Embedding QAPI in the Culture to Combat Staffing Challenges

December 16, 2024

Since March 2020, nursing homes have lost 221,000 jobs. The staffing crisis not only has serious consequences to care but to morale as well. That’s because, without adequate coverage, resident-to-nurse ratios can rise or staff may have to work overtime or pick up uncovered shifts, both of which can contribute to burnout and disengagement. Amid declining morale, now is the time to focus on building a QAPI culture.

An Evolution in QAPI, A Revolution in Mindset
Quality Assurance and Performance Improvement (QAPI) is a data-driven and proactive approach to quality improvement.
While all nursing homes are required to have QAPI programs, CMS’ updated rules of participation have stepped up their scope and importance. Today, QAPI is about addressing more than quality of care or life issues like falls and pain; CMS now requires that QAPI programs deal with the full range of a facility’s processes and systems – everything from resident billing to abuse.

For many nursing homes, this approach will require a complete culture change, says Nancy Tuders, RN, Assistant Director of Education for NADONA. “Rather than simply having a QAPI meeting once a month, QAPI will be the driving force behind everything a facility does.”

Staff Involvement Drives Loyalty
According to Tuders, at the core of this cultural shift is QAPI now requires input from everyone in the facility, and not just leadership. There are a couple of ways facilities can build this level of involvement:

• Subcommittees. In addition to a formal QAPI team, facilities will benefit from forming subcommittees, the members of which are those working in the thick of things every day such as nursing or housekeeping departments. These employees are responsible for doing a lot of the legwork and reporting back up to the QAPI team to effect change more quickly.

• Ad hoc QAPI: These meetings can be initiated any time day or night to address serious issues that could have a wider impact if not addressed right away, like a system failure. The employees involved in these ad hoc meetings will conduct a root cause analysis and start on an intervention. This also enables facilities to demonstrate they’re dealing with adverse events before they occur again.

Everyone involved in QAPI will receive training and education, so they feel informed and empowered to come forward when they have a concern.

“By including everyone in the process, which was historically leadership-driven, employees will feel heard and more valued,” explains Tuders. “Involving employees at all levels and in all areas gives them a purpose beyond just their job description,” shared Tuders. “They will feel more fulfilled.” And when that happens engagement and loyalty rise – critical
amid today’s staffing crisis.

Future Success Starts with Looking Back
With the new rules of participation mention, CMS expects facilities to achieve a new level of quality through a comprehensive approach to QAPI. That requires a close look at your progress to date and evaluating where you can improve to comply with the rules.

As you do so, consider using CMS’ self-assessment tool annually or semi-annually to reflect on your efforts. And keep in mind the five key elements of QAPI in mind in the process:

1. Design and Scope. QAPI must be comprehensive and deal with the full range of services offered and address all  systems of care and management practices.

2. Governance and Leadership. Facilities should develop a culture that involves seeking input from staff, residents, and families, and provide adequate training to all involved so they feel comfortable identifying and reporting quality problems.

3. Feedback, Data Systems, and Monitoring. The facility needs to have systems in place to monitor care and services and incorporate input from all stakeholders. It’s also important to investigate adverse events and implement action plans to prevent reoccurrences.

4. Performance Improvement Project. This is a concentrated effort on a particular problem that involves gathering information and intervening for improvements. “How can a facility assess when it needs to develop a Performance Improvement Project?” asks Tuders. “Audit, audit, audit.”

5. Systematic Analysis and Systemic Action. The facility should use a structured and systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. Facilities are expected to develop policies and procures and demonstrate proficiency in root cause analysis.

In short-staffed environments, there is a lot on everyone’s plate. This new approach to QAPI will require some work upfront, and change won’t happen overnight, but the investment is worth it – improved quality throughout facilities that
positively affects the lives of staff, residents, and families in the process. And it all starts by embedding QAPI in the company culture.

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