QAPI, Goal Setting, Root Cause Analysis, PDSA, and MORE

Goal setting is one of the most important activities in quality improvement.  We use goals every day. Part of creating a culture of continuous quality improvement ensures that all employees and patients understand their roles, expectations, and why they are critical to achieving success.

We know that every dialysis center is mission critical in providing patient-centered care and exceeding quality goals set by the Centers for Medicare & Medicaid Services.  These goals are met in many ways - but all can only be successfully exceeded when every team member is competent and confident in the importance of their role responsibilities, and in understanding goals, benchmarks, processes of their work.

Best Practice Goal Setting provides:

  • Organizational direction and discipline to ensure that everyone is focused on the same objective.
  • Effective utilization of all team members and organizational metrics to ensure appropriate resources, and to reduce the likelihood of delays.
  • An opportunity for the organization to achieve an advantage over the competition.
  • Clarity to the team members regarding what is expected of them.

Patient Quality of Life/Goal Setting

Patient SMART Goal Road Map/Action Plan PDF (English/Spanish)
ESRD NCC Patient Goal Setting Workbook PDF

Goals for QAPI

QAPI involves the entire care team continually reviewing the overall care provided in the dialysis center and seeking ways to improve on the systems and clinical processes as opposed to individual problems as they arise. A robust QAPI program is data driven and improves health outcomes for the facility as a whole, beyond just individual patient needs. QAPI is an ongoing program, not an isolated meeting or event, that should:

  • Include the interdisciplinary care team (IDT), Medical Director, and when possible include the patient voice
  • Be data-driven and incorporate indicators related to improved medical outcomes and reduction of medical errors
  • Aggregate data to allow for tracking, trending, and performance evaluation both clinically and operationally
  • Involve continuous monitoring, evaluation, and adjustment to meet changing facility needs
  • Include a clear statement of the purpose of the improvement, goals, estimated time to attainment, and priority within the system

QAPI is also mandated by the Centers for Medicare and Medicaid Services (CMS) Conditions for Coverage (CfC).

CQI Learning Series

These self guided learning modules were developed to assist dialysis facility staff  and achieving Quality Improvement Activity Goals.

Adopting Sustainability Strategies link
QAPI Framework: Quality Measure Integration

Patient and Healthcare Team

Network Quality Improvement Department

Jeanine Pilgrim, MPH, PMP, CPHQ, CHES, CPXP
Network Program Director
(516) 209-5365

Elena Balovlenkov, RN, BSN, MS
Quality Improvement Director

Anna Bennett
Quality Improvement Coordinator
Emergency Manager
(516) 209-5474