{"ref":"MI-HH-QA-01","title":"Quality Assessment and Performance Improvement (QAPI)","category":"Quality","summary":"Sets out the Agency’s quality assessment and performance improvement (QAPI) program under 42 CFR §484.65: an ongoing, Agency-wide, data-driven program that covers every service (including services under arrangement), focuses on outcomes including emergent care use, hospital admissions and readmissions, tracks adverse patient events, and is overseen by the governing body. It names the QAPI committee and its quarterly cycle, the indicators the Agency measures (OASIS outcomes, Home Health Quality Reporting Program and value-based purchasing results, infections, incidents, complaints, aide supervision, documentation, EVV for Michigan Medicaid visits), how problems are prioritized and corrected, the performance improvement projects recorded on Form MI-HH-QA-01-A, and the evidence the Agency keeps to show CMS that the program works.","inShort":["Our quality program measures how our patients do, including emergency visits and hospital stays, and acts on what it finds.","Report any problem, near miss or idea for doing better. You will not be punished for reporting in good faith.","If something puts a patient at risk, fix what you safely can and tell the clinical manager at once.","Help with improvement projects and follow the new steps they bring in.","Results are shared with staff every quarter."],"primaryCitation":"42 CFR §484.65","citations":["Michigan Medicaid Provider Manual, General Information for Providers, Section 13.4","Michigan Medicaid Provider Manual, Electronic Visit Verification chapter"],"federalCitations":["42 CFR §484.65","42 CFR §484.70(b)","42 CFR §484.45","42 CFR §484.245","42 CFR §§484.340 to 484.375","42 CFR §484.105(a)"],"surveyorAsks":["Show me your QAPI program description and the data the governing body approved you to collect.","What quality indicators do you track, and what do they show about emergent care use and hospital readmissions?"],"forms":[{"ref":"MI-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)","5. Governing Body Responsibilities","6. QAPI Committee","7. Quality Indicators and Data Sources","8. Analyzing Data and Setting Priorities","9. Immediate Correction of Threats to Patient Safety","10. Performance Improvement Projects","11. Staff Involvement and Communication","12. Annual Evaluation of the Program","13. Responsibilities","14. Records and Compliance Monitoring","15. Staff Training","16. References","17. Related Policies and Forms","18. Approval","19. Revision History"],"version":"1.0","sample":false,"pack":"mi-hha","state":"Michigan","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}}