[Code of Federal Regulations]

[Title 42, Volume 3]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR491.11]



[Page 968]

 

                         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]