Policy (Quality Assurance Performance improvement) Quality Assurance Performance Improvement Date Date Reviewed/ Reviewed/ Implemented Revised: Revised By: :

Policy: Title: Quality Assurance Performance Improvement Disciplines: All Approved by: QAPI Committee

Purpose:

Our Quality Assurance and Performance Improvement Program (QAPI) represent our facility’s commitment to continuous quality improvement. The program ensures a systematic performance evaluation, problem analysis and implementation of improvement strategies to achieve our performance goals.

Policy: A. The facility shall implement a QAPI Program designed to ensure the provisions required by The Patient Protection and Affordable Care Act of 2010, section 6102(c).

B. The facility shall establish an inter-disciplinary QAPI Committee. The committee shall consist of, at a minimum, a chairperson, Director of nursing services, physician, and three other facility staff members. Additional staff members may be included when their expertise is needed.

C. The QAPI Committee shall select additional members to participate in various subcommittees based upon the Performance Improvement Project (PIP) topic and participant expertise. These projects may include clinical and non-clinical opportunities to improve.

D. The QAPI Committee shall communicate its activities, and the progress of its subcommittee PIPs, to the administrator or executive director a minimum of quarterly by formal meeting. Additional team communication may occur via email or conference call.

E. The QAPI Committee shall meet at least quarterly to review facility data,

identify opportunities for improvement, and review the activities of its PIP

sub-committees. The committee shall maintain written meeting agendas, minutes, and periodically provide activity reports upon request to the administrator.

F. The QAPI Committee’s oversight responsibilities shall include, but are not limited to the following:

 Annual review of the facility’s QAPI program.  Establishment of PIP subcommittees.  Ensure the subcommittee has the adequate resources to conduct their project.  Submit findings of performance improvement projects to the chairperson that includes a summary of QAPI performance improvement project activities and findings.

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 Utilize facility data to identify opportunities to improve systems and care. Data may include, but is not limited to; grievance logs, medical record review, skilled care claims, fall log, pressure ulcer log, treatment logs, staffing trends, incident and accident reports, quality measures, survey outcomes, etc.

Procedure: Establishment of Facility QAPI Plan  The QAPI Committee shall establish an initial facility plan in its first QAPI meeting.

Revision of Facility QAPI Plan  The QAPI Committee will review the plan annually and make necessary revisions. Revisions shall reflect the findings, discussions, meetings, surveys, interaction with executive leadership, etc. of the previous year.

The plan may be modified during the year, with expanded executive committee approval as needed.

Annual Report to the Executive Director  The committee chair (if other than the executive director or administrator) shall submit an annual summary report of the QAPI activities to the administrator or executive director. The report may be requested more frequently.

QAPI Sub-Committees  Each Sub-committee shall be guided by a QAPI Committee member who will facilitate coordination of the PIP and ensure each Sub-committee is adequately resourced.

Upon conclusion of the PIP, the Sub-committee shall provide the QAPI Committee with a report, which contains a summary and analysis of activities and recommendations for improvement.

Clinical and Non-clinical Performance Improvement Projects  The facility shall conduct PIPs designed to achieve and sustain performance improvement over time. PIP’s shall be designed to have an expected favorable outcome.

The QAPI Sub-committee shall implement PIPs using relevant data collection and analysis with appropriate intervention strategies to improve facility performance.

The QAPI Committee will review the outcome of the PIP and may recommend further assessment of problem areas or corrective systemic interventions.

August 1, 2014 Page 2 of 3 Policy (Quality Assurance Performance improvement) The QAPI Committee shall maintain written documentation of meetings, findings, and progress, and make recommendations.

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