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Quality Assessment and Performance Improvement (QAPI) R eview (HealthInsight)

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Quality Assessment and Performance Improvement (QAPI)
R
eview Worksheet for Hospitals
Instructions: This worksheet consists of items, broken down into separate parts, which are meant to be assessed to evaluate the facility’s QAPI
program. Items are to be assessed considered primarily by review of the hospital’s QAPI program documentation and interviews with hospital
staff. Direct observation of hospital practices plays a lesser role in QAPI compliance assessment but may still be appropriate.
HOSPITAL CHARACTERISTICS
Hospital code_________________________________________________________
Date completed_______________________________________________________
Completed by_________________________________________________________
PART 1: DESIGN AND SCOPE
Elements to be reviewed Notes (if needed)
1.1 Our organization has developed principles
guiding how QAPI will be incorporated into our
culture and built into how we do our work.
☐
Yes
☐
No
1.2 Is there evidence that the hospital has a
formal QAPI program—including written
policies and procedures, budgeted resources,
and clearly identified responsible staff (e.g.,
safety officer, QAPI supervisor, etc.)—approved
by the governing body after input from the CEO
and medical staff leadership?
☐
Written policies and procedures
☐
Budgeted resources
☐
Clearly identified responsible staff
☐
Input from CEO
☐
Input from medical staff leadership
☐
Approved by the governing body
☐
Yes, all of these
☐
No, none of these
Elements to be reviewed
Notes (if needed)
1.3 Is there evidence of the amount of
resources (funding and personnel) dedicated to
the hospital’s QAPI program and the functions
for which those resources are used?
☐
Yes
☐
No
1.3.a QAPI is considered a priority in our
organization. For example, there is a process
for covering staff who are asked to spend time
on improvement teams.
☐
Yes
☐
No
1.3.b QAPI is an integral component of new
employee orientation and training. For
example, new employees understand and can
describe their role in identifying opportunities
for improvement. Another example is that new
employees expect that they will be active
participants on improvement teams.
☐
Yes
☐
No
1.3.c Training is available to all staff on
performance improvement strategies and tools.
☐
Yes
☐
No
1.3.d If there are condition-level QAPI program
deficiencies, is there evidence that lack of QAPI
resources are a significant contributing cause of
these deficiencies?
☐
Yes
☐
No
☐
N/A
1.4 Our organization has established a culture
in which staff are held accountable for their
performance, but not punished for errors and
do not fear retaliation for reporting quality
concerns. For example, we have a process in
place to distinguish between unintentional
errors and intentional reckless behavior and
only the latter is addressed through disciplinary
actions.
☐
Yes
☐
No
PART 2: GOVERNANCE
Elements to be reviewed
Notes (if needed)
2.1 Our governing body is engaged in and
supportive of the performance improvement
work being done in our organization.
Leadership can clearly describe, to someone
unfamiliar with the organization, our
approach to QAPI and give accurate and up-
to-date examples of how the facility is using
QAPI to improve quality and safety of patient
care.
☐
Yes
☐
No
Is there evidence (e.g., in minutes) that the hospital’s governing body, medical staff and administrative officials:
2.2.a Ensures the QAPI program annually
determines the number of distinct QAPI
projects to be conducted in the coming year?
☐
Yes
☐
No
2.2.b Actively reviews the results of QAPI
data collection, analyses, activities, projects
and makes decisions based on such review?
☐
Yes
☐
No
2.2.c The governing body holds the CEO
accountable for the effectiveness of the QAPI
program?
☐
Yes
☐
No
PART 3: DATA COLLECTION AND ANALYSIS
Elements to be reviewed
Notes (if needed)
3.1 Our organization has identified all of our
sources of data and information relevant to
our organization to use for QAPI. This includes
data that reflects measures of clinical care,
input from staff, patients, families, and
stakeholders, and other data that reflects the
services provided by our organization.
☐
Yes
☐
No
3.2 For the relevant sources of data we identify,
our organization sets targets or goals for
desired performance, as well as thresholds for
minimum performance.
☐
Yes
☐
No
Elements to be reviewed
Notes (if needed)
3.3 We have a system to effectively collect,
analyze, and display our data to identify
opportunities for our organization to make
improvements. This includes comparing the
results of the data to benchmarks or to our
internal performance targets or goals.
☐
Yes
☐
No
3.4 Our organization has, or supports the
development of, employees who have skill in
analyzing and interpreting data to assess our
performance and support our improvement
initiatives.
☐
Yes
☐
No
PART 4: PATIENT SAFETY
Elements to be reviewed
Notes (if needed)
4.1 Evaluation regarding whether the hospital’s leadership sets expectations for patient safety:
4.1.a Is there evidence of widespread staff
training or communication to convey
expectations for patient safety to all staff? (e.g.,
training related to steps to take in a situation
that feels unsafe, how to report adverse patient
events, medical errors, near misses/close calls,
etc. that they are expected to report internally)
☐
Documentation was provided (e.g.,
policy, process, plan)
☐
Demonstration through process
☐
Yes, all of these
☐
No, none of these
4.1.b Is there evidence that the hospital has
adopted policies supporting a non-punitive
approach to staff reporting of adverse patient
events, medical errors, near misses/close calls,
etc., and situations they consider unsafe?
☐
Documentation was provided (e.g.,
policy, process, plan)
☐
Demonstration through process
☐
Yes, all of these
☐
No, none of these
4.1.c Can staff explain what the hospital’s
expectations are for their role in promoting
patient safety?
Recommended: ask at least 3 staff members
from different departments.
☐
Yes
☐
No
4.1.d Does the patient safety program include
intentional focus and prioritization of high-risk
and high-volume areas (ED, OR, sterilization,
etc.)?
☐
Yes
☐
No
4.2. Evaluation regarding hospital processes to identify adverse patient events, medical errors, near misses/close calls, etc.
4.2.a Can staff describe the types of adverse
patient events, medical errors, near
misses/close calls, etc. they are expected to
report internally?
Recommended: ask at least 3 staff members
from different departments.
☐
Yes
☐
No
Elements to be reviewed
Notes (if needed)
4.2.b Can staff explain how and/or to whom
they are expected to report adverse patient
events, medical errors, near misses/close calls,
etc.?
Recommended: ask at least 3 staff members
from different departments.
☐
Yes
☐
No
4.2.c Does the hospital employ methods, in
addition to staff incident reporting, to identify
possible adverse patient events, medical errors,
near misses/close calls, etc.?
(Examples of other methods include, but are not
limited to: retrospective medical
records reviews, review of claims data,
unplanned readmissions and patient
complaints/grievances, interview or survey of
patients, etc.)
☐
Yes
☐
No
4.2.d Can the hospital provide evidence of
adverse patient events, medical errors, near
misses/close calls, etc. identified through staff
reports or other methods?
☐
Yes (check all that apply)
☐
Documentation was provided (e.g.,
policy, process, plan)
☐
Demonstration through process
☐
Yes, all of these
☐
No, none of these
4.3 Is there QAPI program collaboration with
infection control officer(s) to identify and track
avoidable healthcare- acquired infections?
☐
Yes
☐
No
4.4 Is there evidence that problems identified
by infection control officer(s) are addressed
through QAPI program activities?
☐
Yes
☐
No
4.5 Does the QAPI program identify and track
medication administration errors, adverse drug
reactions, and drug related incompatibilities?
☐
Medication administration errors
☐
Adverse drug reactions
☐
Drug related incompatibilities
☐
Yes, all of these
☐
No, none of these
Elements to be reviewed
Notes (if needed)
4.6 Is there a QAPI program process for staff to
report blood transfusion reactions, and reviews
of reported blood transfusion reactions to
identify medical errors (including near
misses/close calls) and/or adverse events?
☐
Yes
☐
No
☐
N/A
4.7 Have all preventable patient safety adverse
events been identified?
☐
Yes
☐
No
☐
N/A
4.8 Has the hospital conducted a QAPI review,
including implementing preventive actions for
all serious preventable adverse events it has
identified?
☐
Yes
☐
No
☐
N/A
4.9 Has your facility operated an emergency
department in the past 12 months?
Evaluation regarding ED triage (ESI)-related to
the QAPI program.
☐
Yes - continue
☐
No - skip all 4.9 subquestions
4.9.a Can the hospital provide evidence that the
monthly ED triage (ESI) performance
improvement project is related to improved
health outcomes? (e.g., based on QIO,
guidelines from a nationally recognized
organization, hospital specific evidence, peer-
reviewed research, etc.)
☐
Documentation was provided (e.g.,
policy, process, plan)
☐
Demonstration through process
☐
Yes, both of these
☐
No, neither of these
4.9.b Is the scope of data collection appropriate
to the indicator ED triage (ESI)?
☐
Yes
☐
No
4.9.c Is the method (e.g., chart reviews,
monthly observations, etc.) and frequency of
data collection present and clear?
☐
Yes
☐
No
4.9.d Is there evidence that the data are
actually collected in the manner and frequency
specified for this indicator? For example, is
there evidence of late, incomplete, or wrong
data collection?
☐
Documentation was provided (e.g.,
policy, process, plan)
☐
Demonstration through process
☐
Yes, all of these
☐
No, none of these
Elements to be reviewed
Notes (if needed)
4.9.e If unit staff play a role in data collection,
are they following the specifications for how
the data are to be collected?
☐
Yes
☐
No
☐
N/A
4.9f Are the collected data analyzed? (Complete
analysis includes evaluating the performance,
setting goals, identifying causes/barriers, and
planning next steps.)
☐
Yes
☐
No
4.9.g Are comparisons made to performance
benchmarks when available (e.g., established
by nationally recognized organizations)?
☐
Yes
☐
No
☐
N/A
4.9.h When feasible, are aggregated data
broken down into subsets that allow
comparison of performance among hospital
units covered by the indicator?
☐
Yes
☐
No
☐
N/A
4.9.i If the data analysis identified areas
needing improvement, is there evidence that
the hospital instituted interventions (activities
and/or projects) to address them?
☐
Yes
☐
No
☐
N/A (analysis did not lead to
interventions)
4.9.j Are interventions evaluated for success?
☐
Yes
☐
No
☐
N/A (analysis did not lead to
interventions)
4.9.k If interventions taken were not successful,
were new interventions developed?
☐
Yes
☐
No
☐
N/A (analysis did not lead to
interventions)
4.9.l If interventions were successful, did
evaluation continue longer to assess if success
was sustained?
☐
Yes
☐
No
☐
N/A (analysis did not lead to
interventions)
PART 5: PERFORMANCE IMPROVEMENT
Elements to be reviewed
Notes (if needed)
5.1 Can the hospital provide evidence that its
improvement activities focus on areas that are
high risk (severity), high volume (incidence or
prevalence), or problem-prone? From our
identified opportunities for improvement, we
have a systematic and objective way to
prioritize the opportunities in order to
determine what we will work on. This process
takes into consideration input from multiple
disciplines, patients and families.
☐
Documentation was provided (e.g.,
policy, process, plan)
☐
Demonstration through process
☐
Yes, both of these
☐
No, neither of these
5.2 Can the hospital provide evidence that it
conducts distinct performance improvement
projects?
☐
Documentation was provided (e.g.,
policy, process, plan)
☐
Demonstration through process
☐
Partial documentation provided
☐
Yes, both of these
☐
No, neither of these
5.3 When a performance improvement
opportunity is identified as a priority, we have a
process in place to charter a project. This
charter describes the scope and objectives of
the project so the team working on it has a
clear understanding of what they are being
asked to accomplish.
☐
Documentation was provided (e.g.,
policy, process, plan)
☐
Demonstration through process
☐
Yes, both of these
☐
No, neither of these
5.4 For every performance improvement
project, we use measurement to determine if
changes to systems and process have been
effective. We utilize both process measures and
outcome measures to assess impact on patient
care and quality of life. For example, if making a
change, we measure whether the change has
actually occurred and whether it has had the
desired impact on the patients.
☐
Yes (check all that apply)
☐
Documentation was provided (e.g.,
policy, process, plan)
☐
Demonstration through process
☐
Partial documentation provided
☐
Yes, both of these
☐
No, neither of these
Elements to be reviewed
Notes (if needed)
5.5 Our organization uses a structured process
for identifying underlying causes of problems,
such as root cause analysis.
☐
Documentation was provided (e.g.,
policy, process, plan)
☐
Demonstration through process
☐
Yes, both of these
☐
No, neither of these
5.6 Can every department provide evidence of
at least one quality improvement project?
☐
Documentation was provided (e.g.,
policy, process, plan)
☐
Demonstration through process
☐
Yes, both of these
☐
No, neither of these
5.7 Are all contracted services evaluated at
least annually and an improvement project
initiated as needed?
☐
Documentation was provided (e.g.,
policy, process, plan)
☐
Demonstration through process
☐
Yes, both of these
☐
No, neither of these
☐
N/A
5.8 Can the hospital provide evidence showing
why each project was selected?
☐
Yes (check all that apply)
☐
Documentation was provided (e.g.,
policy, process, plan)
☐
Demonstration through process
☐
No
This material was prepared by Comagine Health (formerly HealthInsight), the Medicare Quality Innovation Network -Quality Improvement Organization for Nevada, New Mexico,
Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents
presented do not necessarily reflect CMS policy. 11SOW-AIAN-19-114
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