{"ref":"DC-HH-QA-01","title":"Quality Assessment and Performance Improvement","category":"Quality","summary":"Runs one agency-wide, data-driven quality assessment and performance improvement (QAPI) program, required by 42 CFR §484.65 for a Medicare-certified agency and applied to every patient as the Agency’s own standard: the governing body approves what data is collected and how often, the QAPI committee tracks indicators and adverse events, focuses on high-risk, high-volume, and problem-prone areas, runs documented performance improvement projects, and feeds the governing body’s annual evaluation under 22-B DCMR §3903.2(c).","inShort":["The Agency measures how well it cares for patients so it can find and fix problems.","Report every incident and near miss. Reports are used to learn, not to blame.","Write accurate, complete notes. The data we track come from your documentation.","You may be asked to help with an improvement project. Your ideas count.","Anything that puts a patient in danger is fixed at once, not at the next meeting."],"primaryCitation":"42 CFR §484.65","citations":["22-B DCMR §3903.2","22-B DCMR §3905.2","22-B DCMR §3916.1","22-B DCMR §3915.7","29 DCMR §5012.7","29 DCMR §4254.7","29 DCMR §4254.11"],"federalCitations":["42 CFR §484.65","42 CFR §484.70(b)","42 CFR §484.45","42 CFR §484.105(a)"],"surveyorAsks":["Show me your QAPI plan and the governing body’s approval of the data you collect and how often.","What performance improvement projects did you run this year? Why did you choose them, and what measurable progress did you make?"],"forms":[{"ref":"DC-HH-QA-01-A","title":"Performance Improvement Project Record"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §484.65; 22-B DCMR §3903.2(c))","5. Governance and the QAPI Committee","6. What the Agency Measures","7. Analyzing Data and Setting Priorities","8. Adverse Patient Events","9. Performance Improvement Projects","10. Reporting and the Annual Evaluation","11. DC Medicaid Quality Requirements","12. Responsibilities","13. Records and Compliance Monitoring","14. Staff Training","15. References","16. Related Policies and Forms","17. Approval","18. Revision History"],"version":"1.0","sample":false,"pack":"dc-hha","state":"Washington, DC","service":"Home health","guides":[{"path":"/guides/home-health-qapi/","h1":"What is QAPI in home health, and what does §484.65 require?"},{"path":"/guides/home-health-agency-policies/","h1":"What policies and procedures are required for home health agencies?"},{"path":"/guides/home-health-conditions-of-participation/","h1":"Home health Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}