Leading the organization-wide approach to performance improvement – QAPI program – as well as policies and procedures related to the program.
Survey Readiness
Collect and analyze data for use by the facility in assessing performance.
Identify and resolve data quality issues.
Communication and education on quality matters to leadership, department managers, staff, and boards.
This is a list of common roles. Roles of the Quality Coordinator may differ in each facility.
This QI Basics course is designed to equip professionals with the knowledge and tools to start quality improvement projects at their facilities. The course may be completed in sequence, or individual modules and tools may be used for stand-alone training and review.
For MT HQIC Facilities. The Cynosure Learning and Improvement Connection, or CLIC, is an online on-demand learning platform. While there is a multitude of on-demand courses the purpose of this offering is to build foundational QI skills for new QI staff, existing QI staff that needs a refresher, or for staff that work the front lines but provided departmental guidance for specific QI projects. For the purposes of this offering, we will ask that you complete the lessons in: Building Blocks of Quality & Patient Safety and Using Data for Improvement. This is open to all staff at the hospital, from environmental services to nutrition to nursing. We encourage you to explore the other courses, discussion forums, and resources as well!
Quality Assurance & Performance Improvement (QAPI) is the foundation of a hospitals QI program and is a provision in the CAH Conditions of Participation.
§ 485.641
Implementation date: March 31, 2021
The CAH must develop, implement, and maintain an effective, ongoing, CAH-wide, data-driven quality assessment and performance improvement (QAPI) program. The CAH must maintain and demonstrate evidence of the effectiveness of its QAPI program.
This is not updated yet in the State Operations Manual. Refer to the Federal Register posting at this link for guidance: https://www.cms.gov/files/document/burden-reduction-discharge-planning-som-package.pdf
Page 314 – Start of Appendix W updates
Page 503 – Start of QAPI Updates
When writing your QAPI plan, you can place individual goals and metrics in an appendix for easy updating.
These resources may not be all inclusive. Edit based on need.
Project management is one of the most sought after skill sets of our time.
Healthcare in the US continues to be under mounting cost and quality pressures and the need for project management in the healthcare setting has become apparent.
Understanding and applying foundational project management practices can significantly improve outcomes across healthcare delivery settings.
AHA: American Hospital Association
AHRQ: Agency for Healthcare Research and Quality
APIC: Association for Professionals in Infection Control and Epidemiology
ASHRM: American Society for Healthcare Risk Management
CDC: Centers for Disease Control and Prevention
CMS: Centers for Medicare and Medicaid Services
HRSA: Health Resources and Services Administration
IHI: Institute for Healthcare Improvement
JB Quality Solutions (Janet A. Brown Healthcare Quality Handbook)
MHA: Montana Hospital Association
MPQH-QIO: Mountain Pacific Quality Health – Quality Improvement Organization
NAHQ: National Association for Healthcare Quality
NCQA: National Committee for Quality Assurance
NHSN: National Health Safety Network
NRHA: National Rural Health Association
NRHRC: National Rural Health Resource Center
