Please note that these answers are only intended as a resource for Rural Health Clinics. Ultimately, CMS and the state surveyors will make the final determination of what constitutes an appropriate QAPI program. Most of these questions and answers are drawn from comments and responses published in the Federal Register

What is a Quality Assessment and Performance Improvement (QAPI) program?

There are two distinct steps in any QAPI program. The first step is to assess the quality of care and identify potential areas for improvement. Ideally, improvements will be focused on high volume/high risk procedures or other services that stand to substantially improve quality of care. The assessment should be based on solid data (i.e. large number of patients presenting with a particular chronic condition or information from chart reviews). When available, RHCs are expected to utilize current practice guidelines and professional practice standards when comparing the care they provide.

The second step is to correct or improve processes of care and clinic operations in a way that is expected to improve overall quality. Some data should be available to monitor the effect of this improvement. This data should be reviewed with an eye towards using the results to modify, strengthen or alter the intervention accordingly. If this process is followed, regularly collecting and analyzing information will result in a continuous improvement in patient care.

What are some available resources for implementing a quality assessment and performance improvement program in an RHC?

This site contains a wealth of information and is continuously being updated with new material. The file RHC Quality Improvement Resources contains a list of websites and articles relevant to those seeking to implement a quality assessment and performance improvement program. In particular, The Agency for Healthcare Research and Quality has a wide array of information on quality improvement.

Are rural health clinics required to complete a specific number of quality assessment and performance improvement projects to fulfill their QAPI requirement?

No. Section 491.11 provides Rural Health Clinics with the flexibility to tailor the amount and flexibility of individual performance improvement projects to the clinic's available resources. It is not expected that small RHCs will have a quality improvement program that is as comprehensive as an RHC that is part of a large integrated system. However, all RHCs must have a QAPI program.

What types of performance measures might be used in an RHC QAPI program?

Section 491.11 provides RHCs with tremendous flexibility with regards to performance measures. RHCs may design their own or may draw on measures from outside sources. Surveyors will check to see that the measures are relevant to the clinic's QAPI program and that the data, or information, collected will enable a clinic, with its available staff and resources, to assess change or improvement. For example, a clinic seeking to increase access by reducing patient wait time might measure the time between a patient presenting and being seen by a physician or mid-level practitioner. Various clinical practice guidelines detail a variety of measures for managing chronic diseases. The American Academy of Family Physicians has suggested guidelines for physician office practice performance measures and the Agency for Health Care Research and Quality has published a guide to performance measures for quality improvement.

What are the characteristics of Rural Health Clinics with outstanding quality assessment and performance improvement programs?

Most rural health clinics that have implemented a successful quality program cite the need for a "cultural change" in the way practitioners and staff deliver medical care. They acknowledge that implementing a quality improvement program was difficult at first, but eventually thinking in terms of quality becomes second nature. Ultimately, quality improvement is about "practicing medicine better tomorrow based on what you are learning today." Quality-oriented Rural Health Clinics are continuously questioning their policies and procedures and looking for better ways to improve care. All practitioners and staff are comfortable identifying weaknesses and suggesting improvement, and clinic employees work collaboratively to improve care.

Is there a list of best practices in Rural Health Clinic Quality Improvement?

The Office of Rural Health Policy is currently speaking with RHCs and attempting to compile a list of best quality improvement practices. If your RHC has a quality improvement program, no matter how seemingly small, ORHP would like to hear about it. Please e-mail or call Craig Williamson at (301) 443-4784.

Does the new QAPI requirement mean that I will have to hire an expensive consultant to ensure sure that I am compliant?

Some Rural Health Clinics may choose to hire outside consultants, and they are certainly entitled to do so. However, sufficient flexibility was built into the regulation that most RHCs, if they use this website and other resources that are available to them, should be able to independently implement a QAPI program that is compliant with Section 491.11