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Quality Assessment and Performance Improvement (QAPI)

Sets the Agency’s quality assessment and performance improvement (QAPI) program: an effective, ongoing, agency-wide, data-driven program that the governing body oversees, that measures and tracks quality indicators (including OASIS-based measures and adverse patient events), focuses on high risk, high volume, and problem-prone areas, corrects threats to patient safety at once, runs documented performance improvement projects each year, and sustains improvement. Required by 42 CFR §484.65 if the Agency is Medicare-certified and applied to all patients as the Agency’s own standard, integrated with the California quality management system (22 CCR §74742).

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About this policy
Policy number
CA-HH-QA-02
Version
1.0
Main rule
42 CFR §484.65
Library
California home health · 58 policies
Category
Quality
Sections
18

In short

  • The Agency tracks how patients are doing, such as hospital visits, falls, infections, and missed visits, to find where care can improve.
  • Report every incident and near miss. That data drives the improvement work.
  • Problems that put a patient’s safety at risk are fixed right away, not saved for a meeting.
  • Each year the Agency runs improvement projects and measures whether they worked.
  • Ask your supervisor about current projects and share your ideas.

What's inside

18 sections. The full text comes with the One-time Policy Pack.

Full text with a package
  • Terms of Reference
  • 1. Purpose
  • 2. Scope
  • 3. Definitions
  • 4. Policy Statement (42 CFR §484.65)
  • 5. Program Scope
  • 6. Data
  • 7. Improvement Activities
  • 8. Performance Improvement Projects
  • 9. Governing Body Responsibilities
  • 10. Annual Program Evaluation
  • 11. Responsibilities
  • 12. Records and Compliance Monitoring
  • 13. Staff Training
  • 14. References
  • 15. Related Policies and Forms
  • 16. Approval
  • 17. Revision History

An inspector may ask

  • Show me your QAPI program. What quality indicators do you track, and who approved how often data are collected?
  • What performance improvement projects did you run this year? Why did you choose them, and what measurable progress did you make?

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