Unraveling a Quality Assessment and Performance Improvement (QAPI) program can be mystifying and overwhelming. Agencies can simplify QAPI by utilizing an effective process improvement framework and prioritize based on an assessment of key performance indicators.  After an accurate assessment of baseline key performance areas, many risk areas and deficiencies are often revealed.  Once a priority area is determined, the journey to improvement begins.

In order to build and execute your process improvements, one effective method that can be leveraged is the Plan-Do-Study-Act (PDSA) cycle:

  • Plan
  • Do
  • Study
  • Act

Understanding these steps in depth and maintaining realistic goals, will lead your agency to building a strong QAPI program and on the path to effective measurable improvement. Each priority area should have its own plan.


At the beginning of your process improvement journey, after pinpointing your agency’s priority areas, record the background and current state of the problems at hand. With these details, you should identify what improvements need to be made, prioritize specific areas of concern, and determine which areas to tackle first. Then, develop a plan of action.

Let’s take a look at an example and understand the plan of action:

  • Currently, a home health agency has a 15% fall rate.
  • They have had clinicians attend fall education and trainings but have not seen any improvement or reduction in the fall rate.
  • To reduce falls, the agency will develop and implement a “fall score” card to identify higher risk patients:
    • Therapy fall evaluation for high-risk patients
    • Handouts on fall prevention areas will be distributed to each patient identified in the population
  • Agency will implement this for one month in their largest branch and then evaluate.


Next in your process improvement journey is the active implementation of intervention(s) developed from the plan phase.  A shared data system with an easily accessible centralized location where all members of your team can house and access items like data, records, tools is highly recommended. Be sure to set a timeframe specific to your plan of action, then proceed to move on to the next phase.

Let’s revisit our example and learn what action items the agency will do:

  • Score cards are completed for all patients in the specified branch for 30 days.
  • Therapy evaluation for fall prevention is performed on every patient scoring above the median score.
  • All patients in this branch are given the fall prevention handout.
  • All information, scores, dates, and whether a fall occurred or not, is captured on a shared Excel spreadsheet.


This third phase can be referred to as ‘study’ or ‘check’.  Here you want to analyze the data that was gathered in the previous phase to determine whether there is true improvement in the output data.  To make this determination, you will need values where no interventions were implemented (the control group) versus those with the PDSA intervention.  If a statistically significant change occurs in the sample where intervention was implemented, then our performance improvement was a success.

Let’s find out if the branch saw a reduction in their fall rate based off their study:

  • When data was originally compiled, the current fall rate for branches that did not implement the interventions was 14.5%.
  • The branch that implemented fall improvement interventions had 13 falls in 356 patients. This means a little less than 4% of the agency’s largest branch patients fell over this past month with interventions in place.
  • Since this improvement is higher in the branches implementing interventions, the interventions seem to be effective.


This is the final phase in the initial process improvement implementation cycle. This phase includes plans for next steps your agency will take based on the results. If the plan succeeded, was the improvement as high as expected?  Could modifications to the initial plan yield greater results?  Were the outcomes of the plan not as expected and is a new course of action needed? Now is the time to act on your findings.

Let’s find out how the agency will act moving forward with their fall reduction plan:

  • Current improvement rate supports continuing with the current plan for another 60 days for all branches, to determine if improved fall rates continue trending upwards agency wide.

QAPI programs and areas for improvement that each organization targets are ever evolving, thus PDSA is a continuous cycle. The general rule of thumb is once steady improvement is achieved for three sequential cycles, it is time to move to a new subject and plan accordingly. Since most agencies have additional process improvement areas awaiting a QAPI program, choosing among high-risk areas by reviewing previous reports is key. The PDSA process takes time and improvements will be delayed in official reports, so it is important to keep in mind that when developing and executing performance improvement plans as it relates to STAR ratings or preparing for Value-Based Purchasing, you may need to choose more than one area at a time.

Building a QAPI program can be challenging, especially during times of change, new rules and regulations, staffing shortages, and more. Partnering with experts, such as McBee, to assist in your improvement journey is a solution many agencies often take.  Contact us today to learn how our team of experts can help you along your QAPI journey.


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