Centers for Medicare &MedicaidServices

HospitalQuality Assessment Performance ImprovementWorksheet

Nameof StateAgency:

Instructions: The followingis a list of items,brokendown into separateParts,which must beassessedduring theon-site surveyin orderto determine compliance with theQAPIConditionof Participation.Itemsareto beassessedprimarily by reviewof thehospital’s QAPIprogramdocumentation and interviews with hospital staff. Directobservation of hospital practicesplays a lesserrole in QAPIcompliance assessment,but maystill beappropriate.The separateParts can beassessedin any order.Within eachParttheremayalso beflexibilityto changetheorderin which thevarious itemsareassessed.

The interviewsshould beperformedwith themost appropriate staff person(s) for theitemsof interest(e.g.,unit/department staff should beaskedhow theyparticipate in thehospital-wideQAPIprogram).

PART I – HOSPITAL CHARACTERISTICS

Section1HospitalCharacteristics

1.1 Hospital name:

1.2 Address, State and Zip Code:

1.3 CMS Certification Number(CCN):

1.4 Dateof surveysite visit:

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UPDATED September 14, 2015 Page 1 of 16

1.5Total numberof StateAgencysurveyorswho participated on thecombined PSI survey:

1.6Approximatetimespent on site performing thecombined PSI surveys(total number of hours):

1.7 Does the hospital participate in Medicare via accredited “deemed” status: Yes

No

1.8a IF YES, which AO(s)? (Check all that apply)AmericanOsteopathic Association (AOA)/HealthcareFacilities Accreditation Program(HFAP)

Center for Improvement in Healthcare quality (CIHQ)

Det Norske Veritas Healthcare (DNV)

The Joint Commission (TJC)

1.8b If YES, according to thehospital,what wastheend dateof themost recentaccreditation survey?

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PART2:DATA COLLECTION ANDANALYSIS-QUALITYINDICATORTRACERS
Instructionsfor Part #2Questions
Select 3distinctqualityindicators(notpatientsafetyanalyses)andtrace them answeringthefollowingmultipartquestion. Focusonindicatorswith relatedQAPIactivitiesor projects.Atleastoneof theindicatorsmusthavebeen inplacelongenoughfor mostquestionstobe applicable.
Elements to be Assessed / Indicator #1 / Indicator #2 / Indicator #3
Writein indicator selected:
2.1.aCan thehospital provide evidencethat eachquality indicator selectedis relatedto improved health outcomes? (e.g., based on QIO,guidelines froma nationally recognizedorganization,hospital specific evidence,peer-reviewed research,etc.) / Yes
No / Yes
No / Yes
No
2.1.bIs thescope of data collection
appropriate to theindicator, e.g.,an indicator relatedto labor and deliverymight beappropriate to all areasof that unit and theED, but indicators relatedto hand hygiene wouldrequiredata frommultiple parts of thehospital. / Yes
No / Yes
No / Yes
No
2.1.cIs themethod (e.g.,chart reviews,monthly observations,etc.) and frequencyof data collection specified? / Yes
No / Yes
No / Yes
No
Elements to be Assessed / Indicator #1 / Indicator #2 / Indicator #3
2.1.dIs thereevidencethat thedata
areactually collectedin themanner and frequencyspecified for this indicator? For example,is there evidenceof late,incomplete or wrongdata collection? / Yes
No / Yes
No / Yes
No
2.1.eIf unit staff play a role in data collection, iscollection consistent with thespecifications for how the data areto becollected? / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
2.1.fAredata that havebeen collected aggregatedin accordance with thehospital methodology specified for this indicator? / Yes
No / Yes
No / Yes
No
2.1.gArethecollected data analyzed? / Yes
No / Yes
No / Yes
No
2.1.hIf theindicator is thetypethat measuresa rate,areratescalculated for points in timeand overtime,and arecomparisons madeto performancebenchmarkswhen available (e.g. established by nationally recognized
organizations)? / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
Elements to be Assessed / Indicator #1 / Indicator #2 / Indicator #3
2.1.iWhenfeasible, areaggregated data brokendown into subsets that allow comparison of performance among hospital units coveredby the indicator?For example,a hand hygieneindicator should allow comparison amongdifferent inpatient units. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
If notoanyof 2.1.athrough2.1.i,cite at42CFR 482.21(a)(1),(a)(2),(b)(1),(b)(3)(TagA-273) HFAP Standard 12.00.01
2.1.jIfthedataanalysis identified areasneeding improvement,is thereevidencethat thehospital institutedinterventions (activities and/or projects)to address them?
  • CheckN/Aif analysis did not lead to interventions, but thehospital could demonstratethat other areaswereof higher priority.
  • CheckNOif analysis did not lead to interventions and thehospitalcould not demonstratethat other improvementactivitieswere of higherpriority.
/ Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
Elements to be Assessed / Indicator #1 / Indicator #2 / Indicator #3
2.1.kAreinterventions evaluated for success? / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
2.1.l If interventions takenwerenot successful, werenewinterventions developed? / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
2.1.m If interventions were successful, did evaluationcontinue longerto assess if successwas sustained? / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
If notoanyof 2.1.j through2.1.m, cite at42CFR 482.21(b)(2)(ii),(c)(1),(c)(3)(TagA-0283) HFAP 12.00.02
PART3–APPLYINGQUALITYINDICATORINFORMATION-ACTIVITIESAND PROJECTS
Elements to be Assessed / Space for Surveyor Notes (if needed)
3.1Can thehospital provide evidencethat its
improvementactivities focus on areasthat arehigh risk(severity), high volume (incidence or prevalence),orproblem-prone? / Yes
No
If noto3.1,cite at42CFR 482.21(c)(1)(i)(ii)(TagA-0283) HFAP 12.00.02
3.2 Can the hospital provide evidence that it conducts distinct performance improvement projects? / Yes
No
3.3 Is thenumber of projects proportionalto the scope and complexityof thehospital’s servicesand operations?Nofixed ratio is required,but smaller hospitalswith a smaller number of distinct services would beexpectedto havefewerprojects than a largehospital with manydifferent services. / Yes
No
3.4Does thescope of projects reflectthescope and complexity of thehospital’s servicesand operations?
For example,if thehospital offers morecomplex services,such as neonatal intensive care,oropen heartsurgery,havetherebeenQAPIproject(s) relatedto any of those services? / Yes
No
If notoanyof 3.2through3.4,cite at42CFR 482.21(d)(1)(TagA-0297) HFAP 12.00.04
3.5Can thehospital provide evidenceshowing why eachprojectwasselected?
(NOTE:If theprojectis a QIOcooperativeprojector an IT project,such as computerized physician order entryoran electronic medical record,no rationale is required.CheckN/Ain thesecases.) / Yes
No
N/A
If noto3.5,cite at42CFR 482.21(d)(3)(TagA-0297) HFAP 12.00.04
PART4 – PATIENTSAFETY–ADVERSEEVENTSAND MEDICALERRORS
Elements to be Assessed / Space for Surveyor Notes (if needed)
4.1Evaluation regardingwhetherthehospital’s leadership setsexpectations for patient safety: Yes No
4.1.aIs thereevidenceof widespread staff training or communication to conveyexpectations for patient safetyto all staff? (e.g. training relatedto steps to takein a situation that feelsunsafe, how to reportadversepatient events,medical errors,near misses/close calls, etc. thattheyareexpectedto reportinternally) / Yes
No
4.1.bIs thereevidencethat thehospital has
adopted policies supporting a non-punitive approach to staff reporting ofadversepatient events,medical errors,nearmisses/close calls, etc.,and situations theyconsider unsafe? / Yes
No
4.1.cOn eachunitsurveyed,can staff explain what thehospital’s expectations arefortheir role in promoting patient safety? / Yes
No
If noto4.1.a,4.1.b,or 4.1.c, cite at42CFR 482.21(e)(3)(TagA-0286) HFAP 12.00.03
4.2.Evaluationregardinghospitalprocessesto identifyadversepatient events,medical errors,nearmisses/close calls, etc.:
4.2.aOn eachunit/program surveyed,can staff describethetypesof adversepatientevents, medical errors,nearmisses/close calls, etc.theyare expectedto reportinternally? / Yes
No
4.2.bOn eachunit/program surveyed,can staff explain how and/or to whom theyareexpectedto reportadversepatient events,medical errors,near misses/close calls, etc.? / Yes
No
Elements to be Assessed / Space for Surveyor Notes (if needed)
4.2.cDoes thehospital employ methods, in addition to staff incident reporting,to identify possible adversepatient events,medical errors,near misses/close calls, etc.?
(Examples of othermethods include, but arenot limited to,retrospectivemedical recordreviews, reviewof claimsdata,unplannedreadmissions and patient complaints/grievances, intervieworsurvey of patients, etc.) / Yes
No
4.2.dCan thehospital provide evidenceofadverse patient events,medical errors,nearmisses/close calls, etc. identified through staff reportsorother methods? / Yes
No
If notoanyof 4.2.athrough4.2.d,cite at42CFR 482.21(a)(2)&482.21(c)(2)(TagA-0286) HFAP 12.00.01; 12.00.03
4.3 Is thereQAPIprogramcollaborationwith infection control officer(s) to identify and track avoidable healthcare-acquiredinfections? / Yes
No
4.4 Is thereevidencethat problems identified by infection control officer(s) areaddressed through QAPIprogramactivities? / Yes
No
If noto4.3or 4.4,cite at42CFR 482.42(b)(1)(TagA-0756)and482.21(a)(2)(TagA-0286) HFAP 07.01.04; 12.00.01
Elements to be Assessed / Space for Surveyor Notes (if needed)
4.5Does theQAPIprogramidentify and track medication administrationerrors,adversedrug reactions,and drug relatedincompatibilities? / Yes
No
If noto4.5,cite at42CFR 482.25(b)(6)(TagA-0508)and42CFR482.21(a)(2)(TagA-0286) HFAP 25.01.10; 12.00.01
4.6 Is therea QAPIprogramprocess for staff to
reportblood transfusion reactions,and reviewsof reportedblood transfusion reactions to identify medical errors(includingnearmisses/close calls) and/or adverseevents? / Yes
No
If noto4.6,cite at42CFR 482.23(c)(4)(TagA-0410)and42CFR 482.21(a)(2)(TagA-0286) HFAP 16.01.06; 12.00.01
4.7Did thesurveyteamhaveprior knowledgeof,or identify while on-site,serious preventableadverse eventsthat thehospital failed to identify? / Yes
No
If yesto4.7,cite at42CFR 482.21(a)(2)(TagA-0286) HFAP 12.00.01
4.8 Has thehospital conducted aQAPIreview, includingimplementing preventiveactions forall serious preventableadverseeventsit has identified?
Useas your sample all serious preventableevents identifiedby thehospitalin theperiod 12months prior to thesurveydate? (Note:for eventsthat occurredless than 2months prior to thesurvey date,thehospital mayhavestarted,but not yet completedits review.) / Yes
No
N/A
If noto4.8,cite at42CFR 482.21(a)(2)(TagA-0286) HFAP 12.00.01
PART4:PATIENTSAFETYTRACERS
Instructionsfor Questions#4.9and4.10:If theanswer toQuestion#4.9is“yes”,theSurveyorshouldselect uptothreesignificantadverse events or close calls/nearmisses thehospitalreviewedfor QAPIpurposesduringthelast12 -24months(“cases”).Donotletthehospitalselect theadverse events/closecallreviews tobe usedfor theTracer.
Thereviews maybe of singleevents/closecalls(e.g., awrongsitesurgery thatactuallyoccurred or thatcame close tooccurring onaparticularpatient), groupsof similarkindsof events/closecalls(e.g., allinpatientfallswithinjuryduringthefirst quarter),oracombinationof bothtypesof review.
Answer allof thequestionsin#4.10for each “case” selected.(Foratleastone,there shouldbe sufficienttime after implementationof preventive measures for thehospitaltohaveevaluatedtheimpactof thosemeasures.)
4.9Has thehospital conducted anyQAPIreviewsof adversepatient events/closecallsin the12–24months prior to thesurveydate? / Yes – IF YES, CONTINUE
No – IF NO, SKIP ALL 4.10 SUB-QUESTIONS
Elements to be Assessed / Case #1 / Case #2 / Case #3
4.10Selectthenumber of hospital conducted QAPIreviewsof adverse events/closecalls that were reviewedfor this survey. / One “case” reviewed / Two “cases” reviewed / Three “cases” reviewed
Writein a generaldescription of eachcase.Avoid using any identifiableinformation on this worksheet.
Answerall of thequestionsbelow for each“case.” / Case#1GeneralDescription: / Case#2GeneralDescription: / Case#3GeneralDescription:
4.10.aHas thehospital identified
potentialunderlying causesor contributing factors? / Yes
No / Yes
No / Yes
No
Elements to be Assessed / Case #1 / Case #2 / Case #3
4.10.bHas thehospital identified all parts of thehospital utilizingsimilar processes/atsimilar risk? / Yes
No / Yes
No / Yes
No
4.10.c Has thehospital developed and implemented preventiveactions based onitsreviewin atleast one areaof thehospital? / Yes
No / Yes
No / Yes
No
4.10.dHasthehospital evaluated theimpact of thepreventive actions, includingtracking reoccurrencesof similar events/closecalls/nearmisses? / Yes
No / Yes
No / Yes
No
4.10.e If evaluation showed the intervention(s) did not meetgoals, did thehospitalimplementa revised intervention(s) and evaluateit? / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
4.10.f Forpreventiveactionsthe
hospitalfound to beeffective,has thehospital implementedthemin all parts of thehospital utilizing similar processes/atsimilar risk, unless therearedocumented reasons for not doing so? / Yes
No / Yes
No / Yes
No
If notoanyof 4.10.athrough4.10.f,cite at42CFR 482.21(a)(1)(a)(2)(c)(2)(TagA-0286) HFAP 12.00.01; HFAP 12.00.03
PART5–BROAD QAPIREQUIREMENTSAND LEADERSHIPRESPONSIBILITIES
Elements to be Assessed / Space for Surveyor Notes (if needed)
5.1Is thereevidencethat thehospital has a formal QAPIprogram- includingwrittenpolicies and procedures,budgeted resources,and clearly identified responsible staff- approved by the governingbody afterinput fromtheCEO and medical staff leadership? / Yes
No
If noto5.1,cite at42CFR 482.21(e)(1)(2)(TagA-0309) HFAP 12.00.05
5.1.a Has thehospital maintained and made available for surveyorreviewsufficient evidenceof its QAPIprogramto allow compliance assessment? / Yes
No
If noto5.1.a,cite at42CFR 482.21(TagA-0263) HFAP 12.00.00
5.2Evaluation regardingwhethertheQAPIprogramis hospital-wide:
5.2.aUsing information on servicesofferedfrom the Hospital/CAH Data BaseWorksheet,can the QAPImanagerprovide evidenceof QAPImonitoring relatedtoeachservice? / Yes
No
If noto5.2.a,cite at42CFR 482.21(TagA-0263or A-0308) HFAP 12.00.00
5.2.bUsing information fromthehospital identifying servicesprovided under arrangement (contract),can theQAPImanagerprovide evidence of QAPImonitoring for eachservicerelatedto clinical careprovidedunder contractor arrangement?(Exclusively administrative contractual services,e.g.,payroll preparation, are not required to beincluded in theQAPIprogram.) / Yes
No
N/A
If noto5.2.b,cite at42CFR 482.12(e)and482.21(TagsA-0083andeither A-0263or A-0308) HFAP 01.01.22; 12.00.00
Elements to be Assessed / Space for Surveyor Notes (if needed)
5.3 Is thereevidencethat thegoverningbody, hospital CEO, Medical Staff leadership, and other senior administrative officials, e.g.,Directorof Nursing,eachplay a role in QAPIprogramplanning and implementation? / Yes
No
If noto5.3,cite at42CFR 482.21(e)(2)(TagA-0309) HFAP 12.00.05
Is thereevidence,e.g. in minutes, that thehospital’s governingbody:
5.4.a ApprovesQAPIprogramindicators selected and frequencyof data collection? / Yes
No
If noto5.4.a,cite at42CFR 482.21(b)(3)(TagA-0273) HFAP 12.00.01
5.4.bEnsures theQAPIprogramannually determinesthenumber of distinct QAPIprojects to beconducted in thecoming year? / Yes
No
5.4.cActivelyreviewstheresults of QAPIdata collection, analyses,activities, projects and makes decisions based on such review? / Yes
No
If notoeither 5.4.bor 5.4.c, cite at42CFR 482.21(e)(2)(e)(5)(TagA-0309) HFAP 12.00.05
5.4.d Holds theCEO accountable for the effectivenessof theQAPIprogram? / Yes
No
If noto5.4.d,cite at42CFR 482.21(e)(2)and482.12(b)(TagsA-0309A-0057) HFAP 12.00.05; 01.01.11
Elements to be Assessed / Space for Surveyor Notes (if needed)
5.5Regardingresourceallocation:
5.5.aIs thereevidenceof theamount of resources (funding and personnel) dedicated to thehospital’s QAPIprogramand thefunctions for which those resourcesare used? / Yes
No
If noto5.5.a,cite at42CFR 482.21(e)(4)(TagA-0315) HFAP 12.00.06
5.5.bIf therearecondition-levelQAPIprogram deficiencies, is thereevidencethat lackof QAPI resourcesarea significant contributing causeof thesedeficiencies? / Yes
No
N/A
If yesto5.5.b,cite at42CFR 482.21(e)(4)(TagA-0315) HFAP 12.00.06
5.6 Did thehospital atany timeduring thecourseof this surveyrefuseto provide requestedinformation, claiming it wasprotectedPatientSafetyWork Product under theFederal PatientSafetyand Quality ImprovementAct? / Yes
No
For informationonly;nocitationrisk.

Updated September 14, 2015 Page 1 of 16