42 CFR 484.65 — Condition of Participation: Quality Assessment and Performance Improvement (QAPI)

What this rule requires your agency to do

• 1The program must be capable of showing measurable improvement in indicators linked to improved health outcomes, patient safety, and quality of care, and the HHA must measure, analyze, and track quality indicators including adverse patient events (subd. a).(42 CFR 484.65 — Condition of Participation: Quality Assessment and Performance Improvement (QAPI))
• 2Performance improvement activities must focus on high-risk, high-volume, or problem-prone areas; lead to immediate correction of identified problems that threaten patient health and safety; track adverse patient events, analyze their causes, and implement preventive actions; and measure and sustain improvements (subd. c).(42 CFR 484.65 — Condition of Participation: Quality Assessment and Performance Improvement (QAPI))
• 3The governing body is responsible for ensuring an ongoing quality-improvement and patient-safety program is defined, implemented and maintained; that efforts address quality-of-care and patient-safety priorities and are evaluated for effectiveness; that clear patient-safety expectations are established; and that any findings of fraud or waste are appropriately addressed (subd. e).(42 CFR 484.65 — Condition of Participation: Quality Assessment and Performance Improvement (QAPI))
• 4The HHA must conduct performance improvement projects whose number and scope reflect the scope, complexity, and past performance of its services, and must document the projects undertaken, the reasons for them, and the measurable progress achieved (subd. d).(42 CFR 484.65 — Condition of Participation: Quality Assessment and Performance Improvement (QAPI))
• 5The program must use quality indicator data, including OASIS-derived measures where applicable, to monitor effectiveness and safety of services and quality of care and to identify improvement opportunities, with the frequency and detail of data collection approved by the governing body (subd. b).(42 CFR 484.65 — Condition of Participation: Quality Assessment and Performance Improvement (QAPI))
• 6The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program; the governing body must ensure it reflects the organization's complexity, involves all HHA services (including contracted services), focuses on indicators related to improved outcomes (including emergent care, hospital admissions and readmissions), and addresses performance across the spectrum of care including prevention and reduction of medical errors; and the HHA must maintain documentary evidence of the program and demonstrate its operation to CMS.(42 CFR 484.65 — Condition of Participation: Quality Assessment and Performance Improvement (QAPI))