QAPI Plan Template

Use the QAPI Plan Template to design your QAPI program, ensuring comprehensive planning and continuous enhancement of healthcare services.​

QAPI Plan Template



2QAPI Plan

1. Is a vision statement provided? Does it provide inspiration and a framework for strategic planning?


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2. Is a mission statement provided? Does it guide the actions of the organization and provide direction to decision-making?


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3. Are guiding principles provided? Do these principles guide staff to deal with crucial elements in the organization?


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4. Is a purpose statement provided? Does it spell out how QAPI will help the organization with its mission and vision?


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Design & Scope

1. Does the scope of the QAPI program encompass all segments of the following: • Administration • Pharmacy • Hospice • Infection Prevention and Control • Palliative care • Restorative care • Post-acute care/Transitional care • Activities • Long term care • Social Services • Dementia care and services • Nursing services • Dietary/Dining/Nutrition • Resident & Family Engagement • Housekeeping • Discharge Planning/Return to the Community Planning • Maintenance and Engineering • Rehabilitation services • Therapy


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2. Does the QAPI Plan describe how it will address key issues of high-quality clinical care, individualized goals and approaches for care, quality of life, and organizational management practices?


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3. Does the QAPI plan include the following policies and procedures: • Identify and use data to monitor its performance; • Establish goals and thresholds for performance measurement; • Utilize resident and staff input; • Identify and prioritize problems and opportunities for improvement; • Systematically analyze underlying causes of systemic problems and adverse events; • Develop corrective action or performance improvement activities • Utilize the best available evidence


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Quality Assessment And Assurance (QAA) Committee

1. Does the organization have the following key people on its committee? • Executive Leadership • Medical Director • Director of Nursing • Infection Preventionist (Phase 3) • Others


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2. How often is the meeting frequency?


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3. Are the following essential elements addressed: • A systematic approach to gathering input from staff, residents, families, and stakeholders • Adequate resources—time, money, etc. • Ongoing and consistent staff training • Accountability for processes and results • Balance culture of safety and rights • Instill a non-punitive culture, just a culture


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4. Are the essential elements communicated to the following stakeholders: • Board of Directors/Corporate leadership • Manager staff • All staff • Residents • Families


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Performance Improvement Projects

1. Are potential topics for PIPs identified?


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2. Are criteria for prioritizing and selecting PIPs described?


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3. Does the QAPI Steering Committee analyze performance to identify and follow up on the following areas of opportunity: • Aspects of care occurring most frequently or affecting large numbers of residents • Diagnoses associated with high rates of morbidity or disability if not treated in accordance with accepted standards of care • Issues identified from demographic and epidemiological data • Access to care post-discharge • Resident/family expectations • Regulatory requirements • Availability of data • Ability to impact the problem and available resources • Critical incidents • Near misses • Safety concerns • Survey deficiencies scope and severity


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4. Is it described how and when PIP charters will be developed?


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5. Is it described how to designate PIP teams?


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6. Is it described how the designated team will conduct the PIP?


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7. Are the results of PIP communicated via: • Dashboards • QAPI interdisciplinary meetings • Board meetings • Posters • Bulletin boards •Newsletters


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8. Does the QAPI committee ensure that the following groups are informed of PIPs and other QAPI activities: • Board members • Staff • Residents • Families • Volunteers • Community members


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Systematic Analysis And Systemic Action

1. Are these indicators planned for evaluation: • Facility Assessment • QAPI Self-Assessment • Resident Satisfaction • Staff Satisfaction


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2. Are the following tools used to identify root causes of issues: • Five Whys • Flowcharting • Fishbone Diagrams • Failure Mode and Effects Analysis (FMEA) • Cause and Effect Diagram • Driver Diagram • Run Charts/Control Charts • Scatter plotting


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3. Are the following courses of action implemented to promote sustainable improvement: • Update policies and procedures that support the change • Clearly define roles and responsibilities for new actions • Communication of the change(s) and its purpose to all those needing to carry out the new actions • Identify and correct barriers/roadblocks that may be in the way of doing things the new way • Integrate the new change(s) into new employee orientation and training • Ensure that there is adequate funding to support the change


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4. Are the planned changes/interventions implemented and effective? • Choose indicators/measures that tie directly to the new action • Conduct ongoing periodic measurement and review to ensure the new action has been adopted and is performed consistently • Review some measures more frequently (even daily) by staff to show incremental changes, which can serve as a reminder for the new action and provide encouragement and reinforcement • Based on the measurement review, make changes in procedure(s) as needed to help facilitate the change


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Current QI Projects

1. What QI Projects are you currently working on?


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2. Are the following organizational goals considered: • Building/Physical • Plant/Foundational • Staff stability • Consistent Assignment • Person-Centered Care


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3. Are the following clinical goals considered: • Pain • Pressure Ulcers • Medication Use • Infections • Any QM or other clinical focus


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4. Is the QAPI self-assessment completed for this year?


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Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

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