Quality Assurance Performance Improvement Plan



The vision of Golden Good Shepherd Home is to create an environment where people are loved, valued and at peace.



Golden Good Shepherd home is each resident’s home.  We are committed to enhancing quality of life by nurturing individuality and independence.  We are growing a value-driven community while leading the way in honoring inherent senior rights and building strong and meaningful relationships with all whose lives we touch.



The purpose of QAPI in our organization is to take a proactive approach to continually improve the way we care for and engage with our residents, caregivers and other partners so that we may realize our vision to create an environment where people are loved, valued and at peace.  To do this, all employees will participate in ongoing QAPI efforts which support our mission of enhancing quality of life. 


Guiding Principles:


Guiding Principle #1:  Our organization uses quality assurance and performance improvement to make decisions and guide our day-to-day operations.


Guiding Principle #2:  The outcome of QAPI in our organization is to improve the quality of care and the quality of life of our residents.


Guiding Principle #3:  In our organization, QAPI includes all employees, all departments and all services provided. 


Guiding Principle #4:  QAPI focuses on systems and processes, rather than individuals.  The emphasis is on identifying system gaps rather than blaming individuals.


Guiding Principle #5:  Our organization makes decisions based on data, which includes the input and experience of caregivers, residents, health care practitioners, families and other stakeholders.


Guiding Principle #6:  Our organization sets goals for performance and measures progress toward these goals.


Guiding Principle #7:  Our organization supports performance improvement by encouraging our employees to support each other as well as be accountable for their own professional performance and practice.


Guiding Principle #8:    Our organization has a culture that encourages, rather than punishes, employees who identify errors or system breakdowns.

  1. QAPI Goals

Our purpose is to provide excellent quality resident care and services. Quality is defined as meeting or exceeding the needs, expectations and requirements of the patients cost-effectively while maintaining good resident outcomes and perceptions of patient care.

Golden Good Shepherd Home has a Performance Improvement Program which systematically monitors, analyzes and improves its performance to improve resident outcomes. It recognizes that value in healthcare is the appropriate balance between good measures, excellent care and services and cost.

  1. Scope

The scope of the QAPI program encompasses all segments of care and services provided by Golden                          Good Shepherd Home that impact clinical care, quality of life, resident choice and care transitions with participation from all departments. 


Clinical Care Services:  We provide comprehensive clinical care to residents with acute and chronic disease, rehabilitative needs, as well as end-of-life care.  All care is resident-centered and focused around choice and individualized treatment plans.  We strive to meet each resident’s goals of care, including developing and executing a transitional plan for discharge back to the community.


Dietary:  We provide nutritious meals under the supervision of a licensed dietitian.  We consider resident choices and preferences by providing several options for meals and embrace open dining hours.


Pharmacy Services:  We provide pharmacy services who supervise and collaborate with the medical and nursing team at Golden Good Shepherd Home by reviewing, dispensing and monitoring medication effectiveness to ensure therapeutic goals are maintained for each and every resident.


Maintenance:  We provide comprehensive building safety, repairs and inspections in ensure all aspects of safety are enforced, assuring the safety and well-being for each resident, visitor and staff who enters the building.


Housekeeping:  We provide and ensure that all health, sanitation and OSHA requirements are met through regular cleaning, disinfection and sanitation of the building.


Administration:  We align all business practices to ensure every resident has individualized care and we work to support the providers with the resources and equipment to meet the care goals of those we care for. 


The QAPI program at Golden Good Shepherd Home will aim for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for resident’s (or resident’s representatives), by ensuring our data collection tools and monitoring systems are in place and are consistent for a proactive analysis.  We will utilize the best available evidence (such as data from the CASPER Report, national benchmarks, published best practices, clinical guidelines, etc.) to define our goals. 


  • Governance and Leadership

Golden Good Shepherd Home’s governing body is ultimately responsible for overseeing the QAPI Committee.  The Administrator has direct oversight responsibility for all functions of the QAPI Committee and reports directly to the governing body.  The QAPI Committee, which includes the Medical Director, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction. 

A facility-wide training will be conducted to inform everyone in the facility about the QAPI plan at Golden Good Shepherd Home.  These trainings will be conducted often and in multiple ways through (e.g., regular all-staff meetings, department staff in-services, change of shifts report time, dialogue, examples, exercises, etc.).  Every caregiver will be made to understand that they are expected to raise quality concerns, that it is safe to do so and that everyone is encouraged to think about systems. 


The QAPI approach at Golden Good Shepherd Home will also be communicated to consultants, contractors and collaborating agencies, to make them understand that they each have a role in the QAPI plan.


Golden Good Shepherd Home will ensure that all residents and families are aware of the facility’s QAPI program and that their views are sought, valued and considered in facility decision-making and process improvements.  The QAPI program will be announced and discussed at the resident council meetings and other resident and family events.

  1. Feedback, Data systems and Monitoring


Golden Good Shepherd Home will put in place systems to monitor care and services, drawing date from multiple sources.  Feedback systems will actively incorporate input from staff, residents, families and others as appropriate.  It will include using performance indicators to monitor a wide range of care processes and outcomes, and reviewing findings against benchmarks and/or goals the facility has established for performance.  It also includes tracking, investigating and monitoring adverse events every time they occur and action plans implemented through the plan, do, study, act (PDSA) cycle of improvement to prevent recurrences. 


The QAPI team at Golden Good Shepherd Home will decide what data to monitor routinely.  Area to consider may include, but not be limited to the following:

  • Clinical care areas (e.g., pressure ulcers, falls, infections)
  • Medications (e.g., those that require close monitoring, antipsychotics, narcotics)
  • Complaints from residents and families
  • Hospitalizations and other service use
  • Resident satisfaction
  • Caregiver satisfaction
  • Care plans, including ensuring implementation and evaluation of measurable interventions
  • State survey results and deficiencies
  • Results from MDS resident assessments
  • Business and administrative processes (e.g., financial information, caregiver turnover, caregiver competencies and staffing patterns). Data related to caregivers who call out sick or are unable to report to work on a short notice, caregiver injuries and compensation claims may also be useful.


Benchmarks for performance such as the Nursing Home Compare, CASPER report, facility’s own

Performance, etc. will be used to monitor the facility’s progress.

  1. Performance Improvement Projects (PIP)

The QAPI team at Golden Good Shepherd Home will review our sources of information to determine if gaps or patterns exist in our systems of care that could result in quality problems; or if there are opportunities to make improvements.


Examples of potential areas to consider when reviewing date include:

  • MDS data for problem patterns
  • Nursing Hoe Compare
  • State survey results and plans of correction
  • Resident care plans for documented progress towards specified goals
  • Trends in complaints
  • Resident and family satisfaction for trends
  • Patterns of caregiver turnover or absences
  • Patterns of emergency room visits and/or hospital use


Based on the result of the review of information, the QAPI team at Golden Good Shepherd Home will

prioritize opportunities for improvement, taking into consideration the importance of the issues (high

risk, high frequency and/or problem prone).  The QAPI team will determine which problems will become

the focus for a performance improvement project (PIP).


Depending on the PIP to be started, the QAPI team will charter a PIP Team who is entrusted with a

mission to look into a problem area and come up with plans of correction and/or improvement to be



  1. Systematic Analysis and Systematic Action


Golden Good Shepherd Home uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes and implications of a change.  Golden Good Shepherd Home applies a thorough and highly organized/structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized and delivered.  Golden Good Shepherd Home’s approach comprehensively assesses all involved systems to prevent future events and promote sustained improvement.  Golden Good Shepherd Home also has developed policies and procedures regarding expectations for the use of root cause analysis when problems are identified.  This element includes a focus on continual learning and continuous improvement.


Examples of root cause analysis tools:

  • Fish bone
  • Five whys
  • Generic root cause analysis forms
  • Communication

At a minimum, Department Heads will report annually on the status of the current QAPI plan as well as the proposed QAPI plan and goals for the coming year.  The report will be made available to:

  • Board of Directors
  • Facility Management Team
  • Facility Staff
  • Resident Council
  • Other designated stakeholders
  • Evaluation

The key elements of the program will be reviewed annually to assure that they are occurring, that the program is efficient, it is accessible to community members and that the results are communicated to the appropriate audience.

  • Performance indicators that are monitored will be reviewed – are they still relevant, do we need to monitor them as frequently, or more frequently? Are our goals, thresholds still relevant, achievable, etc.
  • Ongoing training needs will be identified and addressed.
  1. Establishment of Plan
  • This plan was established on February 28, 2018
    • This plan was reviewed and updated on March 15, 2019
  • The plan will be revisited on an annual basis.