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Quality Assessment and Performance Improvement and the Quality Management Committee

Sets out the Agency’s hospice-wide, data-driven quality assessment and performance improvement (QAPI) program under 42 CFR §418.58: governing body responsibilities, the QAPI lead, the multidisciplinary Quality Management Committee, the indicators measured, performance improvement projects, quality reporting to CMS, the annual evaluation, and, if the Agency is enrolled in DC Medicaid, the quality management and peer review program submitted to DHCF by June 30 each year.

Preview: full text with a package
About this policy
Policy number
DC-HSP-QA-01
Version
1.0
Main rule
42 CFR §418.58
Library
Washington, DC hospice · 60 policies
Category
Quality
Sections
20

In short

  • The Agency measures the quality and safety of its care and uses the data to improve.
  • The Quality Management Committee meets every quarter to review results and projects.
  • Your incident reports, visit notes and assessments are the data. Keep them complete and on time.
  • Each year the governing body reviews the whole quality program and sets the projects.
  • Ask the QAPI lead about current projects and how you can help.

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)
  • 5. Governing Body Responsibilities
  • 6. Quality Management Committee
  • 7. What the Agency Measures
  • 8. Quality Management and Peer Review Program (If the Agency Is Enrolled in DC Medicaid)
  • 9. Performance Improvement Activities and Projects
  • 10. Quality Reporting to CMS
  • 11. Annual Plan and Evaluation
  • 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 program. What indicators do you track, and who approved how often data is collected?
  • What performance improvement projects are you working on, why did you choose them, and what progress have you measured?

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