{"ref":"MI-HSP-QA-01","title":"Quality Assessment and Performance Improvement, Medical Audit and Utilization Review","category":"Quality","summary":"Sets out the Agency's quality assessment and performance improvement (QAPI) program as Michigan's licensing rules and the Medicare Conditions of Participation require: governing body oversight, the QAPI lead and committee, the quality indicators the Agency tracks, how adverse events are identified, reported, investigated and prevented, performance improvement projects every year, medical audits of individual records and utilization review of services in aggregate, and the annual evaluation.","inShort":["If something goes wrong or nearly goes wrong (a fall, a medicine error, a missed visit), make the patient safe and tell your supervisor at once.","Complete an incident report before your shift ends. Reporting is about fixing systems, not blaming people.","Suspected abuse or an injury nobody can explain goes straight to the Administrator.","You may be asked to help with an improvement project. Your ideas count."],"primaryCitation":"Mich. Admin. Code R 325.45161","citations":["Mich. Admin. Code R 325.45161","Mich. Admin. Code R 325.45163","Mich. Admin. Code R 325.45165","Mich. Admin. Code R 325.45167","Mich. Admin. Code R 325.45159","Mich. Admin. Code R 325.45143","Mich. Admin. Code R 325.45123(1)","Mich. Admin. Code R 325.45201(1)(c)","Mich. Admin. Code R 325.45241(8)","Mich. Admin. Code R 325.45351(3)","Mich. Admin. Code R 325.45353","Mich. Admin. Code R 325.45357","Mich. Admin. Code R 325.45365(3)","MCL 333.21418","MCL 333.20175(13)"],"federalCitations":["42 CFR §418.58","42 CFR §418.60(b)(1)","42 CFR §418.108(d)","42 CFR §418.312"],"surveyorAsks":["Who runs your QAPI program, and show me the governing body's approval of what data you collect and how often.","Which performance improvement projects did you run last calendar year? If none, where is the written justification?"],"forms":[{"ref":"MI-HSP-QA-01-A","title":"Performance Improvement Project Record"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (Mich. Admin. Code R 325.45161; 42 CFR §418.58)","5. Governing Body Responsibilities","6. QAPI Committee","7. What the Agency Measures","8. Adverse Events","9. Performance Improvement Projects","10. Medical Audit","11. Utilization Review","12. Using the Data","13. Confidentiality and Department Access","14. Responsibilities","15. Records and Compliance Monitoring","16. Staff Training","17. References","18. Related Policies and Forms","19. Approval","20. Revision History"],"version":"1.0","sample":false,"pack":"mi-hospice","state":"Michigan","service":"Hospice","guides":[{"path":"/guides/hospice-policies/","h1":"What policies are required for hospice?"},{"path":"/guides/hospice-conditions-of-participation/","h1":"Hospice Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}