Five Elements of QAPI

Element 4: Performance Improvement Projects (PIPs)

A Performance Improvement Project (PIP) is a concentrated effort on a particular problem in one area of the facility or facility wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements. The facility conducts PIPs to examine and improve care or services in areas that the facility identifies as needing attention. Areas that need attention will vary depending on the type of facility and the unique scope of services they provide.


QAPI is the merger of two complementary approaches to quality management, Quality Assurance (QA) and Performance Improvement (PI). QA and PI combine to form QAPI, a comprehensive approach to ensuring high quality care. 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 proactive 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.

ELEMENT 4 – Performance Improvement Project: Keys to Success

Conducting PIPs allows the nursing home to examine performance and make improvements in any area identified as needing attention, or that is found to be a high priority based on the needs of the residents.

Draft a Charter – Clarify Team Purpose and Goals

A charter is typically a documented plan that identifies the problem, goals, and the team members’ roles and responsiblilities. The purpose of the charter is to provide the PIP team with key information that will allow them to have a clear understanding of what they are being asked to do. The charter helps a team stay focused by setting timelines and displaying milestones. Note that the charter does not tell the team how to complete the work; rather, it tells them what they are trying to accomplish. Chartering can help teams get off to a good start, avoid misunderstandings, and gain organizational support.

Get the Right People on the Team; Provide Clarity about Team Membership and Roles
  • How do you regularly ask for feedback from residents and families? Remember that QAPI Element 3—Feedback, Data Systems, and Monitoring—requires that some of your data are derived from feedback from residents and families.
  • Do you investigate resident and family complaints and generate action plans if validated?
  • How do you create a climate where residents and families are comfortable raising issues?
  • Do you have a resident and/or family council that can help individuals speak in a shared voice to effect change
  • Do you address the concerns raised in resident and family council?
  • Do you have, or would you consider having a resident and/ or family member on your Quality steering committee?

QAPI Five Elements



Element 4 – Performance Improvement Projects

Implement performance improvement projects

  • Focus on topics that are meaningful and address the needs of residents and staff
  • Charter PIP teams
  • Support staff in being effective PIP team members. Use tools that support effective teamwork.
  • Plan, implement, measure, monitor, and document changes, using a structured PI approach
Worksheet to Create a PIP Charter PIP Launch Checklist: Helpful hints for project leaders, managers, and coordinators Plan-Do-Study-Act (PDSA) Cycle Template PIP Inventory Sustainability Decision Guide Brainstorming, Affinity Grouping, and Multi-Voting Tool

Enhance QAPI communications

QAPI at a Glance Communications Plan Worksheet Storyboard Guide for PIPs Improvement Success Story Template