[Code of Federal Regulations]
[Title 42, Volume 3]
[Revised as of October 1, 2004]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR491.11]

[Page 967]
 
                         TITLE 42--PUBLIC HEALTH
 
  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 
                  HEALTH AND HUMAN SERVICES (CONTINUED)
 
PART 491_CERTIFICATION OF CERTAIN HEALTH FACILITIES--Table of Contents
 
Subpart A_Rural Health Clinics: Conditions for Certification; and FQHCs 
                         Conditions for Coverage
 
Sec. 491.11  Quality assessment and performance improvement.

    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]