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. See the final section of this page for an excerpt of QAPI regulation.
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.
The Network encourages facilities to enroll in the CDC's National Healthcare Safety Network (NHSN) surveillance program to obtain comparison data with national performance measures.
2010 guide from the Association For Professionals In Infection Control And Epidemiology.
CDC Healthcare Infection Control Practices Advisory Committee
Infection Tracking Log [Word doc, 39.5Kb]
§494.110 Condition: Quality Assessment and Performance Improvement .
"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."
(a) Standard: Program Scope.
(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.
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.