Quality Assurance Performance Improvement Tabletop Game
Concept: Attendees will participate in a QAPI tabletop game that will demonstrate how to select and
utilize data, determine the best evidence-based practice or data tracking needs to evaluate performance
improvement, and implement a fully functioning QAPI Performance Improvement Project.
Tools Utilized:
Large d20
QAPI Framework Document
Root Cause Analysis – 5 Whys
Goal Setting Worksheet
QAPI PDSA PIP Worksheet
Game Format: The game will utilize existing CMS QAPI templates and tools with randomized scenario
tables to inject some unknown factors into the tabletop exercise. Participants will utilize skills
demonstrated during the first part of the training day to execute a mock PIP focused on several different
QM categories.
Game Rule:
1. Select a QM category by rolling a die in front of you.
a. 1-5: Rehospitalizations rates are above the national average and the regional
expectations set by the community health goals established with local providers last
year.
b. 5-10: Fall rates have increased greatly over the last 3 months and falls with injury have
spiked last month to the highest level in 2 years
c. 11-15: Antipsychotic use rates have increased over the last year from 17% to 30%, even
though we have spoken to our providers about our desire to decrease rates below the
national average.
d. 16-20: The Case Mix Index and Medicaid reimbursement rates have decreased over the
last year even though the rate issued from the state has increased slightly. Census has
remained steady with the same long-term residents and less than 20 admissions in the
last year.
2. Select the roles of the team members that have been assembled for the PIP
a. 1-2: DON
b. 3-4: MDS Coordinator
c. 5-6: Administrator
d. 7-8: CNA
e. 9-10: Maintenance Director
f. 11-12: Housekeeper
g. 13-14: Charge nurse
h. 15-16: Therapist
i. 17-18: B.O.M.
j. 19-20: ADON
3. Identify the data for the specific QM category selected in step 1
a. Dummy data will be available on the template CASPER Report
b. Utilize dummy Facility Performance Report to look at the data trend for the last year
c. Identify data needs that will be utilized outside of these reports
4. Establish a S.M.A.R.T. goal based on existing data and where the organization thinks the
performance indicators should be
5. Create a change plan based on meeting the established S.M.A.R.T. goals and Evidence Based
interventions that have been identified for the QM
6. Identify barriers and establish how you will overcome these barriers if they occur during the
course of the PIP timeframe.
7. Execute your “Do” cycle of the PDSA process
8. Roll for random barriers that have occurred during the “Do” cycle to see what hindrance
occurred.
a. The day shift is short 2 aides for the last month.
b. Management/Leadership staff is resistant to change: “Why do I need to change what I
do in ___________ dept. when I don’t provide direct resident care?”
c. Unexpected high dollar repair expense (non-capitalized) requires funds be diverted from
the budget for the month.
d. Annual survey results resulted in several “G” tags in areas the PIP team hasn’t focused
e. Family/Resident representatives have expressed vocal opposition to the changes tested
in their family members neighborhood
f. The Board/CEO is hesitant to commit funds for CQI startup costs
g. The data is being collected by different staff members and is inconsistent
h. The PIP team lead has submitted their resignation and will be leaving in 2 weeks
i. The Administrator has “suddenly” changed without much notice to staff
j. The community has been sold and the existing owner isn’t supporting any efforts for CQI
k. The residents don’t like the tested changes in the community neighborhood.
l. The leadership team didn’t communicate upcoming changes with Family/Resident
representatives causing a backlash.
m. Changes implemented from a “top down” mentality and the floor staff are not executing
the change processes.
n. Change recommendations are written at a higher reading competency level that the
average reading level of the staff
o. Flu outbreak occurs in the neighborhood the PIP changes are being tested
p. Flu outbreak occurs among the staff and the community has been short staffed for the
last month
q. A complaint survey tag was issued for the QM area that the PIP team is evaluating
r. The DON has been relieved of their duties
s. Another QM has presented an opportunity for improvement and shifted the focus of the
PIP team
t. A natural disaster occurs and has caused normal operations to cease for a week.
9. Reconvene PIP to evaluated data and overcome the random barrier then execute the second
“Do” phase
10. Determine if the data indicates that a full scale roll out should be considered or if the
interventions need to be examined again.
