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Chapter 1

Mary Maven - Chapter 1

We Can Do This!

End-of-Chapter Questions  



1. Compare and contrast the old and new conditions of participation regarding QAPI and consider implications for your hospice organization. What are the elements of an effective, hospice wide, data driven QAPI program in your hospice setting?

Answer:  Question 1

Compare and contrast

The “Old” Conditions of Participation addressed Quality Assurance in only one paragraph with no standards. The New Conditions of Participation for QAPI-Quality Assessment-Performance Improvement - have 5 standards (See appendix 2 In We Can DO This to review these standards). In addition, quality assessment and improving performance are woven into many other standards in other sections of the new CoPs.

The clear change in the focus in this section is from monitoring quality to improving outcomes in end of life care for each patient and across the organization. In the previous CoPs, hospices reported quality retrospectively and in the new CoPs hospices are required to integrate the measurement of quality outcomes and improve those outcomes if needed as care and services are provided.

Changes in conditions of participation regarding quality are signaling CMS’s increasing interest in seeing end of life outcomes measured and improved. CMS wants hospices to be aware of their quality status and focus on improving outcomes where there is room for improvement. There is a shift in the focus from trying to maintain “benchmark” as a sign of quality to demonstrating improvements in outcomes.

The elements of an effective, hospice-wide, data driven QAPI program in a hospice organization include:

  • Evidence of an overarching goal for your organization of improving quality in end of life, patient centered -care for patients in your hospice. For example: Is improving quality part of your mission, vision, goals? Do descriptions for board, staff, volunteer and patient and caregiver roles and responsibilities reflect quality improvement? Does new employee and volunteer orientation describe the organization’s commitment to improving quality?
  • The Board’s role for improving quality is written in board documents and reflected in board meetings minutes, job descriptions and committee assignments.
  • Structures and processes are in place to assess quality outcomes for each patient and across the organization; to identify areas for improvement; to do performance improvement projects, to involve all staff in improving outcomes, to document these processes and to track measures of quality improvement over time.
  • Outcome and process data can be gathered, analyzed, recorded and displayed to document and communicate results of performance improvement.
  • All team members have the skills, time and resources for involvement in quality improvement activities and to identify “best practices” to improve palliative outcomes.
  • Leadership with the skills and vision to lead and manage change.

2. How will your programs position descriptions change to address the QAPI requirements of the new conditions of participation for CEO, QAPI Coordinator, medical director and other hospice team members?

Answer:  Question 2

Position descriptions will include references to roles and responsibilities for patient safety, quality assessment and performance improvement including descriptions for:


  • Oversee and maintain overall responsibility for a patient safety and quality assessment and performance improvement program for the organization.
  • Review quality outcomes, oversee the selection and results of performance improvement projects and prioritize areas for improvement.
  • Ensure sufficient resources are deployed for a successful QAPI program.


  • Allocate resources ( time, schedule flexibility, technical experts if needed) to the staff to carry out the QAPI program.
  • Communicate Board’s QAPI goals to the staff and stay informed of progress and outcomes of QAPI projects.
  • Support the QAPI agenda and demonstrate interest, encouragement and enthusiasm for QAPI teams to all staff.
  • Remove barriers to success.
  • Take overall responsibility to lead and manage change.

QAPI Coordinator/QA Staff
(Defined as staff whose primary responsibility is enacting the quality agenda for the organization.)

  • Gather and work with others to analyze organization-wide data and report to CEO or designee.
  • Assist with identifying areas for improvement and report to CEO in a systematic way.
  • Turn quality agenda into specific goals, teams and projects.
  • Teach hospice staff a quality improvement system (such as the Model for Improvement). Ensure that projects use methodology as taught.
  • Work with improvement teams to set aims, determine outcome measures, help identify changes to test, and determine process measures and help team with PDSA cycles until desired outcome is achieved.
  • Post results of team improvement projects (using a storyboard or similar display) and report progress to senior leaders and staff on a regular basis.
  • Provide technical improvement skills and coaching to teams as needed.
  • Ensure that team is documenting progress and activities.

Medical Director

  • Act as a champion for quality improvement, taking an active role in quality improvement teams when improving medical practice and/or interdisciplinary practice to affect patient or organizational outcomes.
  • Act as a liaison with other physicians who are part of the process that is changing for improvement.
  • Provide content knowledge expertise as requested for better practices for patient care.

Hospice Staff

  • Act as improvement team members.
  • Identity and report areas for improvement and  concerns for safety of patients, family and staff.
  • Suggest alternative ways of intervening that may improve outcomes based on knowledge and familiarity of situations.
  • Recognize that quality improvement is part of everyone’s job responsibilities.
  • Stay abreast of performance improvement projects and their outcomes.

3. Review your most recent past quality projects and determine what you will need to change in order to meet the new QAPI requirements.

Answer: Question 3

If “yes” is the answer to the following questions, you are QAPI ready for PIPs.

  • Was the project selected as a result of system wide quality assessment reflecting a need for this improvement project?
  • Has the project been reviewed by the QAPI Committee or Board Committee to determine it is the right project and the right time for it?
  • Were stakeholders and those affected by the change included in the improvement team?
  • Were the aim, measures, changes, and PDSA cycles documented and displayed for others to see?
  • Were tests of changes done?
  • Was performance improved?
  • Did you meet your aim within the timeframe you predicted?
  • Were the results reported to the board and other stakeholders?
  • Have the successful changes that helped you reach your outcome been implemented, documented and spread throughout your organization?