CMS SOM App. H, Tag V712

following: (a) Quality assessment and performance improvement program.

Interpretive Guidance § 494.150(a):

While these regulations charge the facility governing body with the responsibility for allocating

necessary staff and resources for the QAPI program (refer to V756), the medical director is

assigned operational responsibility for the QAPI program. Operational responsibility includes,

but is not limited to: review of quality indicators related to improved patient health outcomes

and monitoring this data on a continual basis as is required by the Condition for QAPI;

education of facility and medical staff in the QAPI objectives; reviewing the method of

prioritizing the importance of improvement projects; inclusion/encouragement of all staff in

participating towards achievement of QAPI goals; communication with the governing body

regarding the needs identified by QAPI; and, participating in the evaluation of the effectiveness

of performance improvement plans/activities.

Materials documenting the QAPI program should include evidence of active participation and

oversight by the medical director (e.g., discussion of issues, guidance and contribution to the

development of performance improvement plans, assessment of the effectiveness of those plans).