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Quality Assessment and Performance Improvement

Sets out the Agency’s hospice-wide, data-driven quality assessment and performance improvement (QAPI) program: the QAPI Committee, the measures it tracks (including adverse events, complaints, infections and medication errors), how incidents are reported on Form TX-HSP-QA-01-A, performance improvement projects, hospice quality reporting to CMS, the annual evaluation, and the governing body’s role.

Preview: full text with a package
About this policy
Policy number
TX-HSP-QA-01
Version
1.0
Main rule
42 CFR §418.58
Library
Texas hospice · 59 policies
Category
Quality
Sections
20

In short

  • Report every fall, medication error, missed visit, injury or near miss on an incident report before the end of your day.
  • Make the patient safe first and call the on-call nurse if needed: (512) 555-0199.
  • Incident reports are for learning, not blame. Write only the facts.
  • Do not put the incident report in the patient’s chart or mention it there.
  • Our QAPI Committee reviews what goes wrong and what we change. Ask your supervisor about our current improvement projects.

What's inside

20 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 §418.58; 26 TAC §558.287)
  • 5. QAPI Committee
  • 6. What the Program Measures
  • 7. Reporting Adverse Events and Incidents
  • 8. Analysis and Performance Improvement Activities
  • 9. Performance Improvement Projects
  • 10. Hospice Quality Reporting Program
  • 11. Annual Evaluation and Governing Body Oversight
  • 12. Confidentiality
  • 13. Responsibilities
  • 14. Records and Compliance Monitoring
  • 15. Staff Training
  • 16. References
  • 17. Related Policies and Forms
  • 18. Approval
  • 19. Revision History

An inspector may ask

  • Show me your QAPI plan, the minutes of the last two committee meetings and who attended.
  • What adverse events have you tracked this year, and what did you change as a result?

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