Quality Assessment and Performance Improvement
Sets up the Agency's hospice-wide, data-driven quality assessment and performance improvement (QAPI) program: governing body oversight and annual evaluation, the QAPI lead and committee, the indicators the Agency measures (including California's own clocks: the two-hour in-person response, caseloads of 12 or fewer, 48-hour and 5-day assessments, 15-day updates and 24-hour significant change notices), outcome data, adverse events, performance improvement projects, the Hospice Quality Reporting Program, and the California reviews that feed the program (acuity system, legend devices, plans of correction).
- Policy number
- CA-HSP-QA-01
- Version
- 1.0
- Main rule
- 42 CFR §418.58
- Library
- California hospice · 60 policies
- Category
- Quality
- Sections
- 21
In short
- The Agency measures its care every month, including whether a nurse reached each patient in person within two hours.
- Report every fall, medication error, missed visit or other problem so the team can learn from it.
- Your accurate notes are the data: an assessment or update done but not documented counts as not done.
- Ask your supervisor how to join a performance improvement project.
- Results and changes are shared at team meetings. Speak up if you see a better way.
What's inside
21 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (42 CFR §418.58)
- 5. Governance, the QAPI Lead and the Committee
- 6. What the Agency Measures (42 CFR §418.58(a)-(b))
- 7. Patient Outcome Data (22 CCR §74864(b)(3); 42 CFR §418.54(e))
- 8. Adverse Patient Events
- 9. Analysis and Improvement (42 CFR §418.58(c))
- 10. Performance Improvement Projects (42 CFR §418.58(d))
- 11. California Reviews That Feed the Program
- 12. Hospice Quality Reporting Program (If Medicare-Certified)
- 13. Annual Evaluation
- 14. Responsibilities
- 15. Records and Compliance Monitoring
- 16. Staff Training
- 17. References
- 18. Related Policies and Forms
- 19. Approval
- 20. Revision History
An inspector may ask
- Who runs your QAPI program, and how often does the governing body review it?
- What indicators do you track? Show me the last two quarters of data and what you did about the results.
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