Quality assurance and performance improvement (QAPI) is federal regulation for nursing homes participating in the Medicare and Medicaid programs.

It’s a program that focuses on improving the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident choice in consideration of safety.

Regulations require that a QAPI program include the full range of services offered by nursing homes, including food and nutrition services.

Yet many dietitians or dietary managers might be unfamiliar with QAPI or the crucial role they play in the program.

This article explains everything dietitians and dietary managers need to know about QAPI, including what it is, why it’s important, and how food- and nutrition-related services fit into the program.

What is QAPI?

QAPI combines two components of quality management — quality assurance (QA) and performance improvement (PI).

QA is a process-driven approach designed to maintain a desired level of quality in a service. Nursing homes set QA standards to ensure that care is maintained at acceptable levels for compliance with federal regulations.

PI is a systematic approach designed to improve existing processes, and prevent or decrease the risk of problems. In nursing homes, PI aims to improve processes involved in resident care and quality of life.

QA and PI combine to form QAPI, a data-driven approach to ensuring high quality of care for nursing home residents by addressing gaps in the systems that involve care and quality of life.

The Centers for Medicare and Medicaid (CMS) developed a framework for implementing QAPI programs based on five elements of quality management.

These elements include (1):

  • Design and scope: The QAPI program is ongoing and comprehensive, addressing all systems of care and management practices.
  • Governance and leadership: Nursing home administration sets expectations around safety, quality, rights, choice, and respect.
  • Feedback, data systems, and monitoring: Nursing home establishes systems to monitor care processes, services, and outcomes.
  • Performance improvement projects (PIP): Nursing home conducts performance improvement projects to examine and improve care or services in areas requiring attention.
  • Systematic analysis and systemic action: Nursing home analyzes problems and looks across all involved systems to prevent future problems.

QAPI committee

Nursing homes are required to have a committee that meets at least quarterly to coordinate and evaluate the activities of the QAPI program.

Many nursing homes, however, choose to meet monthly or even weekly to review and evaluate progress towards quality improvement goals.

Regulations require the following members to be on the committee:

  • Director of nursing
  • Medical director
  • Administrator, owner, or board member
  • Two other staff members
  • The infection prevention and control officer

Other members — including the dietitian and dietary manager — are suggested members of the committee.

Dietitians or dietary managers who are not on the QAPI committee should still participate in meetings, especially when quality improvement goals are related to food and nutrition.

The role of the dietitian and dietary manager in QAPI

Facilities identify, collect, and use data from all departments and services to develop and monitor performance indicators that reflect care and quality of life.

Many of these performance indicators or sources of data monitored through QAPI can be related to food and nutrition.

Quality measures

Two nursing home quality measures are highly-specific to nutritional status — unintentional, significant weight loss and pressure ulcers (2, 3).

The percentage of residents with too much weight loss or pressure ulcers can be compared with a predetermined goal and state or national data.

If it’s found that the percentage is trending up, a PIP might be conducted to improve nutrition-related care and services leading to fewer residents with significant weight loss or pressure ulcers.

The PIP team — which could include nursing staff, the dietitian, and dietary manager — could then perform a root cause analysis to direct the plan of corrective action and recommend the appropriate interventions.

State survey results

State survey results are crucial data sources that can be used as performance indicators for care outcomes and quality of life.

The objective and goal of every nursing home is to have a deficiency-free survey.

But when tags are issued, it represents an opportunity to review current systems in place (if present), identify why they aren’t working, and establish a plan of correction that includes ongoing monitoring.

Dietitians and dietary managers can review any tags cited for food and nutrition services, address the immediate problem, and take the appropriate steps to prevent a recurrence of the problem.

Resident satisfaction

Resident satisfaction is another area that be used as measure of quality improvement, especially in regards to dining and food choices.

Complaints about the quality, variety, or choice of food offered by one or more resident can adversely affect quality of life and nutritional status.

Similarly, complaints about the dining atmosphere, dining staff, or table mates are also quality concerns.

These complains should be addressed immediately to determine the root cause so that the problem can be eliminated at its source.

Questionnaires that ask about satisfaction with meals and dining atmosphere can then be used to monitor the effectiveness of the correction action and keep the problem from resurfacing.

Questions might include (4):

  • Is the portion size right for you?
  • Do you like how the food tastes?
  • Is there enough variety of foods to choose from?
  • Is the food appealing?
  • Are you offered foods that you do not like?
  • Do you like your table mates?
  • Does the dining staff treat you with respect?

The bottom line

QAPI is a data-driven approach that focuses on the indicators that reflect outcomes of care and quality of life in nursing home residents.

Dietitians and dietary managers play important roles in QAPI by identifying and correcting quality deficiencies as well as opportunities for improvement that relate to food and nutrition.


Gavin Van De Walle, MS, RD
Gavin Van De Walle, MS, RD

Gavin Van De Walle, MS, RD is a registered dietitian with a master's of science in human nutrition and bioenergetics. Gavin specializes in nutrition for older adults and regulations surrounding long-term care as they relate to food and nutrition.