Home Health QAPI Readiness Template

This Home Health QAPI Readiness Template is designed for Home Health Agencies to assess their readiness and actions required to meet QAPI program goals.

Home Health QAPI Readiness Template



Overall Program Goals And Focus

1. Is the Agency QAPI Program designed to monitor all agency services and processes, including contracted services?


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2. Is the QAPI program capable of improving outcomes, especially patient readmissions, emergent care, and prevention of medical errors?


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3. Does the agency have documentary evidence of its QAPI program and can demonstrate its effectiveness to CMS?


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Standard - Executive Responsibility

1. Are the agency board and executives responsible for ensuring that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained? Do executives modify their behavior to make quality a primary focus?


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2. Have executives appointed a QAPI accountable staff member?


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3. Have executives and the board structured, reviewed, and approved a QAPI plan for the agency?


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4. Have executives and the board defined QAPI Committee goals, scope of responsibility, membership, monitoring and improvement actions, and a meeting schedule?


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5. Have executives defined a budget and allocated time and training resources for the QAPI program?


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6. Have executives and the board prioritized areas for improvement after reviewing performance on key indicators and setting improvement goals?


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7. Have executives taken steps to create a quality/patient safety culture?


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8. Have executives educated themselves about the PIP process and constructively guided and supported PIP teams to achieve their goals?


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9. Do executives and the board monitor adverse events and patient safety failures and ensure that causes have been identified and preventive activities instituted?


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10. Do executives and the board monitor regulatory compliance, identify instances of fraud and abuse, institute improvements, and report violations?


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11. Do executives and the board evaluate the effectiveness of the QAPI program at least annually, focusing on the achievement of improvement results?


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Standard - Program Scope

1. Is the QAPI program capable of achieving measurable improvement in health outcomes, patient safety, and quality of care indicators?


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2. Are QAPI indicators, including measures derived from OASIS, selected by the agency based on adverse events, negative patient outcomes, or processes that the agency wants to monitor?


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3. Is each key indicator measurable and uses data to evaluate the effectiveness of any HHA change in procedure, policy, or intervention?


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4. Does the HHA maintain an agency-wide surveillance, investigation, and control of infectious and communicable diseases as an integral part of the QAPI program?


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5. Does the agency have a list of key indicators that includes data definitions, defined measurement processes, and a schedule for data collection and analysis?


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6. Do the HHA’s performance improvement activities focus on high-risk, high-volume, or problem-prone areas, or those areas where there are performance gaps?


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7. Does the HHA use the data collected to identify opportunities for improvement, and quantify gaps between actual performance and goals?


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8. Does the agency have a robust, adverse event root cause analysis process that immediately corrects any problem that threatens the health and safety of patients?


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9. Do performance improvement activities track adverse patient event trends, analyze their causes, and include preventive actions?


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10. Does the HHA select the right methods for closing performance gaps, and after implementing improvement, does it track performance to ensure that improvements are sustained and document results?


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11. Does the HHA conduct performance improvement projects annually, with the number and scope reflecting the scope, complexity, and past performance of the HHA’s services and operations?


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12. Does the HHA have one performance improvement project either in development, ongoing, or completed each calendar year, deciding based on QAPI program activities and data what projects are indicated and the priority of the projects?


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13. Does the HHA document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects?


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14. Has the agency adopted a standardized, evidence-based process improvement method?


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15. Are there facilitators trained in the agency’s preferred improvement methodology and group facilitation skills?


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16. Have both senior management and the QAPI committee been trained in process improvement?


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17. Does the agency allocate sufficient resources for the PIP team’s work?


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18. Does the agency provide structured, scheduled guidance to PIP teams?


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19. Does the HHA document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects?


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20. Does the agency continually identify and eliminate barriers to patient safety, compliance, quality, and positive outcomes?


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Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

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