QAPI Self Assessment Tool

Has our organization developed principles for guiding how QAPI will be incorporated into our culture and built into how we do our work, considering it as a method for approaching decision-making and problem-solving rather than a separate program?

Has our organization identified how all service lines and departments will utilize and be engaged in QAPI to plan and do their work, ensuring that all service lines and departments use data to make decisions and drive improvements?

Has our organization developed a written QAPI plan that contains the steps taken to identify, implement, and sustain continuous improvements in all departments, and is it revised on an ongoing basis?

Is our board of directors and trustees (if applicable) engaged in and supportive of the performance improvement work being done in our organization, evident from meeting minutes and leadership involvement in performance improvement projects or teams?

Is QAPI considered a priority in our organization, with processes in place for covering caregivers asked to spend time on improvement teams?

Is QAPI an integral component of new caregiver orientation and training, ensuring that new caregivers understand their role in identifying opportunities for improvement and actively participating on improvement teams?

Is training available to all caregivers on performance improvement strategies and tools?

When conducting performance improvement projects, does our organization make a small change and measure the effect of that change before implementing it more broadly, using pilot testing and measurement?

Does our organization focus on making changes to systems and processes when addressing performance improvement opportunities, rather than focusing on addressing individual behaviors?

Has our organization established a culture in which caregivers are held accountable for their performance, but not punished for errors, and do caregivers not fear retaliation for reporting quality concerns?

Can leadership clearly describe our approach to QAPI and provide accurate and up-to-date examples of how the facility is using QAPI to improve the quality and safety of resident care?

Has our organization identified all sources of data and information relevant to QAPI, including data reflecting measures of clinical care, and input from caregivers, residents, families, and stakeholders?

For the relevant sources of data identified, has our organization set targets or goals for desired performance, as well as thresholds for minimum performance?

Does our organization have a system to effectively collect, analyze, and display data to identify opportunities for improvements, comparing results to benchmarks or internal performance targets or goals?

Does our organization support the development of employees who have skills in analyzing and interpreting data to assess performance and support improvement initiatives?

Does our organization have a systematic and objective way to prioritize opportunities for improvement, taking into consideration input from multiple disciplines, residents, and families?

When a performance improvement opportunity is identified as a priority, does our organization have a process in place to charter a project, describing the scope and objectives clearly?

For performance improvement projects, does our organization have a process for documenting what has been done, including highlights, progress, and lessons learned?

Does our organization use the measurement for every performance improvement project to determine if changes to systems and processes have been effective, utilizing both process and outcome measures?

For every Performance Improvement Project, is a measurement used to determine if changes to systems and processes have been effective? Are both process measures and outcome measures used to assess the impact on resident care and quality of life?

Does our organization use a structured process for identifying underlying causes of problems, such as Root Cause Analysis?

Does our organization use Root Cause Analysis to investigate events or problems, focusing on identifying system and process breakdowns and avoiding a focus on individual performance?

When systems and process breakdowns have been identified, does our organization consistently link corrective actions with the system and process breakdown, rather than defaulting to training, education, or asking caregivers to be more careful?

When corrective actions have been identified, does our organization put both process and outcome measures in place to determine if the change is happening as expected and resulting in the desired impact on resident care?

When an intervention has been put in place and determined to be successful, does our organization measure whether the change has been sustained over time?