Current through Register 1531, September 27, 2024
(A) A Program shall develop and implement an
ongoing, program-wide, data-driven Quality Assessment and Performance
Improvement (QAPI) program.
(B) A
Program shall form a QAPI committee to implement the QAPI program.
(1) The QAPI committee shall include at least
the Program Director, a registered nurse employed by the program, and one or
more individuals appointed by the Program Director.
(2) The QAPI committee shall meet at least
two times per year and shall maintain minutes of all meetings.
(C) The QAPI program shall
measure, analyze, and track quality indicators, including adverse events and
other aspects of performance that enable the Program to assess the quality of
Program services and operations.
(D) The QAPI program shall collect quality
indicator data in order to:
(1) Monitor the
effectiveness of services;
(2)
Monitor quality of care at the Program;
(3) Monitor safety at the Program;
and
(4) Identify opportunities and
priorities for improvement.
(E) The QAPI program's activities shall:
(1) Focus on high risk, high volume, or
problem-prone areas;
(2) Consider
incidence, prevalence, and severity of problems in those areas;
(3) Positively affect participant safety and
quality of care;
(4) Track adverse
participant events, analyze their causes, and implement preventive actions and
mechanisms that include feedback and learning throughout the Program;
(5) Take actions aimed at performance
improvement; and
(6) Measure
success and track performance to ensure that improvements are
sustained.
(F)
QAPI Projects.
(1)
QAPI programs must develop, implement, and evaluate performance improvement
projects.
(2) The number of QAPI
projects shall be based on the needs of the Program's population and internal
organizational needs, and must reflect the scope, complexity, and past
performance of the Program's services and operations.
(3) The QAPI program shall document the
performance improvement projects it conducts, the reasons for conducting the
projects, and the measurable progress achieved on the projects.
(G) The Program Director shall be
responsible for the following:
(1) Ensuring
that the QAPI program reflects the complexity of the Program's organization and
services, involves all Program services, focuses on indicators related to
improved outcomes, and exhibits improvement in Program performance;
(2) Approving the frequency and content of
the data collection;
(3) Obtaining,
reviewing, and acting upon the findings of the QAPI Committee;
(4) Ensuring that the QAPI program efforts
address priorities for improved quality of care and participant safety, and
that all improvement actions are evaluated for effectiveness;
(5) Preparing and submitting a report to the
Participant and Family Advisory Council that details QAPI program activities
and projects at least two times per year; and
(6) Responding to the Participant and Family
Advisory Council feedback regarding the QAPI program.
(H) The QAPI program must be capable of
showing measurable improvement in indicators related to improved outcomes and
Program services.
