Quality assessment and performance improvement – Wis. Admin. Code DHS §131-22

Quality Assessment and Performance Improvement at Hospices

This law puts forth requirements for quality assessment and performance improvement programs at hospices.  The law states that hospices are required to develop and maintain and effective data-based quality assessment and performance improvement program, and places responsibility on the hospice's governing body to ensure that the program accurately takes into account all the services and the complexity of the hospice.  The law further requires that the hospice maintain documents as evidence of this program that may be examined by the department of health services (DHS).

The scope of the program must include data that can show measurable improvement in outcomes and services, and the hospice must measure and track quality indicators to help the hospice assess care and operations.  The law further requires that the hospice's performance improvement activities focus on high risk and problem prone areas while considering the incidence and severity of the problems in those areas that affect patient safety and quality of care.  These activities are also requires to track adverse patient events in order to analyze the cause and make any changes possible to prevent occurrence of such events in the future.

Hospices are also required to develop and implement performance improvement projects based on the needs of the hospice and its patients, and to document these projects.  The law further assigns the hospice’s governing body the responsibility of ensuring that these quality assessment and performance improvement measure are carried out effectively, and of naming designated individuals.