{"ref":"MO-HH-QA-01","title":"Quality Assessment and Performance Improvement (QAPI)","category":"Quality","summary":"Sets out the Agency's effective, ongoing, agency-wide, data-driven quality assessment and performance improvement (QAPI) program under 42 CFR §484.65 as adopted by 19 CSR 30-26.010(1)(A): who leads it, the quality indicators it measures (including emergent care use, hospital admissions and readmissions, and adverse events), how data are used, how problems are corrected, performance improvement projects, the governing body's executive responsibilities, and, if the Agency is Medicare-certified, its part in the Home Health Quality Reporting Program and the expanded Home Health Value-Based Purchasing Model.","inShort":["Our quality program (QAPI) measures how our care is going and fixes what can be better.","We track hospital admissions, emergency care, falls, medication errors, infections and complaints.","Anything that threatens patient safety is fixed right away, not saved for a meeting.","We always run at least one improvement project. Ask your manager which one is active.","Report incidents and ideas. Every staff member is part of QAPI."],"primaryCitation":"42 CFR §484.65 (adopted by 19 CSR 30-26.010(1)(A))","citations":["19 CSR 30-26.010(1)(A)","RSMo §197.478"],"federalCitations":["42 CFR §484.65","42 CFR §484.65(a) to (e)","42 CFR §484.70(b)","42 CFR §484.105(a)","42 CFR §484.245","42 CFR §§484.340 to 484.375","42 CFR Part 484 Subpart F (HHVBP), if Medicare-certified"],"surveyorAsks":["Show me your QAPI program. What indicators are you tracking and what do the data show?","What performance improvement projects have you done this year, why did you choose them, and what changed?"],"forms":[{"ref":"MO-HH-QA-01-A","title":"QAPI Program Plan and Performance Improvement Project Record"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §484.65)","5. Leadership and the QAPI Committee","6. What the Program Measures","7. Using the Data","8. Choosing Priorities and Correcting Problems","9. Performance Improvement Projects","10. Federal Quality Reporting (if the Agency is Medicare-certified)","11. Reporting to the Governing Body","12. Executive Responsibilities of the Governing Body","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":"mo-hha","state":"Missouri","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}}