diagram. Download the PDF handout at https://bit.ly/QII8-9-22.

In this Aug. 16, 2022, recording of the Quality Assurance Performance Improvement (QAPI) series, learn how to develop SMART goals to advance your change efforts to improve COVID-19 booster acceptance. The TMF Quality Improvement Network-Quality Improvement Organization (QIN-QIO) guides you in creating a successful plan using proven performance improvement tools, and in determining process, outcome and balancing measures to track your progress. Download the PDF handout at https://bit.ly/QII8-16-22.

In this Aug. 23, 2022, recording of the Quality Assurance Performance Improvement (QAPI) series, TMF Quality Innovation Network-Quality Improvement Organization consultants illustrate how to gather data from Plan-Do-Study-Act cycles to decide if you will adapt, adopt or abandon your tests of change. Listeners will also learn how to communicate your findings to leadership and set your change in action.

This Aug. 30, 2022, recording of the Quality Assurance Performance Improvement (QAPI) series begins with a discussion on strategies to help boost nursing home vaccine rates with short-stay residents. Then a panel of TMF QIN-QIO specialists answer questions related to nursing home challenges with COVID-19 and vaccinations

This Sept. 6, 2022, session wraps up the TMF Quality Innovation Network-Quality Improvement Organization’s (QIN-QIO) Quality Assurance Performance Improvement (QAPI) series with a self-assessment guide. TMF specialists walk you through a sample assessment based on improving COVID-19 booster rates.

In this Aug. 2, 2022, webinar recording, the TMF Quality Innovation Network-Quality Improvement Organization (QIN-QIO) kicks off a series explaining Quality Assurance Performance Improvement (QAPI) tools, methods and applications, and how to incorporate them into your daily nursing home operations.Download the PDF handout at https://bit.ly/QII8-2-22.

In our recent Quality Assurance Performance Improvement (QAPI) During COVID-19 series, we introduced a fun tool called QAPI Land. In this Nov. 1, 2022, recording, TMF Quality Innovation Network-Quality Improvement Organization (QIN-QIO) specialists show you how to engage your staff and track progress with this tool to improve COVID-19 vaccine and booster rates.

Use this Excel tool to measure and graph your performance improvement measures.

This step-by-step guide, developed by the Centers for Medicare & Medicaid Services (CMS), is a resource for nursing homes striving to embed QAPI principles into their daily work of providing quality care and services.

Download and display this brightly-colored Quality Assurance and Performance Improvement (QAPI) road map where all of your team members can see and access it. This document was designed to help your facility develop and implement a QAPI program.

Use this two-page document as a guide for you and your team as you move through the steps outlined in the QAPI Land document, which is also available in the Resource Library as a PDF.

Use this guide to implement leadership rounding in your facility, a process in which leaders speak directly with staff and residents about their organization’s services and care. This resource will help you monitor your progress in Quality Assurance Performance Improvement (QAPI) initiatives.

Development of quality measures is a crucial element in Quality Assurance Performance Improvement (QAPI) programs. This fact sheet describes the four most common types of measures in a QAPI plan: Structural, Process, Outcome and Balancing.

Download and use this MS Word form to help guide and document your Quality Assurance Performance Improvement (QAPI) meetings. There are suggested topics for nursing facilities to choose as needed, as well as space to add your own topics.

In this first issue of the QAPI News Brief, read a definition of Quality Assurance and Performance Improvement (QAPI), and learn about the 5 Elements of QAPI.

Use this Quality Assurance Performance Improvement (QAPI) form to summarize your problem, root cause analysis, goals, interventions and measures all on one page.

This Quality Assurance and Performance Improvement self-assessment tool can be used for evaluation of your organization's progress.

Nursing homes can use this Quality Assurance Performance Improvement (QAPI) tool to help develop goals that are Specific, Measurable, Attainable, Relevant, Timebound, Inclusive and Equitable, as requested by CMS.

This how-to-guide, developed by the Lake Superior Quality Innovation Network, can help nursing homes write their Quality Assurance Performance Improvement (QAPI) plan.

Nursing homes can use this document to help them work through building their Quality Assurance & Performance Improvement (QAPI) process and plan.

This quality improvement plan provides an example of how to identify a concern, determine the root cause(s) and develop a plan with outcome measures. This is to be used only as a reference.

This quality improvement plan provides an example of how to identify a concern, determine the root cause(s) and develop a plan with outcome measures. This is to be used only as a reference.

Nursing facilities can use this TMF QIN-QIO template when requested to perform a Quality Improvement Initiative (QII) Plan. This template will assist you with performing your root cause analysis and determining what appropriate interventions to implement and monitor.

Use this quality improvement tracking Table as a standalone tool or use it to include additional measures to your quality improvement plan.

This webinar features leadership from Grace Living Center - Tahlequah University Northwest, The Renaissance at Kessler and Wedgewood Nursing Home sharing their experiences in implementing successful strategies and interventions for improving bowel and bladder rates, implementing Quality Assurance Performance Improvement (QAPI) and reducing the use of psychotropic medications.

This article provides information on implementing the TeamSTEPPS® program in nursing homes and other long-term care settings.

This Texas Health and Human Services (HHS) website provides links and resources for MDS completion. It also includes links to other state’s MDS websites.

This storyboard is a colorful, graphic, shorthand representation of a quality improvement project or initiative. It is a communication vehicle to easily and effectively display the work of your team in your quality improvement projects. It can be used as an external vehicle for outreach, an educational component for your peers and staff and a public relations tool at conferences and trade association meetings.

Learn how Spring Branch Transitional Care Center in Houston and the TMF QIN-QIO worked together on a QAPI plan to identify opportunities for quality improvement, as well as how to execute solutions.

Watch this video from the Learning and Action Network National Coordinating Center and discover how applying the 5 S's (Sort, Straighten, Shine, Standardize, Sustain), a quality improvement technique, can improve any work space.

This is a tool to help implement the Plan Do Study Act (PDSA) process improvement method. “Plan”: The organization digs deep to determine the root causes that triggered the need for improvement. “Do”: The plan is put into action. “Study”: How well did the plan work? If it worked well, proceed to “act.” If not, go back to “plan” and start over. “Act”: Integrate successful plans into organizational processes.

Use this Quality Assurance Performance Improvement (QAPI) form in Spanish for Puerto Rico to summarize your problem, root cause analysis, goals, interventions and measures all on one page.

Use this U.S. Spanish Quality Assurance Performance Improvement (QAPI) form to summarize your problem, root cause analysis, goals, interventions and measures all on one page.

This is a tool to help implement the Plan Do Study Act (PDSA) process improvement method. “Plan”: The organization digs deep to determine the root causes that triggered the need for improvement. “Do”: The plan is put into action. “Study”: How well did the plan work? If it worked well, proceed to “act.” If not, go back to “plan” and start over. “Act”: Integrate successful plans into organizational processes.