CMS SOM App. M, Tag L559

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: reflects the complexity of

its organization and services; involves all hospice services (including those services

furnished under contract or arrangement); focuses on indicators related to

improved palliative outcomes; and 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 CMS.

Interpretive Guidelines §418.58

The condition requires each hospice to develop its own QAPI program to meet its needs.

Hospice outcome measures, data elements, tools, and instructions for using them have

been developed by the hospice industry and quality improvement organizations. Quality

improvement in hospice is a developing field. The methods used by the hospice for self-assessment are flexible and may include a review of current documentation (e.g., review

of clinical records, incident reports, complaints, patient satisfaction surveys, etc.); patient

care, direct observation of clinical performance, operating systems and interviews with

patients and/or staff. The information gathered by the hospice should be based on criteria

and/or measures generated by the medical and professional/technical staffs and reflect

hospice best practice patterns, staff performance, and patient outcomes.

Ongoing means that there is a continuous and periodic collection and assessment of data.

Assessment of such data enables areas of potential problems to be identified and indicates

additional data that should be collected and assessed in order to identify whether a

problem exists.

The following elements should be considered within the QAPI plan however it is

structured:

• Program objectives;

• All patient care disciplines;

• Description of how the program will be administered and coordinated;

• Methodology for monitoring and evaluating the quality of care;

• Priorities for resolution of problems;

• Monitoring to determine effectiveness of action;

• Oversight responsibility reports to governing body; and

• Documentation of the review of its own QAPI program.

The fundamental purpose of the QAPI CoP is to set a clear expectation that hospices

must take a proactive approach to improve their performance, and focus on improved

patient/family care and activities that impact patient health and safety. CMS stresses the

improvement in systems in order to improve processes and patient outcomes.

Hospices must have all of the components of a QAPI program in place hospice-wide.

CMS expects hospices to demonstrate, with objective data, that improvements have taken

place in actual care outcomes, processes of care, patient/family satisfaction levels,

hospice operations, or other performance indicators.

The QAPI program will be evaluated for its hospice-wide effectiveness on the quality of

care provided and activities that impact upon patient health and safety. The impact of the

program can be assessed by looking at data gathered and compared at different points in

time, and actions taken based on that comparison. The hospice should be analyzing data

and evaluating the effectiveness of their own program continually.

The organized hospice-wide QAPI program must be ongoing and have a written plan of

implementation. Opportunities to improve care should be applied on a hospice-wide

basis, when appropriate. The hospice takes and documents remedial action when

problems are identified and evaluates the outcome of these actions. The results must be

transmitted to the governing body to fulfill its responsibility to ensure an effective QAPI

program.

Quality assessment and performance improvement is a process of continual assessment of

a hospice’s performance with implementation of solutions, assessment of the

effectiveness of the solutions, and evaluations to determine how it can do even better.

The QAPI program fosters the continual striving of improvement of the delivery of care

and services provided by a hospice. Performance improvement fosters a “blame-free”

environment and encourages hospices to evaluate the operating systems and processes in

the agency instead of fixing one problem at a time.