Mont. Medicaid Hospice Policy Manual, Policy 412

QUALITY ASSESSMENT

AND PERFORMANCE

IMPROVEMENT

The hospice must develop, implement, and maintain an effective,

ongoing, hospice-wide, data-driven quality assessment and

performance improvement program. The hospice's governing body

must ensure that the program:

1. Reflects the complexity of its organization and

services;

2. Involves all hospice services (including those services

furnished under contract or arrangement);

3. Focuses on indicators related to improved palliative

outcomes; and

4. Takes actions to demonstrate improvement in hospice

performance.

The hospice must maintain documentary evidence of its quality

assessment and performance improvement program and be able to

demonstrate its operation to Centers for Medicare and Medicaid

Services.

PROGRAM SCOPE

The program must at least be capable of showing measurable

improvement in indicators related to improved palliative outcomes

and hospice services.

The hospice must measure, analyze, and track quality indicators,

including adverse member events, and other aspects of

performance that enable the hospice to assess processes of care,

hospice services, and operations.

PROGRAM DATA

The program must use quality indicator data, including member

care, and other relevant data, in the design of its program. The

hospice must use the data collected to do the following:

1. Monitor the effectiveness and safety of services and

quality of care.

2. Identify opportunities and priorities for improvement.

The frequency and detail of the data collection must be approved

by the hospice's governing body.

PROGRAM

ACTIVITIES

The hospice's performance improvement activities must:

1. Focus on high risk, high volume, or problem-prone

areas.

2. Consider incidence, prevalence, and severity of

problems in those areas.

3. Affect palliative outcomes, member safety, and quality

of care.

Performance improvement activities must track adverse member

events, analyze their causes, and implement preventive actions

and mechanisms that include feedback and learning throughout the

hospice.

The hospice must take actions aimed at performance improvement

and, after implementing those actions; the hospice must measure

its success and track performance to ensure that improvements are

sustained.

PERFORMANCE

IMPROVEMENT

PROJECTS

CMS requires hospices to develop, implement, and evaluate

performance improvement projects. The projects should include:

1. The number and scope of distinct performance

improvement projects conducted annually, based on

the needs of the hospice's population and internal

organizational needs, and must reflect the scope,

complexity, and past performance of the hospice's

services and operations; and

2. The hospice must document what performance

improvement projects are being conducted, the

reasons for conducting these projects, and the

measurable progress achieved on these projects.

EXECUTIVE

RESPONSIBILITIES

The hospice's governing body is responsible for ensuring the

following:

1. That an ongoing program for quality improvement and

member safety is defined, implemented, and

maintained, and is evaluated annually;

2. That the hospice-wide quality assessment and

performance improvement efforts address priorities

for improved quality of care and member safety, and

that all improvement actions are evaluated for

effectiveness; and

3. That one or more member(s) who are responsible for

operating the quality assessment and performance

improvement program are designated.