The QAPI Process

494.110 Condition: Quality Assessment and Performance Improvement.

"The dialysis facility must develop, implement, maintain, and evaluate an effective, data-driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team. The program must reflect the complexity of the dialysis facility’s organization and services (including those services provided under arrangement), and must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors. The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS."

Interpretative Guidance states: “There must be an operationalized written plan describing the QAPI program, scope, objectives, organization, responsibilities of all participants, and procedures for overseeing the effectiveness of monitoring, assessing, and problem-solving activities….The important aspects of the QAPI program are appropriately monitoring data/information; prioritizing areas for improvement; determining potential root causes; developing, implementing, evaluating, and revising plans that result in improvements in care. Records of QAPI activities including minutes or another method of demonstrating this analysis and action must be available for review.”

  • Start with a Root Cause Analysis of your problem, identifying sub-categories (template attached). List everything you can think of that contributes to the identified problem, whether you think you can change it or not.
  • Next, complete the NW 16 Quality Assessment and Performance Improvement template (attached).
  • After identification of your goals, barriers, etc., complete the QI Action Plan (attached) with specific goal end-dates and re-measurement dates.
  • Institute your QAPI, and monitor its progress through your QI Committee. It is important that every QAPI that is occurring in your facility has documentation in the minutes of your QI meetings.
  • Your Action Plans can and should be updated as appropriate.
  • These documents will serve to demonstrate analysis and actions per the IG.
For a Root Causes Template and other handy tools, see .
Page updated December 29, 2014