Quality Assessment and Performance Improvement
The new Conditions for Coverage (effective October 14, 2008) have specific requirements for Quality Assessment and Performance Improvement (QAPI) (§494.110). The QAPI program must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors. Click on following link for an excerpt of QAPI regulation.
- Download the Measures Assessment Tool (MAT) version 1.9 [PDF, 93.3KB] for an overview of conditions, measures and related resources.
- Download the following QAPI meeting minutes templates to assist your team keep track of meeting outcomes and goals:
- Download the following Root Cause Analysis (RCA) [Excel, 80KB] tool to assist your facility’s Vascular Access Team in determining underlying causes of poor Vascular Access outcomes.
- Download Network 15 Chart for Identifying Root Causes of Low AVF Rates [PDF, 42Kb]
Required indicators include: (click on links to access monitoring tools)
- Adequacy of Dialysis,
- Nutritional Status,
- Mineral Metabolism,
- Vascular access,
- Adverse Events, Medical Injuries and Errors,
- Patient Satisfaction and Grievances
- Infection Control
- Transplant Referral
The Medical Director has operational responsibility for the QAPI program and ensures that data is used to develop actions to improve quality of care and must ensure that the facility's program is effectively developed, implemented, maintained, and periodically evaluated.
NOTE: The Renal Network will be developing resources to assist your facility in meeting the QAPI requirements. It is NOT a requirement to use these specific tools, only that you monitor the indicators in some way. Bookmark this page and check periodically for additional tools and resource updates.