Quality Assessment and Improvement


Description and Background


QAPI is the merger of two complementary approaches to quality, Quality Assurance (QA) and Performance Improvement (PI).  Both involve seeking and using information, but they differ in key ways:

  •  QA is a process of meeting quality standards and assuring that care reaches an acceptable level.  Nursing homes typically set QA thresholds to comply with regulations.  They may also create standards that go beyond regulations.  QA is a reactive, retrospective effort to examine why a facility failed to meet certain standards.  QA activities do improve quality, but efforts frequently end once the standard is met.
  • PI (also called Quality Improvement - QI) is a pro-active and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems.  PI in nursing homes aims to improve processes involved in health care delivery and resident quality of life.  PI can make good quality even better.

QAPI is a data-driven, proactive approach to improving the quality of life, care, and services in nursing homes.  The activities of QAPI involve members at all levels of the organization to: identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor effectiveness of interventions.  

Five Elements

We developed a general framework for implementing a QAPI program in nursing homes, based on five key elements of effective quality management. Click Here for detailed information of the Five Elements


The existing Quality Assessment and Assurance (QAA) provision at 42 CFR, Part 483.75(o) specifies the QAA committee composition and frequency of meetings in nursing facilities and requires facilities to develop and implement appropriate plans of action to correct identified quality deficiencies. This provision provides a rule but not the details as to the means and methods taken to implement the QAA regulations. CMS is now reinforcing the critical importance of how nursing facilities establish and maintain accountability for QAPI processes in order to sustain quality of care and quality of life for nursing home residents.

In March 2010, Congress passed the Patient Protection and Affordable Care Act, referred to as the Affordable Care Act. The Provisions set forth at Section 6102 (c) of the Affordable Act provide the opportunity for CMS to mobilize some of the best practices in nursing home QAPI and to identify technical assistance needs in advance of a new QAPI regulation. The provision states that the Secretary shall establish and implement a QAPI program for facilities that includes development of standards relating to quality assurance and performance improvement through regulations.  It also requires that the Secretary provide technical assistance to facilities on the development of best practices in order to meet such standards. This new provision significantly expands the level and scope of required QAPI activities to ensure that facilities continuously identify and correct quality deficiencies as well as sustain performance improvement.

Beginning in September 2011, CMS launched a prototype QAPI program in a small number of nursing homes.  The demonstration provided us with best practices for helping facilities upgrade their current quality programs.  We then combined results from the demonstration with consumer, provider, and stakeholder feedback to establish QAPI tools and resources.