I do not think that anybody would disagree that creating a culture to support QAPI efforts begins with leadership. Support from the top is essential, and that support should foster the active participation of every caregiver.   The administrator and senior leaders must create an environment that promotes QAPI and involves all caregivers.  The challenge becomes creating the culture of QAPI throughout the entire organization as opposed to it being seen as “just another initiative that the top dogs are pushing down”.

Some recommendations for creating this culture include:

• Develop a steering committee that will provide QAPI leadership.  The steering committee typically consists of department manager staff and has overall responsibility to develop and modify the plan, review information, and set priorities for performance improvement projects. The steering committee charters teams to work on particular problems. It reviews results and determines the next steps. The steering committee must learn and use systems thinking. Top leadership such as the Administrator and the Director of Nursing must be part of this structure and it is also important to have a medical director who is actively engaged in QAPI. It is possible to adapt your Quality Assurance committee to become your “Steering committee” to oversee QAPI. For this to work, the QA Committee may need to meet more often, include more people, and establish permanent and time-limited workgroups that report to it.
• Provide resources for QAPI—including equipment, training and a budget.  Caregivers may need time to attend team meetings during working hours, requiring others to cover their clinical duties for a period of time.  Equipment might include anything from additional computers, to low-cost supplies like posters to create story boards, or multiple copies of resource books or CDs. Leadership may want to consider sending one or more team members to a specialized training.  Budgets are important for the time-limited workgroups—there is nothing worse than giving a workgroup a project to work on and having them come back to you with ideas that cannot realistically be supported from a financial perspective.
• Establish a climate of open communication and respect. Leadership may wish to consider having an open-door policy to communicate with staff and caregivers, emphasizing communication across shifts and between department heads, and creating an environment where caregivers feel free to bring quality concerns forward without fear of punishment.   It is important to evaluate all of these issues before initiating QAPI—every member of the steering committee needs to be open to these philosophies.
• Understand your home’s current culture and how it will promote performance improvement. Expect and build effective teamwork among departments and caregivers.

Creating the expectation that everyone in your nursing home is working on improving care and services is crucial to the QAPI culture.  Establish an environment where caregivers, residents, and families feel free to speak up to identify areas that need improvement.  Many leaders try to avoid these discussions but the fact is the staff, residents and families often know issues and problems before the leaders do.  The most dynamic workgroups I have seen include not only caregivers and staff but resident and family representation as well.

Executive leadership sets the tone and provides resources. Their challenge is to help leadership flourish throughout the organization and create a culture that supports QAPI efforts.  The typical evolution of any new culture is approximately 6 years:

• Phase I – 1 year

–        Leaders educate themselves

–        Mission statement developed and is adopted by facility leaders and made known throughout the organization

• Phase II – 1 year

–        Middle management is trained

–        Priorities are established for what the facility will try to improve

• Phase III – 2 years

–        Trial projects are initiated across departments

–        Employees are trained in methods and philosophy of quality improvement

• Phase IV – 2 years

–        Projects are initiated throughout the organization

–        Efforts of different departments are integrated

–        A culture change takes place

So, the time is now to evaluate where your facility is in the process of disseminating a culture of QAPI throughout the organization.