HomeStrategiesCase StudiesQAPI planning and assessment tool helps keep facility survey-ready

QAPI planning and assessment tool helps keep facility survey

How quality management adds up to resident satisfaction and national recognition.

nurse in a mask talking to a patient in a mask
nurse in a mask talking to a patient in a mask

QAPI planning and assessment tool helps keep facility survey-ready

How quality management adds up to resident satisfaction and national recognition.


When it comes to growing your revenue, it’s important to create a following for your facility with residents, the community and referral partners. This means you have to shape and manage your reputation. But who has time for that? You already have your hands full taking care of the day-to-day challenges of just running your facility.

This case study is about capitalizing on the performance data you’re already gathering for survey and using it to build and share your strongest marketing story. We introduced Oregon Veterans home Lebanon to a comprehensive solution that simplifies quality management. This cloud-based system keeps the facility survey ready, residents feeling at home and census high.


Oregon Veterans’ Home Lebanon (OVHL)

Oregon Veterans’ Home Lebanon (OVHL) provides rehabilitation, memory care and long-term care for eligible US military veterans, their spouses and Gold Star Parents. Set on 12 acres next to Samaritan Lebanon Community Hospital, OVHL’s communities, or neighborhoods, consist of three houses each, serving a total of 154 residents. The main driver of its success is making residents truly feel at home, with care that goes beyond simply meeting their needs.


  • Find ways to improve resident/family satisfaction and well-being
  • Gather and analyze key performance indicators efficiently
  • Be better prepared for surveys


  • Put a quality management system in place
  • Leverage technology to manage survey readiness and QAPI
  • Implement a systems approach to performance improvement


  • Resident satisfaction 30 percentage points higher than national average
  • Higher survey scores
  • Recognized with national awards for quality


OVHL’s overall objective was to develop a system focused on resident needs and care. It also wanted to gather and analyze key performance indicators to help improve the facility as a whole and provide excellent customer service.

“We value our veterans and their families, and we strive to provide the highest quality of care for them on a daily basis,” said OVHL’s Quality Improvement Coordinator (QIC) Terri Silkett.

OVHL wanted to prioritize the most important quality improvements and establish realistic, obtainable goals. It also wished to increase resident loyalty and grow its reputation with preferred providers.

“Our main challenge was choosing the right quality assessment and performance improvement system and putting it in place,” explained Silkett.


Through our partnership, OVHL determined that abaqis was the best quality management system to meet all of its goals. abaqis uses a combination of resident interviews, observations and reviews to provide actionable data that identifies the regulatory areas in which to focus quality improvement efforts.

According to Silkett, “It made sense to put abaqis in place to help us meet our goals. We were already familiar with the program because most of us had used it at other facilities.”

Key components of OVHL’s overall performance improvement system included:

  • Sharply defined use of abaqis and its Quality Assurance Performance Improvement (QAPI) template
  • Collecting and trending data against established benchmarks
  • Creating performance improvement teams to address results that didn’t meet OVHL’s goals
  • Using a variety of techniques—root cause analysis: the Plan, Do, Study, Act (PDSA) model and the Malcolm Baldrige framework

“All of these techniques helped us work toward the goal of excellence in our field,” said Silkett.


The abaqis QAPI platform helps OVHL identify areas for improvement and gives direction for establishing further investigations, PIP teams and training/education. Also, the built-in QAPI and PIP tools allows the facility to track the progress of their quality improvements.

Each quarter OVHL divides the QAPI sample and investigation snapshot among its 30 trained staff members, who each receive a deadline for completion. The information is captured by handheld tablets and iPads. Their current QAPI sample consists of mostly department managers, nursing and social services.

“As QIC, I oversee completion of the investigations, along with our nurse case managers and social services,” explained Silkett. “The results are sent to all of our staff via email. The changes are implemented through follow-up investigations and PIP teams are set up to address any concerns.”

How abaqis helped OVHL build their reputation:
  • Upheld quality ensuring ratings and regulation compliance
  • Established a measurable standard of care quality
  • Deepened connections with residents
abaqis helped OVHL prepare for state and federal surveys

The abaqis system is a key factor in helping OVHL stay on top of issues that may arise at survey time.

“We are confident at survey time because we know abaqis is the only assessment and reporting system that replicated the entire survey methodology,” said Silkett. “It’s a great tool to help prevent survey tags and issues because it allows staff to address quality concerns as they come up and put interventions in place before a survey.”

Resolving concerns in advance helps improve OVHL’s survey outcomes and better prepares and educates staff on the survey process itself. Because abaqis also assesses compliance with regulations set forth in the CMS Final Rule, OVHL is confident about its ability to succeed in the new hybrid survey process as well.

“It made sense to put abaqis in place to help us meet our goals. We were already familiar with the program because most of us had used it at other facilities.”

Terri Silkett, OVHL’s Quality Improvement Coordinator (QIC)

abaqis engages staff and residents, improving everyone’s satisfaction

A key part of abaqis centers on staff interviewing residents and their families because it lets OVHL know where the facility is doing well and where it may need to improve. The interviews spark conversations to help resolve any issues and give the veterans OVHL serves another way to express their needs and wants. They also help the nursing staff learn about issues they may need to address, such as asking social services to make a dental or hearing appointment for a veteran.

“We always take negative responses seriously, investigating, responding to and resolving those concerns as soon as possible,” explained Silkett. To help track progress, abaqis has built-in graphing tools that illustrate quarterly trends. This gives OVHL the ability to assign a PIP team to help resolve any downward trends.

abaqis has been well received because the staff sees the benefits of how it helps them get to know the veterans and their families better. “For example, it’s an opportunity for the veteran or family to be complimentary of the care they receive from staff,” said Silkett.

Most of OVHL’s veterans enjoyed being interviewed by staff and answering questions. In fact, some saw it as an opportunity to discuss a variety of matters and to compliment staff. “Our abaqis interview questions about activities have allowed us to plan meaningful outings for our veteran residents,” noted Silkett. “For example, one veteran who was a retired flight nurse, said she had flown on just about every type of aircraft except a helicopter. The activities department set up a trip for her with a local helicopter service and she was able to fulfill that wish.


As seen in the graphs above, OVHL’s residents and their families are extremely likely to recommend their facility. Satisfaction scores exceeded the national average by double digits.

Using abaqis has led OVHL to receive recognition for high quality care both regionally and nationally. OVHL was given the Bronze Commitment to Quality Award in 2018 from the American Health Care Association and National Center for Assisted Living, which spotlights providers who have shown significant dedication to improving the quality of care for residents in long-term and post-acute care.

In 2019, OVHL was recognized with the Silver National Quality Award for achievement in quality. The facility was one of only three Oregon-based facilities to earn this national recognition.

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  1. Collins, R. Bring Nurses Back to the Bedside. For the Record. 2015;27(9):10. Available at: Accessed March 2, 2020.
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