CHAP, JCAHO, ACHC & Medicare require that “The group of professional personnel meets frequently to advise the agency on professional issues, to participate in the evaluation of the agency’s quality assurance program...”

Your Agency's Incident Reporting System is the foundation for compliance with Medicare's CoP §484.65 Quality assessment and performance improvement (QAPI). The practice of documenting all incidences and then taking effort to mitigate the incident (change in policy, employee training etc) and evaluating the effectiveness of the effort (as evidenced by same statistics after policy change, training etc.) is an effective Performance Improvement Program and meets the criteria required by Medicare, JCAHO, CHAP and ACHC.

What is Performance Improvement (PI)

Your Home Health Quality Assurance Performance Improvement (QAPI) Program is based on identifying and correcting problems. Problems in patient care are reported as “incidences”. When all incidences are reported and documented, employee training needs and/or policy and procedure changes are identified. The cycle of

1. data collection ...
2. policy and procedure change, employee training ... and
3. incident occurrence after training, policy changes

...becomes the cycle of an ongoing and effective QAPI Program.  Your EMR software should provide an Incident Reporting System that enables the ability to run reports that show trends in problems with patient care.

Step 1. Train Staff on Identifying and Reporting 'Incidences'

At orientation and then as necessary, train all home health staff - administrative and clinical - on events that require reporting. Your EMR should have a method for recording incidences. 

Events that should be reported and monitored as 'Incidences':

• • • direct exposure to patient body fluid including needlestick(s)
    • equipment maintenance and/or operational problems
    • error(s) in medication administration, dosage, route, frequency
    • error(s) in treatment
    • errors in documentation/reporting
    • failure of patient education material
    • fire or utility hazard
    • hazardous waste management violation
    • inadequate Agency and/or community resources
    • inadequate supplies
    • missing medical records
    • patient or employee injury during care
    • scheduling error(s)
    • significant side effect(s) associated with medication
    • significant side effect(s) associated with treatment
    • violation of patient confidentiality, privacy, or security
    • workplace safety violation

Step 2.  Analyze All Reports Every Three (3) Months

1. Every three (3) months you should summarize the occurrence of all incidences.
2. For which there are reported results, determine if the cause of the incidence(s) is related to employee training, agency policies and/or procedures. 
3. Determine the changes that need to be made to employee training, policies and/or procedures to eliminate the incident risk.

Step 3.  Implement Training and/or Policy & Procedure Changes to Mitigate Future Results

1. Implement changes to employee training, policies and/or procedures.
2. Review the incident occurrence at the next three (3) month interval.
3. Determine if the change to training, policies and/or procedures improved the occurrence of the incident.
4. Implement additional changes if the prior changes were not fully effective.

Example of Effective QAPI...

Staff are Trained on Incident Identification & Reporting

1. Orientation of new employees includes training on the Agency's incident reporting system. The Agency's policies and procedures clearly define what constitutes an incident, and how and when to report incidences.  One of the reportable incident types is 'patient falls', i.e. the employee must document the occurrence of a patient fall on the Agency's Incident Form.
2. Over a three-month period the agency receives six (6) incidences relating to patient falls.
3. When the Professional Advisory Committee (PAC) meets, they discuss the occurrence of the patient falls.  From the documentation on the incident reports, the group determines that patients/caregivers need more teaching on basic home safety.
   

Policy and Procedure Change, Employee Training

1. The agency develops a new home safety training sheet for patients/caregivers and instructs all direct caregivers to reinforce the safety training tips at each visit.
   

Evaluation of Performance Improvement

1. Over the next reporting period, the agency receives four (4) incidences related to patient falls.  Although there is a decrease in patient falls, the PAC determines that certain patients, those with mobility deficits, still have an increased incidence of falls.
2. The group determines that patients with mobility deficits should have a physical therapy evaluation.

The Cycle of Data Collection, Policy Changes & Re-Evaluation Never Ends.

Performance improvement never 'ends'.  Your Agency should always be collecting data, and then refining your policies and procedures.

Expect These Surveyor Questions on QAPI

1. How are hazardous wastes, such as sharps containers, handled at your office site? What is the process for removal and disposal of such waste?
2. Storage and handling of hazardous wastes, if any, such as sharps containers
3. Describe your organization's process for surveillance, identification, and reporting of infections. What do you consider reportable infections? Who is responsible for collecting and analyzing these data?
4. What is a reportable accident or incident and what is the process?
5. What is the Agency's safety and security plan for employees during and after Agency hours and in the patient's home?

Expect This Surveyor Documentation Review for QAPI

1. An incident-reporting system, including defined, specific criteria for the type(s) of accidents, injuries, and safety hazards to be reported; actual reports and documented investigations of accidents, injuries, and safety hazards
2. Maintenance of fire detection and extinguish equipment
3. Definition of the scope and content of the infection control program
4. Evidence of implementation of the infection-control program, including: data collection, aggregation and analysis of data, external reports
5. Identification of the types of data to be collected as part of the infection-control program
   

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