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QAPI. Achieving a Culture of Excellence. Objectives . To demonstrate an understanding of how to use the elements of QAPI within  the performance excellence framework . To verbalize how a SVH can mobilize an organization to create and sustain a culture of excellence .

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Achieving a Culture of Excellence


  • To demonstrate an understanding of how to use the elements of QAPI within  the performance excellence framework.

  • To verbalize how a SVH can mobilize an organization to create and sustain a culture of excellence.

  • To identify at least one method to involve team members in creating a culture of learning

Baldrige quality award
Baldrige Quality Award

  • All about results and improvement

  • Using a framework

  • A systematic approach

  • Established by congress in 1987

  • Designed to improve the competitiveness of US businesses

  • Identifies role model organization

  • Internationally recognized and emulated.

Baldrige background
Baldrige Background

  • Studies done related to industries in the US who were losing market share- such as steel and auto industries.

  • Found a common set of values and process that successful organizations used

  • These process and values are now the framework for performance excellence

Why baldrige
Why Baldrige

  • Study by Thompson Reuters found that hospitals using the Baldrige criteria were 6X more likely to be in the top 100 hospitals and outperformed non- Baldrige hospitals in:

    • Risk-adjusted mortality index

    • Risk-adjusted complications index

    • Patient safety index

    • CMS core measures score

    • Severity-adjusted average length of stay

    • Adjusted operating profit margin






Baldrige categories
Baldrige categories

  • Leadership: How do leaders create a sustainable organization?

  • Strategic Planning: How do you develop strategy?

  • Customer Focus: How do you listen to customers and determine solutions upon feedback from the customer?

  • Measurement, Analysis and Knowledge Management: How do you select and use data to measure and improve performance?

Baldrige categories1
Baldrige categories

  • Workforce: How do you assess capacity and capability to meet the needs of the customer and accomplish the plan?

  • Operations: How do you manage key work processes and systems to create long term sustainable value?

  • Results: What results are important to leadership and your customers and how do you share with those that impact performance?

What s the goal
What’s the Goal?

Improvement of some components, processes, or outcomes?


Complete system transformation to ensure success every time?

Tension for change
“Tension for Change”

“To leave the comfort of the status quo, most individuals need to believe that change is truly imperative and there is a more attractive alternative.”

Silversin, J. & Kornacki M.J, ,(2000) Leading Physicians Through Change


  • Affordable Care Act

  • A system to provide technical assistance to nursing homes

  • Transformation of how we deliver quality

  • Shift on delivering excellence proactively, not reactively

  • Approach where problems are caught before serious


“The Centers for Medicare & Medicaid Services (CMS) is leading an initiative that could transform the way nursing homes ensure quality. This initiative goes beyond the current QAA provision, and aims to significantly expand the intensity and scope of current activities in order to not only correct quality deficiencies (quality assurance), but also to put practices in place to monitor all nursing home care and services to continuously improve performance.”


A framework of 5 elements:

1. Design and scope

2. Governance and leadership

3. Feedback and monitoring

4. PI projects

5. Analysis and systematic action



Quality of Care, Quality of Life, Resident Choice



Feedback, Data


Performance Improvement


Systematic Analysis and Action

Qapi design and scope
QAPI: Design and Scope

  • Plan should be comprehensive and include all the care and services your facility provide

  • Balancing safety and quality of care with resident choice and autonomy

  • Not just about nursing or the food in the kitchen—involves every aspect of the care and services provided

Qapi governance and leadership
QAPI: Governance and Leadership

  • Expectation that the executive leadership of your facility must be actively engaged and involved in QAPI

  • It must be real visible involvement at all levels

Qapi feedback data systems and monitoring
QAPI: Feedback, Data Systems, and Monitoring

  • This element emphasizes the establishment of systems for proactively identifying and using data to measure performance and identifying opportunities for improvement

Qapi performance improvement projects
QAPI: Performance Improvement Projects

  • Performance Improvement Projects (PIPs) to improve care

  • Builds on the other elements to ensure that the opportunities for improvement are prioritized and incorporated into PIPs

Systemic analysis and action
Systemic Analysis and Action

  • Using a systematic formal process for analysis

    • Example: root cause analysis

  • Ensuring that actions taken address changes or improvements to the system

  • Continual improvement and learning


Design & Scope

Governance & Leadership

Performance Improvement Projects


Systematic Analysis/

Systematic Action

Feedback, Data Systems


Call the question
“Call the Question”

  • Are you proud of “your” performance?

  • How do your clinical scores compare to your competitors?

  • What did "we" do differently?

  • Does improving quality really matter in your organization?

  • How are quality initiatives prioritized within your organization?

  • Do you “know” how you do what you do to make success repeatable?

    Developed from AHA Get w/ the Guidelines program (Houston, 2005)

Q api

Maine Veterans Homes Journey

Converging on qapi
Converging on Qapi

  • Silver award applications

  • Affordable Care Act mandate: QAPI

  • Hardwire a culture of excellence

  • Strategic Plan: Direction from the board

  • Needed a framework

Leadership and governance
Leadership and Governance

  • Developing the QAPI Workgroup:

    • Educate board

    • Obtain senior leadership support

    • Identified initial membership of the Workgroup

    • Board steers the QAPI workgroup

Mvh qapi workgroup
MVH QAPI Workgroup

  • Representatives from all 6 homes and central office

  • Standardized education to introduce QAPI

  • Charter established and approved by Board

    • Purpose – establish a fact based, data-driven system for improving healthcare, safety, operational performance and competitiveness of Maine Veterans’ Homes

    • Goals:

      • Development of an annual QAPI plan

      • Development of a results dashboard

      • Review of outcome results and identification of opportunities for improvement

Design and scope
Design and Scope

  • Reviewed organizational profiles

    • Baldrige definition: What are your key organizational characteristics? What is your organization's strategic situation?

    • Products, vision, mission, workforce, assets, regulatory requirements, organizational structure, customers/stakeholders, suppliers/partners

  • Self Assessment:

    • CMS QAPI tools: QAPI at a Glance

    • Organizationally and at each home

  • QAPI Plan Development:

    • Purpose Statement

    • Development of guiding principles

Design and scope1
Design and Scope

MVH QAPI Purpose Statement

The purpose of our Quality Assurance and Performance Improvement (QAPI) Program is to achieve and sustain a culture of excellence by using a fact based, data driven decision making model with a proactive approach to continually improving the way we “Care for Those Who Served”.

Qapi plan goals
QAPI Plan Goals

  • QAPI Plan Goals:

  • Utilize a  dashboard to monitor key measures and improve organizational performance

  • Establish a framework for performance improvement practices at MVH

  • Promote a culture of safety for residents, families, and staff

  • Enhance quality of life for our resident through culture change activities

Design and scope2
Design and Scope

MVH QAPI Guiding Principles

1. In our organization, QAPI includes all employees, all departments, and all services.

2. QAPI has a prominent role in our management and board functions.

3. Our organization uses QAPI to make informed decisions and guide our day to day operations.

4. The outcome of QAPI in our organization is the quality of care and quality of life of our residents within a framework of resident directed care and recognition that “Veterans are Unique”.

5. QAPI focuses on systems and process. The emphasis is on identifying system gaps rather than blaming individuals.

Design and scope3
Design and Scope

MVH QAPI Guiding Principles

6. Our organization has a culture that supports “Honesty and Integrity” by encouraging employees to identify errors and system breakdown.

7. Our decisions to improve will be guided by data, in conjunction with individual care and choice, which includes to input and experience of residents, families, caregivers, health care practitioners, and other stakeholders.

8. Our organization sets goals for performance and measures progress towards those goals with a focus on “Leading the Way” within our industry and sustaining a culture of “Excellence”.

9. Our organization supports performance improvement by encouraging our employees to “Respect” and support each other as well as be accountable for their own professional performance and practice.

10. MVH encourages “Team” collaboration, sharing of best practices, and celebrating successes across the organization.

Development of measures
Development of Measures

  • Measures were reviewed for alignment with:

    • Industry goals and initiatives

    • MVH Strategic Plan

    • Customer Expectations

    • Core Values

    • Performance Excellence Framework for Improving Organizational Quality

  • QAPI elements

Dashboard measures
Dashboard Measures

  • Non-clinical Measures:

    • Workforce – Total facility turnover; Nursing turnover; Days Away Restricted Transferred Duties (DART)

    • Operations – Days in Accounts Receivable; Occupancy

    • Customer – Overall satisfaction; Recommends to others; Culture change

  • Clinical Measures:

    • Healthcare – Hospital Readmissions; Serious Reportable Events; Long-Stay, Short-Stay, & Res Care Antipsychotic Drug Use

Results dashboard
Results Dashboard

  • Visual representation of organizational performance

  • Displays clinical and non-clinical results called measures

  • Displays MVH target

  • Reflects trends in organizational performance

Review of measures
Review of Measures

  • Measures approved by board and senior leaders

  • QAPI Element: Actively involved governing body

  • Standardized training across organization

Systematic analysis and action root cause analysis
Systematic Analysis and action: Root Cause Analysis

  • Developed a root cause analysis tool

  • Reviewed with VAMC liaison

  • Educated clinical leaders

  • Implemented

Root cause analysis tool
Root Cause analysis Tool

  • What happened?

  • Why did it happen?

    • Policy/procedures/practice

    • Human Factors

    • Communication Factors

    • Equipment Factors

    • Information Factors

    • Environmental Factors

    • Other

Performance improvement projects
Performance Improvement projects

  • One of our organization-wide PIPs was regarding hospital readmissions

  • We began this PIP by looking at best practices and researching tools to assist us

  • Reviewed data using Trend Tracker

  • Chose to use Interact tools

  • Interfaced with local hospitals

Next steps
Next Steps

Finalization of MVH QAPI Plan to include:

  • Descriptions of:

    • Scope

    • Guidelines for Governance and Leadership

    • Feedback, Data Systems, and Monitoring

    • Guidelines for Performance Improvement Project Teams

    • Systematic Analysis and Systemic Action

    • Communications

    • Evaluation

      Board review and Approval of Annual QAPI Plan

      Standardized training across the organization



Achieving a Culture of Excellence

One home s journey
One Home’s Journey

Maine Veterans’ Home, Scarborough

The past
The past

  • Reviewing QIQM reports

  • Counting beans

Department measures
Department Measures

  • Each department measuring their own area

  • Narrow focus

Functional measures
Functional Measures

  • Transition to functional measures

  • Interdisciplinary

  • Measures across departments for functional groups

Engaging and building relationship with stakeholders
Engaging and Building Relationship with Stakeholders

In the true sense of resident directed and person-centered approach to all that we do, we have developed and/or revised seven teams.

Engaging and building relationship stakeholders
Engaging and Building Relationship stakeholders

  • These committees are:

    • Communications

    • Safety

    • Employee Recognition

    • Wellness

    • Public Relations & Marketing

    • Activities and Dining

    • Recycling


  • Staff, residents, and family members agreed to populate them.

Where we are now
Where we are now

  • Prior to QAPI we were adding pieces but not building from the foundation

  • Using the Baldrige criteria and the elements of QAPI to hardwire a culture of excellence

  • Not only understand HOW but WHY we have quality assurance and performance improvement activities

Engaging and building relationship with staff cultivating excellence improve staff satisfaction
Engaging and Building Relationship with Staff:Cultivating Excellence & Improve Staff Satisfaction

  • Not easy

  • Persevere

Engaging and building relationship with staff cultivating excellence improve staff satisfaction1
Engaging and Building Relationship with Staff:Cultivating Excellence & Improve Staff Satisfaction

  • Hear the negatives

  • Stay focused

  • Don’t overwhelm

  • Make it THE most important

  • Let them do their work, if they do it wrong at least they are doing it.

Engaging and building relationship with staff cultivating excellence improve staff satisfaction2
Engaging and Building Relationship with Staff:Cultivating Excellence & Improve Staff Satisfaction

  • Celebrate the successes

  • Acknowledge the failures

    • Thomas Edison said, “I did not fail, I discovered thousands of things that did not work”

Contact information
Contact Information

Debra Fournier, Chief Operations Officer

Maine Veterans’ Homes


Kevin Warren, Deputy Commissioner

Texas State Veterans Homes & Cemeteries