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Quality Assurance or QAPI

Quality Assurance or QAPI

Policy: It is the policy of this Agency to implement and maintain a Quality Assurance/QAPI Program. This program is designed to have a method of objectivity and systematically monitor and evaluate the quality and appropriateness of patient care. It also demonstrates the Agency’s commitment to continually provide quality health care. The committee members consist of the Administrator, Director of Nursing, community representative, and a member from each service discipline the agency offers. The term is three years. This term may be renewed for an additional three years by the Administrator.

None of the information, interviews, reports, statements, memoranda, and recommendations produced during or resulting from the agency’s quality improvement program may be admissible as neither evidenced nor be discoverable in any action of any kind in any court, as provided in Article VIII, Part 21 of the Code of Civil Procedure (Medical Studies).

Our agency is a private, for-profit, certified, and licensed home health/care agency providing service to all patients without regard to racial ethnicity, religion, age, gender, sexual orientation, or handicap.

The goal is to continuously improve the quality of services rendered.  The responsibility of the Quality Assurance or QAPI Committee will be to assist in carrying out the objectives and activities of monitoring and evaluating as identified in the Quality Assurance or QAPI Plan.

The Agency’s program consists of but is not limited to the following:

      1. Program/staff performance assessment activities.
      2. Staff recruitment, training, orientation, and continuing education programs.
      3. Case conferences.
      4. Management meetings.
      5. Ongoing review of clinical records.
      6. Clinical staff peer review activities.
      7. Review of records requested by utilization/record review.
      8. High volume services, conditions, or diagnoses.
      9. Evaluation of systems designed to support clinical operations.
      10. Compliance with clinical practice standards and recognized professional standards.
      11. Program evaluations are based on measurable objectives, patient outcomes, and cost-effectiveness.
      12. Management systems that support infection control functions.
      13. Patient/physician satisfaction assessment.
      14. Quality control activities.
      15. Annual program evaluation.
      16. Orientation/training program.
      17. Continuing education.
      18. Performance appraisals.
      19. Re-prioritization of performance activity.

Objectives of Quality Assurance or QAPI Program

      1. To administer and coordinate the Agency’s QAPI program which is designed to ensure all quality improvement activities are implemented.
      2. To evaluate the delivery of well-coordinated care to patients.
      3. To provide and validate the comprehensive optimal level of safe and effective care/services at a reasonable cost.
      4. To improve access to community services.
      5. To evaluate the appropriateness and outcome of care provided by staff/contract personnel.
      6. To monitor and ascertain compliance with Agency policies and procedures and state and Federal regulations.
      7. To identify problems, establish a plan, and take action to resolve, reprioritize if necessary, and reevaluate results.
      8. To evaluate staff performance, delivery of care, documentation, and patient outcomes and the Agency’s mechanism for addressing them.
      9. To evaluate patient and staff education.
      10. To determine patient and physician satisfaction of rendered services.
      11. To identify opportunities to improve patient care using ongoing collection and screening and evaluating information about the outcome of customer satisfaction surveys.
      12. To minimize risk exposure to staff and/or Agency.
      13. To oversee the effectiveness of the program and detect trends, patterns of performance, or potential problems that may affect different areas of the organization.
      14. To develop effective information systems to communicate quality assessment and improvement activity outcomes to Agency staff and committees.
      15. To ensure patient and staff confidentiality throughout the quality assessment and improvement process.
      16. To ensure performance-based credentialing for each professional and paraprofessional caregiver.
      17. To evaluate the scope, organization, and effectiveness of the quality improvement program ensuring that actions taken are within the mission and goals of the Agency.
      18. To identify the need for revisions in patient care services, policies, and procedures.
      19. To identify the extent to which the Agency program is adequate, effective, and efficient in the use of all manpower and financial resources.