42 C.F.R. § 491.11 Quality assessment and performance improvement.
Title 42 - Public Health
The RHC must develop, implement, evaluate, and maintain an effective, ongoing, data-driven quality assessment and performance improvement (QAPI) program. The self-assessment and performance improvement program must be appropriate for the complexity of the RHC's organization and services and focus on maximizing outcomes by improving patient safety, quality of care, and patient satisfaction. (a) Standard: Components of a QAPI program. The RHC's QAPI program must include, but not be limited to, the use of objective measures to evaluate the following: (1) Organizational processes, functions, and services. (2) Utilization of clinic services, including at least the number of patients served and the volume of services. (b) Standard: Program activities. (1) For each of the areas listed in paragraph (a)(1) of this section, the RHC must do the following: (i) Adopt or develop performance measures that reflect processes of care and RHC operation and is shown to be predictive of desired patient outcomes or be the outcomes themselves. (ii) Use the measures to analyze and track its performance. (2) The RHC must set priorities for performance improvement, considering either high-volume, high-risk services, the care of acute and chronic conditions, patient safety, coordination of care, convenience and timeliness of available services, or grievances and complaints. (3) The RHC must conduct distinct improvement projects; the number and frequency of distinct improvement projects conducted by the RHC must reflect the scope and complexity of the clinic's services and available resources. (4) The RHC must maintain records on its QAPI program and quality improvement projects. (5) An RHC may undertake a program to develop and implement an information technology system explicitly designed to improve patient safety and quality of care. This activity will be considered to fulfill the requirement for a project under this section. (c) Standard: Program responsibilities. The RHC's professional staff, administrative officials, and governing body (if applicable) are responsible for the following: (1) Ensuring that quality assessment and performance improvement efforts effectively address identified priorities. (2) Identifying or approving those priorities and for the development, implementation, and evaluation of improvement actions. [68 FR 74817, Dec. 24, 2003]
Title 42: Public Health
PART 491—CERTIFICATION OF CERTAIN HEALTH FACILITIES
Subpart A—Rural Health Clinics: Conditions for Certification; and FQHCs Conditions for Coverage
§ 491.11 Quality assessment and performance improvement.
