Skip to content

Quality Assessment and Performance Improvement, Medical Audit and Utilization Review

Sets out the Agency's quality assessment and performance improvement (QAPI) program as Michigan's licensing rules and the Medicare Conditions of Participation require: governing body oversight, the QAPI lead and committee, the quality indicators the Agency tracks, how adverse events are identified, reported, investigated and prevented, performance improvement projects every year, medical audits of individual records and utilization review of services in aggregate, and the annual evaluation.

Preview: full text with a package
About this policy
Policy number
MI-HSP-QA-01
Version
1.0
Main rule
Mich. Admin. Code R 325.45161
Library
Michigan hospice · 59 policies
Category
Quality
Sections
21

In short

  • If something goes wrong or nearly goes wrong (a fall, a medicine error, a missed visit), make the patient safe and tell your supervisor at once.
  • Complete an incident report before your shift ends. Reporting is about fixing systems, not blaming people.
  • Suspected abuse or an injury nobody can explain goes straight to the Administrator.
  • You may be asked to help with an improvement project. Your ideas count.

What's inside

21 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 (Mich. Admin. Code R 325.45161; 42 CFR §418.58)
  • 5. Governing Body Responsibilities
  • 6. QAPI Committee
  • 7. What the Agency Measures
  • 8. Adverse Events
  • 9. Performance Improvement Projects
  • 10. Medical Audit
  • 11. Utilization Review
  • 12. Using the Data
  • 13. Confidentiality and Department Access
  • 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 show me the governing body's approval of what data you collect and how often.
  • Which performance improvement projects did you run last calendar year? If none, where is the written justification?

See Cura Core with your agency's name on it.

Choose your state and type of agency, buy your Policy Pack online and get your sign-in by email. Already a customer? Sign in to your portal.

Get startedSign in