Quality Assessment and Performance Improvement

Sets out the Agency's written quality assessment and performance improvement (QAPI) plan: its goals and objectives, the person responsible for the program, the designated group that reviews it, what is measured in every service (including contracted services), how problems are resolved and corrective actions documented and checked for effect, how adverse events are tracked, how performance improvement projects are run, and how the governing body reviews and approves the plan at least once a year as 19 CSR 30-35.010(2)(N) requires.

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About this policy

Policy number: MO-HSP-QA-01
Version: 1.0
Main rule: 19 CSR 30-35.010(2)(N)
Library: Missouri hospice · 59 policies
Category: Quality
Sections: 21

In short

The Agency follows a written quality plan every year. Lee Sample runs it.
Report every incident, near miss and complaint. That data is how problems are found.
When a problem is found, a fix is chosen, written down, and checked again to see if it worked.
You may be asked to help collect data or join an improvement project. Your ideas count.
The governing body reviews the whole plan at least once a year and approves the next one.

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 (19 CSR 30-35.010(2)(N))
5. The Written QAPI Plan
6. The QAPI Committee
7. What Is Measured
8. Collecting and Analyzing Data
9. Method for Resolving Identified Problems
10. Adverse Events
11. Performance Improvement Projects
12. Governing Body Review
13. Confidentiality of QAPI Work
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

Show me your written QAPI plan. Who is the person responsible for the program, and where does the plan say so?
Show me the governing body minutes for the last two years where the QAPI plan and activities were reviewed and approved.

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Rules it follows

19 CSR 30-35.010(2)(N)19 CSR 30-35.010(2)(A)119 CSR 30-35.010(1)(J)119 CSR 30-35.010(2)(J)113 CSR 70-50.010(7)(D)42 CFR §418.5842 CFR §418.100(b)42 CFR §418.108(d)

Forms included

MO-HSP-QA-01-A Annual QAPI Plan and Governing Body Review

Read a sample in full

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