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QAPI Accreditation: Impact on Survey Performance

Authors: Andrew M Kramer MD; Ron Fish MBA; Sung-Joon Min PhD;

Ian Schreuder MS; Peter Kramer BS


Quality Assurance and Performance Improvement (QAPI) is a systematic process by which health care providers can identify quality problems and initiate corrective actions. Although the Affordable Care Act requires that nursing homes have an acceptable QAPI plan within a year of new regulations, even without these regulations CMS encourages nursing homes to embrace the QAPI principles: “…a more basic reason to build care systems based on a QAPI philosophy is to ensure systematic, comprehensive, data-driven approach to care.” (Survey-and-Cert-Letter 13-05; QAPI at a Glance). In keeping with this philosophy, Providigm developed measurable standards for a voluntary QAPI accreditation program. The purpose of this study was to evaluate whether nursing homes that implemented a QAPI process meeting Providigm’s data-driven accreditation standards demonstrated improved quality.


Study Design: Because QAPI is aimed at performance improvement, validation required demonstrating improved quality among facilities that met accreditation standards. In this study, annual survey results were used as the measure of quality. For each facility, three annual survey periods were specified based on the facility’s annual survey dates, and the timing of QAPI implementation. The Before Period was defined as the most recent survey period with no QAPI system meeting the accreditation standards. The Transition Period was the annual period following the Before Period, during which QAPI was implemented at some point during the year without meeting accreditation standards. The After Period was the first annual survey period following the  Transition Period if the organization met the QAPI standards.

QAPI Accreditation Standard Summary: The accreditation standards were intended to ensure that facilities were implementing systematic QAPI that involved comprehensive assessment of quality, conducted continuously throughout the year, with sufficient coverage of the residents admitted to and residing long-term in the facility, and involving corrective action of identified concerns. All assessments and corrective actions were reported in the abaqis® web-based QAPI system.

The abaqis QAPI system is based on similar data elements to the Quality Indicator Survey (QIS) utilized by state agencies to ensure facilities are in compliance with federal regulations for quality of care and life. The abaqis system includes the following types of assessments: 1) resident interviews; 2) family interviews; 3) resident observations; 4) record audits of residents in current census; 5) record audits of admissions; and 6) staff interviews.

The reports from these six assessments inform the user about systemic quality problems in the facility, and a performance improvement stage is then provided to identify the root cause of problems and initiate corrective action. To determine if facilities met the QAPI accreditation standards, a year of facility data on abaqis use was compared with quantitative standards. These standards included criteria for whether the facility QAPI process was comprehensive, i.e., all assessment types were conducted; continuous, i.e., assessments were completed throughout the year; coverage was adequate, i.e., a sufficient sample of residents was assessed; and corrective action was conducted. Only facilities that met criteria for all four of these standards were accredited.

Sample: The sample included 463 nursing facilities using abaqis that met accreditation in 2011 or 2012. These facilities were from 42 states, and were 88% for-profit.


The study included facilities with a spectrum of quality in the Before Period. While about 12% had 0-2 deficiencies, about 64% had 9 or more deficiencies, and 7 were Special Focus Facilities. During the Before Period, 13% of facilities paid Civil Money Penalties (CMPs) that averaged in excess of $43,000. This mix of study facilities that fully adopted the QAPI process, ultimately meeting the QAPI standards, is reflected in the average of 14.7 deficiencies in the Before Period. Thus, the accreditation standards using abaqis were achieved not only by higher performing facilities, but also facilities that struggled to meet minimum survey outcomes.

In the first full year of meeting the QAPI accreditation standards, the average number of deficiencies dropped by 40% to 8.8 (p<.001). This was accompanied by about a 50% increase in the proportion of facilities with 0-2 deficiencies to about 19% of the total. Particularly striking was the 73% drop in facilities that received penalties to 3.5% of facilities (p<.001). The average reduction in CMPs was in excess of $31,000 (p<.001). Thus, both higher performing and struggling facilities made significant improvements when QAPI accreditation standards were met.


The objective of Quality Assurance and Performance Improvement (QAPI) is to continuously improve quality of care and life for residents regardless of the quality of the facility at the outset. QAPI is argued to be of value to both struggling facilities in order to help them achieve a higher standard of care, while at the same time assisting high performing facilities to improve. Providigm’s QAPI Accreditation Program is the first accreditation that is aimed at voluntarily accrediting organizations that meet standards for rigorous QAPI. The web-based abaqis QAPI system provides a systematic approach for conducting QAPI, in addition to yielding data to determine if facility QAPI actions meet accreditation standards. This research strongly suggests that organizations meeting
these QAPI standards improve significantly in their quality of care and life for their residents, providing validation for the QAPI standards.

Despite the current policy emphasis on QAPI in nursing homes, no studies have demonstrated that any particular QAPI system has improved the quality of care in nursing homes. A national demonstration of QAPI methods is underway to provide a basis for federal regulations on QAPI. In the meantime, nursing homes are adopting the various principles of QAPI based on available education and resources. This study suggests that voluntary QAPI that meets proposed standards for comprehensiveness, continuity, coverage, and corrective action can have substantial impacts on quality of care in nursing homes resulting in reduced deficiencies, and substantially reduced penalties in facilities that have received them.

Most forms of accreditation involve an application and/or on-site examination of providers at one point in time to determine whether processes and procedures are in place to ensure ongoing adherence to standards. Ensuring that examiners are exposed to a valid representation of facility practices over a period of a year or more is difficult during a site visit. To enhance validity of their determinations, accreditation bodies will sometimes review outcome data over a more extended time period. Providigm’s QAPI Accreditation takes advantage of health information technology advances to not only determine if the necessary systems, policies, and procedures exist, but ensures that these systems are continuously used as intended. Accrediting facilities based on QAPI actions enables facility staff to use their time for measuring and improving quality while simultaneously meeting accreditation standards.

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