ESRD Medical Director Resources - CfC Resources - Quality Assessment and Performance Improvement (QAPI)

 

§ 494.110 Condition: Quality Assessment and Performance Improvement

Overview	The dialysis facility must develop, implement, maintain, and evaluate an effective, data- driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team. The program must reflect the complexity of the dialysis facility's organization and services (including those services provided under arrangement), and must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors. The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS. (See Overview & Introduction to the Network Role in QAPI & CMS Compliance - Peter B. DeOreo, MD, Chair, Medical Review Board, Chief, Medical Affairs & Quality Assurance, Centers for Dialysis Care, Cleveland , OH)
Implementation	1. Program Scope (Proposed § 494.110(a) (1) The program must include, but not be limited to, an ongoing program that achieves measurable improvement in health outcomes and reduction of medical errors by using indicators or performance measures associated with improved health outcomes and with the identification and reduction of medical errors. CMS Clinical Performance Measures - (http://www.cms.gov/CPMProject/Downloads/ESRDPhaseIIICPM04012008Final.pdf) Keeping Kidney Patients Safe - Patient Safety Improvement Plan Basics and forthcoming Educational Modules QAPI: Quality & Safety - The Big Picture - Alan S. Kliger, MD, President, The Renal Physicians Association Professor of Medicine, Yale U. School of Medicine , New Haven , CT (2) The dialysis facility must measure, analyze, and track quality indicators 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: Measures Assessment Tool (MAT) version 1.9 (PDF 93.3 KB)- provides standards and values (i) Adequacy of dialysis. CMS Clinical Performance Measures - HD/PD Adequacy (http://www.cms.gov/CPMProject/Downloads/ESRDPhaseIIICPM04012008Final.pdf) KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations http://www.kidney.org/Professionals/kdoqi/guideline_upHD_PD_VA/index.htm 5 Diamond Patient Safety Program - Missed Treatments module (http://www.esrdnet5.org/5DiamondMT.asp) The Renal Network - QAPI - Adequacy Monitoring Tools (includes action tool, barriers questionnaire and data collection tool) (ii) Nutritional status. KDOQI Nutrition (http://www.kidney.org/professionals/kdoqi/guidelines_updates/doqi_nut.html) (iii) Mineral metabolism and renal bone disease. CMS Clinical Performance Measures - Mineral Metabolism (http://www.cms.gov/CPMProject/Downloads/ESRDPhaseIIICPM04012008Final.pdf) (iv) Anemia management. KDOQI Anemia (http://www.kidney.org/professionals/kdoqi/guidelines_anemia/index.htm) The Renal Network - QAPI - Anemia Monitoring Tools (includes action tool, barriers questionnaire and data collection tool) (v) Vascular access. KDOQI Vascular Access (http://www.kidney.org/Professionals/kdoqi/guideline_upHD_PD_VA/index.htm) Fistula First (http://www.fistulafirst.org/) The Renal Network - QAPI - Vascular Access Monitoring Tools (includes needs assessment, action tool, barriers questionnaire and data collection tool) (vi) Medical injuries and medical errors identification. Keeping Kidney Patients Safe - Patient Safety Events (http://www.kidneypatientsafety.org/events.cfm) 5 Diamond Patient Safety Program (http://www.esrdnet5.org/5Diamond.asp) QAPI: Quality & Safety - The Big Picture - Alan S. Kliger, MD, President, The Renal Physicians Association Professor of Medicine, Yale U. School of Medicine , New Haven , CT (vii) Hemodialyzer reuse program, if the facility reuses hemodialyzers. AAMI RD47 [preview only] (http://marketplace.aami.org/eseries/scriptcontent/docs/Preview%20Files/RD470806_preview.pdf) CMS Clinical Performance Measures - HD Adequacy (http://www.cms.gov/CPMProject/Downloads/ESRDPhaseIIICPM04012008Final.pdf) (viii) Patient satisfaction and grievances. CAHPS surveys (https://www.cahps.ahrq.gov/content/resources/PM/RES_PM_ProjectImplementation.asp?p=103&s=33) (ix) Infection control; with respect to this component the facility must - (A,B,C) AAMI RD52: Dialysate for hemodialysis ( http://www.spectra-labs.com/resources/pdf_tech/AAMI_RD520408.pdf) Keeping Kidney Patients Safe - Patient Safety Improvement Plan Basics (http://www.kidneypatientsafety.org/pdf/toolkit/Staff%20Activity%20Planning%20Guide.pdf) Keeping Kidney Patients Safe - Patient Safety Events (http://www.kidneypatientsafety.org/events.cfm) ESRD Patient Safety Annotated Bibliography (http://www.kidneypatientsafety.org/pdf/ESRD%20and%20Safety%20Literature%20Search.pdf) (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; Keeping Kidney Patients Safe - Patient Safety Improvement Plan Basics (http://www.kidneypatientsafety.org/pdf/toolkit/Staff%20Activity%20Planning%20Guide.pdf) (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and Keeping Kidney Patients Safe - Patient Safety Improvement Plan Basics (http://www.kidneypatientsafety.org/pdf/toolkit/Staff%20Activity%20Planning%20Guide.pdf) Joint Commission - National Patient Safety Goals (http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/) 5 Diamond Patient Safety Program (http://www.esrdnet5.org/5Diamond.asp) (C) (a)Take actions to reduce future incidents. Keeping Kidney Patients Safe - Patient Safety Improvement Plan Basics (http://www.kidneypatientsafety.org/pdf/toolkit/Staff%20Activity%20Planning%20Guide.pdf) Keeping Kidney Patients Safe - ESRD Patient Safety Best Practices (http://www.kidneypatientsafety.org/bestpractices.cfm) Joint Commission - National Patient Safety Goals (http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/) 5 Diamond Patient Safety Program (http://www.esrdnet5.org/5Diamond.asp)
	2. Monitoring Performance Improvement (Proposed § 494.110(b) Standard: Monitoring performance improvement. The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. Joint Commission Practice Guidelines (http://www.jcrinc.com/30595/) 5 Diamond Patient Safety Program (http://www.esrdnet5.org/5Diamond.asp)
	3. Prioritizing Improvement Activities (Proposed § 494.110(c) Standard: Prioritizing improvement activities. The dialysis facility must set priorities for performance improvement, considering prevalence and severity of identified problems and giving priority to improvement activities that affect clinical outcomes or patient safety. The facility must immediately correct any identified problems that threaten the health and safety of patients. Keeping Kidney Patients Safe - Patient Safety Improvement Plan Basics (http://www.kidneypatientsafety.org/pdf/toolkit/Staff%20Activity%20Planning%20Guide.pdf) Joint Commission - National Patient Safety Goals (http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/) 5 Diamond Patient Safety Program (http://www.esrdnet5.org/5Diamond.asp) QAPI: Quality & Safety - The Big Picture - Alan S. Kliger, MD, President, The Renal Physicians Association Professor of Medicine, Yale U. School of Medicine , New Haven , CT