{"ref":"TX-HSP-QA-01","title":"Quality Assessment and Performance Improvement","category":"Quality","summary":"Sets out the Agency’s hospice-wide, data-driven quality assessment and performance improvement (QAPI) program: the QAPI Committee, the measures it tracks (including adverse events, complaints, infections and medication errors), how incidents are reported on Form TX-HSP-QA-01-A, performance improvement projects, hospice quality reporting to CMS, the annual evaluation, and the governing body’s role.","inShort":["Report every fall, medication error, missed visit, injury or near miss on an incident report before the end of your day.","Make the patient safe first and call the on-call nurse if needed: (512) 555-0199.","Incident reports are for learning, not blame. Write only the facts.","Do not put the incident report in the patient’s chart or mention it there.","Our QAPI Committee reviews what goes wrong and what we change. Ask your supervisor about our current improvement projects."],"primaryCitation":"42 CFR §418.58","citations":["26 TAC §558.287","26 TAC §558.813","26 TAC §558.853(c)","26 TAC §558.243(b)(1)(J)","26 TAC §558.250"],"federalCitations":["42 CFR §418.58","42 CFR §418.54(e)","42 CFR §418.312","42 CFR §418.306(b)","42 CFR §418.104(a)(4)"],"surveyorAsks":["Show me your QAPI plan, the minutes of the last two committee meetings and who attended.","What adverse events have you tracked this year, and what did you change as a result?"],"forms":[{"ref":"TX-HSP-QA-01-A","title":"Adverse Event and Incident Report"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §418.58; 26 TAC §558.287)","5. QAPI Committee","6. What the Program Measures","7. Reporting Adverse Events and Incidents","8. Analysis and Performance Improvement Activities","9. Performance Improvement Projects","10. Hospice Quality Reporting Program","11. Annual Evaluation and Governing Body Oversight","12. Confidentiality","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":"tx-hospice","state":"Texas","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 Hospice","legalName":"Sample Hospice, LLC","logo":null}}