Performance Improvement Projects put focus on data-driven decision making

FRIDAY, MAY 31, 2019

For nearly three years, facilities across the nation have been working to fulfil new requirements mandated by the Centers for Medicare & Medicaid Services aimed at improving long-term care. Quality Assurance and Performance Improvement (QAPI), according to CMS, takes “a systematic, comprehensive and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving.” A major component of the Reform of Requirements for Long-Term Care Facilities, QAPI provisions are included in all three phases of the regulations. Phase 3 QAPI requirements emphasize data-driven decision making.
As part of Phase 3, nursing homes must implement performance improvement policies and actions. The actions must be measured and tracked to ensure improvements are realized and sustained. Annually, facilities must complete at least one Performance Improvement Project (PIP). The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility’s services and available resources, as reflected in the facility assessment. One of the five key elements of QAPI, CMS defines a PIP as “a concentrated effort on a particular problem in one area of the facility or facility wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements. The facility conducts PIPs to examine and improve care or services in areas that the facility identifies as needing attention. Areas that need attention will vary depending on the type of facility and the unique scope of services they provide.” CMS recommends that facilities prioritize projects that are high risk, high frequency and/or problem prone areas that impact quality of care and quality of life. Ideally, the PIP should be an interdisciplinary effort that leads to process improvement and better quality care.
PIP process
CMS recommends that facilities use the Plan-Do-Study-Act (PDSA) modelto aid in structuring their PIPs. Divided into four areas, the idea of the model is to help with planning and documenting progress. According to CMS, in the Plan area, facilities should do activities such as establish their objectives and plan for data collection. For the Do area, facilities should carry out their plan, document observations and record data. The Study area is when facilities should do activities such as analyzing the collected data and summarizing what was learned. Finally, in the Act area, facilities should decide what changes need to be made.
PIPs provide opportunities for facilities to be more proactive in identifying and correcting problem areas before they become future survey deficiencies. These projects also help facilities use data to better care for residents and improve their quality of life. The Compliance Store has resources to aid facilities in planning and implementing Performance Improvement Projects. We also have templates for PIPs that address common problem areas for facilities such as pressure injury and medication error reduction. To learn more, go to
Centers for Medicare & Medicaid Services. (n.d.). QAPI at a Glance: A Step by Step Guide to Implementing Quality Assurance and Performance Improvement (QAPI) in Your Nursing Home. Retrieved from:
Centers for Medicare & Medicaid Services. (n.d.). QAPI Five Elements. Retrieved from:

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