CMS SOM App. H, Tag V628

or other aspects of performance that the facility adopts or develops that reflect processes of

care and facility operations. These performance components must influence or relate to the

desired outcomes or be the outcomes themselves. The program must include, but not be

limited to, the following:…

Interpretive Guidance § 494.110 (a)(2):

The facility’s QAPI program monitors the assessment and improvement of care in the facility.

CMS-generated data reports, including the Dialysis Facility Reports (DFR) are available to

facilities to help them focus their QAPI improvement programs. Each facility should be

comparing their performance with community-based standards and with other facilities in their

State, their Network and the U.S. and working to improve their outcomes where needed. This

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comparative data is readily available to all facilities, whether they are corporate-owned or

independent.

QAPI requires the use of aggregate patient data to evaluate the facility patient outcomes.

Hemodialysis patients and peritoneal dialysis patients should be reviewed separately since

factors affecting their clinical outcomes may be different; both groups of patients must be

reviewed on an ongoing basis.

Data related to patient outcomes, complaints, medical injuries, and medical errors (e.g., clinical

variances, occurrences, and adverse events) should be used to identify potential problems and to

identify opportunities for improving care. Some common areas for dialysis care and facility

operations that should be in the QAPI program for monitoring include, mortality, hospitalization

rates, readmission rates, psychosocial assessment completion rates, water and dialysate quality

monitoring, dialysis equipment maintenance, and equipment repairs.

Data should be analyzed by the IDT on an ongoing basis. Based upon the data review, the IDT

should discuss the areas which need improvement and develop, implement, and evaluate a plan

for such improvement. The facility may use broadly accepted, community-developed standards

(e.g.,NKF KDOQI, AAMI) as indicators or performance measures associated with improved

health outcomes. Where minimum outcome values have been determined, facilities are expected

to provide care directed at achievement of at least the minimum outcome value by all patients.

The IDT must work with individual patients who do not reach the target; this work must be

reflected in the patient’s plan of care for that outcome. Refer to the applicable tag under the

Condition for plan of care for individual patient issues.