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Quality Assessment and Performance Improvement (QAPI)

Sets up an ongoing, Agency-wide, data-driven quality assessment and performance improvement (QAPI) program that meets 42 CFR §484.65 for a Medicare-certified agency and is applied to the whole Agency as its own standard: a QAPI committee, quality indicators including OASIS outcomes and adverse events, immediate correction of threats to patient safety, performance improvement projects, and governing body oversight. It builds on the Georgia quarterly record review and annual evaluation in Policy GA-HH-QA-01.

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About this policy
Policy number
GA-HH-QA-02
Version
1.0
Main rule
42 CFR §484.65
Library
Georgia home health · 56 policies
Category
Quality
Sections
18

In short

  • Our quality program measures how our patients do, such as hospital visits, falls, infections, and complaints, and works to improve the results.
  • If you see something that puts patients at risk, tell your supervisor or the Administrator right away. It will be fixed the same day.
  • Report every incident and mistake. We use reports to fix systems, not to blame people.
  • You may be asked to help with an improvement project. Your ideas from the field matter.

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; Ga. Comp. R. & Regs. 111-8-31-.07(8))
  • 5. The QAPI Committee
  • 6. What the Program Measures
  • 7. Performance Improvement Activities
  • 8. Performance Improvement Projects
  • 9. Immediate Correction
  • 10. Governing Body Responsibilities
  • 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 plan and the data you track. Who approved the frequency and detail of data collection?
  • 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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