Quality Assessment and Performance Improvement (QAPI)
Establishes the Agency’s data-driven, agency-wide quality assessment and performance improvement (QAPI) program under 42 CFR §484.65, which NC Medicaid also requires: the indicators the Agency tracks, including OASIS outcomes, emergent care use, hospital admissions and adverse events; the governing body’s approval of data collection; immediate correction of problems that threaten patient safety; performance improvement projects; and how the annual evaluation and 90-day record reviews required by 10A NCAC 13J .1004 feed the program.
About this policy
- Policy number
- NC-HH-QA-02
- Version
- 1.0
- Main rule
- 42 CFR §484.65
- Library
- North Carolina home health · 57 policies
- Category
- Quality
- Sections
- 17
In short
- Our quality program (QAPI) tracks outcomes such as hospital admissions, emergency care, falls, medication errors and infections.
- Report every adverse event so it can be counted, its cause found, and steps taken to prevent it.
- A problem that threatens a patient’s health or safety is corrected at once, not saved for the next meeting.
- Each year the Agency runs at least one performance improvement project chosen from its data (Agency standard). You may be asked to join the team.
- On-time aide supervision, plan of care reviews every 90 days, and signed verbal orders are checked every month.
What's inside
17 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 §484.65; NC Medicaid Clinical Coverage Policy 3A)
- 5. Governing Body and Leadership
- 6. Program Scope and Data
- 7. Program Activities
- 8. Performance Improvement Projects
- 9. Link to the North Carolina Evaluations
- 10. Responsibilities
- 11. Records and Compliance Monitoring
- 12. Staff Training
- 13. References
- 14. Related Policies and Forms
- 15. Approval
- 16. Revision History
An inspector may ask
- Show me your QAPI program. Which indicators do you track, and who approved how often the data is collected?
- What performance improvement projects did you run this year, why did you choose them, and what changed?
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