Beyond Compliance: Why Quality Improvement Must Be in Your RCFE's DNA

This isn't happening in a vacuum. The 2022 National Academies of Sciences, Engineering, and Medicine report on quality care in nursing homes highlights continuous quality improvement as central to delivering person-centered care. Quality Assurance and Performance Improvement (QAPI) programs are referenced more than 160 times in the 2025 Long-Term Care Surveyor Guidance for skilled nursing.

What Quality Improvement Looks Like in Practice

State requirements vary, but common elements include:

Establishment of quality assurance committees

Creation of written quality improvement programs

Regular reviews of resident and staff outcome data

Systematic approaches to identifying and addressing care gaps

Some states are going further, offering regulatory incentives for facilities that pursue excellence. New Jersey, for example, allows communities that achieve accreditation (a process built on continuous quality improvement) relief from regularly occurring state inspections.

Wisconsin has embraced an even more comprehensive model through the Wisconsin Coalition for Collaborative Excellence in Assisted Living—a voluntary, large-scale, data-driven quality improvement program. Participating communities access a secure data platform to assess their programs, compare themselves with peers, and become eligible for abbreviated state surveys.

The message? Excellence is becoming a competitive advantage, not just a philosophical goal.

The Five Whys (originally conceived by Sakichi Toyoda) helps uncover the root cause of problems. Instead of treating symptoms, this technique asks "why" repeatedly until you reach the fundamental issue driving a challenge—whether that's medication errors, documentation gaps, or care coordination breakdowns.

Plan: Identify a change and predict its impact

Do: Implement the change on a small scale

Study: Analyze data and results

Act: Decide whether to adopt, adapt, or abandon the change

The Center for Excellence in Assisted Living (CEAL@UNC) has compiled 96 evidence-based measures and instruments spanning person-centered care, medication management, care coordination, resident outcomes, and workforce development. These tools help RCFEs gather information, focus improvement efforts, and chart a path toward excellence.

One example: The Toolkit for Person-Centeredness in Assisted Living provides research-quality metrics specifically designed for assisted living settings, developed with input from numerous organizations to guide meaningful quality improvement.

Sound familiar? This is the most common objection RCFE administrators voice when discussing systematic quality improvement efforts. And it's understandable. Your team is stretched thin. Resources are limited. The idea of adding another initiative feels overwhelming.

But here's the truth that transformative facilities have discovered: Quality improvement doesn't drain resources—it optimizes them.

As the business principle states: "You can't improve what you don't measure." Assisted living communities cannot expect to achieve sustainable change, adopt evidence-based best practices, or even maintain consistent operations without understanding the processes that drive outcomes.

Studies show that weaving quality improvement into everyday routines contributes not only to better resident outcomes but also to increased efficiency and resource management. When you systematically identify bottlenecks, eliminate redundancies, and standardize best practices, you actually save time and resources while improving care.

With rising medical acuity, medication errors pose significant risks. Systematic reviews of medication administration processes, documentation protocols, and staff training can reduce errors and improve resident safety.

As assisted living residents present more complex healthcare needs, seamless coordination with external providers becomes critical. Quality improvement efforts should focus on care transitions, communication protocols, and integrated care planning.

Beyond the buzzword, person-centered care requires measurable practices and outcomes. Tools like the Toolkit for Person-Centeredness provide concrete ways to assess and improve how your facility honors resident preferences, autonomy, and dignity.

Staff turnover undermines quality care. Quality improvement programs that examine recruitment, training, support, and retention contribute to workforce stability—and better resident outcomes.

Administrative burdens shouldn't compromise care delivery. Streamlining documentation through quality improvement methods ensures regulatory compliance without overwhelming staff.

Leading RCFEs are embracing a different mindset: Quality improvement as standard operating procedure. This means:

✅ Every team member understands their role in quality outcomes

✅ Data collection and analysis inform decisions, not guesswork

✅ Problems are viewed as opportunities for systematic improvement

✅ Continuous learning and professional development are cultural priorities

✅ Processes are regularly evaluated and refined

Organizations like the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) recognize these achievements through programs like the National Quality Award, based on the evidence-supported Baldridge Excellence Framework. Hundreds of assisted living communities have received this recognition—proof that systematic quality improvement is achievable, not aspirational.

Start small, but start systematically:

Choose one priority area (medication management, care transitions, person-centered practices)

Gather baseline data using available tools and measures

Identify a specific, measurable goal (reduce medication errors by 20%, improve care coordination documentation)

Apply the PDSA cycle to test small changes before facility-wide implementation

Engage your team in identifying root causes and proposing solutions

Track progress and celebrate incremental improvements

Make it routine—integrate quality review into standing meetings and workflows

The goal isn't perfection overnight. It's embedding a culture where quality improvement becomes "how we do things here"—the DNA of your organization.

With nearly half of states already mandating quality improvement programs—and that number continuing to grow—the question isn't whether your RCFE will adopt systematic quality practices. It's whether you'll be proactive or reactive.

Facilities that embrace quality improvement as standard practice position themselves for:

Regulatory compliance and potential incentives

Improved resident outcomes and satisfaction

Enhanced operational efficiency

Stronger workforce stability

Competitive differentiation in the marketplace

Most importantly, they deliver on the promise at the heart of residential care: providing a safe, dignified, person-centered environment where residents thrive.

Investing in professional development around quality improvement frameworks isn't just about meeting evolving standards—it's about building the knowledge and skills to lead your facility toward sustainable excellence.

Because at the end of the day, you truly can't improve what you don't measure. And your residents deserve a facility where quality isn't an afterthought—it's embedded in everything you do.