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Quality Assurance & Performance Improvement (QAPI) Program Audit
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Audit of a facility's QAPI program covering the five elements, data-driven improvement, adverse event analysis, and governing body accountability.
CMS 42 CFR 482.21CMS 42 CFR 483.75TJC Performance Improvement (PI)
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Program Design & Scope
- Is there a written, ongoing, comprehensive, data-driven QAPI program? *
- Does the program address all systems of care and management practices, including clinical and non-clinical? *
- Is a written QAPI plan present and available to surveyors on the first day of survey? *
Data Collection & Monitoring
- Does the program collect and use data (including from the QIS/MDS/claims) to monitor performance? *
- Are performance indicators established to monitor effectiveness and safety of services? *
- Is feedback obtained from staff, residents/patients, and families? *
Performance Improvement Projects (PIPs)
- Are performance improvement projects conducted with a documented methodology and outcomes? *
- Has the governing body set priorities and the number/scope of improvement projects annually? *
- Number of active performance improvement projects currently underway?
Adverse Events & Root Cause Analysis
- Is there a system to identify, report, track, and analyze adverse events and near misses? *
- Are root cause analyses conducted for adverse events with corrective actions and re-monitoring? *
- Are corrective actions implemented and their effectiveness measured? *
Governance & Accountability
- Is the governing body/administration responsible for and accountable to the QAPI program? *
- Does leadership ensure the QAPI program is adequately resourced and sustained? *
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