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Quality Assessment and Performance Improvement

Runs one agency-wide, data-driven quality assessment and performance improvement (QAPI) program, required by 42 CFR §484.65 for a Medicare-certified agency and applied to every patient as the Agency’s own standard: the governing body approves what data is collected and how often, the QAPI committee tracks indicators and adverse events, focuses on high-risk, high-volume, and problem-prone areas, runs documented performance improvement projects, and feeds the governing body’s annual evaluation under 22-B DCMR §3903.2(c).

Preview: full text with a package
About this policy
Policy number
DC-HH-QA-01
Version
1.0
Main rule
42 CFR §484.65
Library
Washington, DC home health · 58 policies
Category
Quality
Sections
19

In short

  • The Agency measures how well it cares for patients so it can find and fix problems.
  • Report every incident and near miss. Reports are used to learn, not to blame.
  • Write accurate, complete notes. The data we track come from your documentation.
  • You may be asked to help with an improvement project. Your ideas count.
  • Anything that puts a patient in danger is fixed at once, not at the next meeting.

What's inside

19 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; 22-B DCMR §3903.2(c))
  • 5. Governance and the QAPI Committee
  • 6. What the Agency Measures
  • 7. Analyzing Data and Setting Priorities
  • 8. Adverse Patient Events
  • 9. Performance Improvement Projects
  • 10. Reporting and the Annual Evaluation
  • 11. DC Medicaid Quality Requirements
  • 12. Responsibilities
  • 13. Records and Compliance Monitoring
  • 14. Staff Training
  • 15. References
  • 16. Related Policies and Forms
  • 17. Approval
  • 18. Revision History

An inspector may ask

  • Show me your QAPI plan and the governing body’s approval of the data you collect and how often.
  • 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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