Program objectives; All patient care disciplines; Description of how the program will be administered and coordinated;

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Gabriella Phelps
5 years ago
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1 A self-assessment is conducted. Can be accomplished through methods such as review of current documentation, patient care, direction observation of clinical performance, operating systems or interviews with patients/staff The following elements are considered in the written QAPI plan: Program objectives; All patient care disciplines; Description of how the program will be administered and coordinated; Methodology for monitoring and evaluating the quality of care; Priorities for resolution of problems; Monitoring to determine effectiveness of action; 1

2 Oversight responsibility reports to governing body; and Documentation of the review of its own QAPI program. Minutes are taken and maintained for any meetings PROGRAM SCOPE Objective data demonstrates improvements in: care outcomes, processes of care, patient/family satisfaction levels, agency operations, or other performance indicators QAPI program measures, analyzes and tracks quality indicators related to processes of care, safety and quality of care Includes aspects of performance that enable the agency to assess processes of care, agency 2

3 services, and operations address all areas of operations that might adversely affect patient care PROGRAM DATA Quality indicator data includes data beyond that collected during patient assessments. Includes but is not limited to: physician services, nursing services, medical social services, counseling services, therapy services clinical records, infection control, durable medical equipment (DME), patient rights, administrative services, contract services, Data collected is used to identify opportunities for improvement Opportunities for improvement are prioritized Data collected is used to monitor the effectiveness and safety of services and quality of care 3

4 Governing body approves frequency and detail of data collected Governing body ensures compliance with this requirement through direct control or appointment of one or more individuals to manage the structure and administration of the QAPI program. If through appointment, should be documented appointment and governing body retains ultimate responsibility for the individual(s) appointed. PROGRAM ACTIVITIES Performance activities: focus on high risk, high volume, or problemprone areas consider incidence, prevalence, and severity of problems in those areas affect palliative outcomes, patient safety, and quality of care Performance improvement activities: track adverse patient events, analyze their causes, and 4

5 implement preventive actions and mechanisms that include feedback and learning throughout the hospice Actions are taken that are aimed at performance improvement and, after implementing those actions, success is measures and performance tracked to ensure that improvements are sustained PERFORMANCE IMPROVEMENT PROJECTS (PIPS) PIPs are developed, implemented and evaluated PIPs are conducted annually PIPs reflect the scope, complexity, and past performance of the hospice's services and operations Reasons for PIPs are documented Progress achieved is documented EXECUTIVE RESPONSIBILITIES The hospice s governing body is responsible for ensuring the following: 5

6 That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually Agency-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness Documents evidence governing body s involvement in oversight of the QAPI program Source: CMS HH Conditions of Participation, FINAL 6

5/3/2017. QAPI Quality and Compliance HOSPICE. Hospice Quality Reporting Program QAPI & HQRP: DIFFERENCES AND SIMILARITIES

5/3/2017. QAPI Quality and Compliance HOSPICE. Hospice Quality Reporting Program QAPI & HQRP: DIFFERENCES AND SIMILARITIES QAPI Quality and Compliance HOSPICE Katie Wehri, CHPC Director of Operations Consulting Healthcare Provider Solutions Kwehri@healthcareprovidersolutions.com QAPI & HQRP: DIFFERENCES AND SIMILARITIES Hospice