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Medicare and Medicaid programs; hospital conditions of participation: quality assessment and performance improvement. Final rule.
Fed Regist. 2003 Jan 24; 68(16):3435-55.FR

Abstract

This final rule requires hospitals to develop and maintain a quality assessment and performance improvement (QAPI) program. In the December 19, 1997 Federal Register, we published a proposed rule to revise the hospitals conditions of participation (CoPs). The QAPI CoP was one of the conditions included in the proposed rule. We separated the QAPI CoP from the larger set of hospital CoPs so that it could be published in advance of the remaining CoPs to implement the Administration's initiatives regarding medical errors. QAPI focuses provider efforts on the actual care delivered to patients, the performance of the hospital as an organization, and the impact of treatment furnished by the hospital on the health status of its patients. Specifically, it is important to note that a QAPI is not designed to measure a hospital's quality, but rather a minimum requirement that the hospital systematically examine its quality and implement specific improvement projects on an ongoing basis. State agencies (SAs) during their surveys, review all aspects of a hospital's operations and this review provides a framework in which the SA can assess a hospital's QAPI program. In addition, the QAPI entails all activities required for measuring quality of care and maintaining it at acceptable levels. This typically includes; 1) Identifying and verifying quality-related problems and their underlying cause; 2) Designing and implementing corrective action activities to address deficiencies; 3) Following up to determine the degree of success of an intervention and to detect new problems and opportunities for improvement. Performance improvement activities aim to improve overall performance assuming that there is no permanent threshold for good performance. Under performance improvement framework, hospitals will continuously study and improve the processes of healthcare and delivery of service.

Authors

Pub Type(s)

Journal Article

Language

eng

PubMed ID

12545996

Citation

Centers for Medicare & Medicaid Services (CMS), HHS. "Medicare and Medicaid Programs; Hospital Conditions of Participation: Quality Assessment and Performance Improvement. Final Rule." Federal Register, vol. 68, no. 16, 2003, pp. 3435-55.
Centers for Medicare & Medicaid Services (CMS), HHS. Medicare and Medicaid programs; hospital conditions of participation: quality assessment and performance improvement. Final rule. Fed Regist. 2003;68(16):3435-55.
Centers for Medicare & Medicaid Services (CMS), HHS. (2003). Medicare and Medicaid programs; hospital conditions of participation: quality assessment and performance improvement. Final rule. Federal Register, 68(16), 3435-55.
Centers for Medicare & Medicaid Services (CMS), HHS. Medicare and Medicaid Programs; Hospital Conditions of Participation: Quality Assessment and Performance Improvement. Final Rule. Fed Regist. 2003 Jan 24;68(16):3435-55. PubMed PMID: 12545996.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Medicare and Medicaid programs; hospital conditions of participation: quality assessment and performance improvement. Final rule. A1 - ,, PY - 2003/1/28/pubmed PY - 2003/1/30/medline PY - 2003/1/28/entrez SP - 3435 EP - 55 JF - Federal register JO - Fed Regist VL - 68 IS - 16 N2 - This final rule requires hospitals to develop and maintain a quality assessment and performance improvement (QAPI) program. In the December 19, 1997 Federal Register, we published a proposed rule to revise the hospitals conditions of participation (CoPs). The QAPI CoP was one of the conditions included in the proposed rule. We separated the QAPI CoP from the larger set of hospital CoPs so that it could be published in advance of the remaining CoPs to implement the Administration's initiatives regarding medical errors. QAPI focuses provider efforts on the actual care delivered to patients, the performance of the hospital as an organization, and the impact of treatment furnished by the hospital on the health status of its patients. Specifically, it is important to note that a QAPI is not designed to measure a hospital's quality, but rather a minimum requirement that the hospital systematically examine its quality and implement specific improvement projects on an ongoing basis. State agencies (SAs) during their surveys, review all aspects of a hospital's operations and this review provides a framework in which the SA can assess a hospital's QAPI program. In addition, the QAPI entails all activities required for measuring quality of care and maintaining it at acceptable levels. This typically includes; 1) Identifying and verifying quality-related problems and their underlying cause; 2) Designing and implementing corrective action activities to address deficiencies; 3) Following up to determine the degree of success of an intervention and to detect new problems and opportunities for improvement. Performance improvement activities aim to improve overall performance assuming that there is no permanent threshold for good performance. Under performance improvement framework, hospitals will continuously study and improve the processes of healthcare and delivery of service. SN - 0097-6326 UR - https://www.unboundmedicine.com/medline/citation/12545996/Medicare_and_Medicaid_programs L2 - https://medlineplus.gov/medicare.html DB - PRIME DP - Unbound Medicine ER -