Case Study:

QAPI Makes Effective Change Possible

Quick Facts

Community Type: Nursing Home

Number of Locations: 6

Resource: Clinical Risk Management

Valued Client Since: 1999


Recently, a 150-bed nursing home located in an urban area of a mid-size Midwestern city experienced multiple staff to resident abuse events. The nursing home hired an experienced nurse aide with a clean background check and references and an uneventful orientation. Early one morning, before 3 months of employment had past, the aide seriously abused three residents causing physical and emotional trauma over the course of an hour and a half. This event resulted in a local news blitz and survey results of immediate jeopardy that lead to an intensive investigation into the facility’s clinical and environmental systems by facility leadership. The outcome of this investigation brought to light many gaps in multiple systems that been in place for most of the previous 10 years and allowed employees to deviate from the policy expectations with minimal notice of anyone.


A team of facility leaders and a Risk Management Solutions (RMS) Consultant designed an organized, logical, system-wide written plan that had six components: assessment, identification of deviations from policy, resident and best practice goals establishment, QAPI staff data collection and change process, intervention decision and implementation, and process correction with periodic evaluation.


The initial outcome was compliance to regulations but that result did not end with a pizza party and return to “before event” practice methods. The new QAPI team had learned to measure success from a different point of view. Success had moved from completion of a task in a policy to positive response from residents who were achieving goals that they wanted. The staff was listening in a different way and then thinking outside the box for possibilities rather than the way it has always been.

Not every attempt to change to the QAPI way is immediately successful but during the year following the event there has been much more right than wrong and being wrong does not end in being stuck. The Director of Nurses was reviewing the following months Quality Measure results with the QAPI team and made the comment that “looking at the number of indicators below the facility benchmark percentage continued to amaze her and made her want to cry with joy.