Leaders establish priorities for performance improvement.

(1)

The hospital develops, implements, maintains, and documents an effective, ongoing, data-driven, hospitalwide quality assessment and performance improvement (QAPI) program. Note: For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital maintains and demonstrates evidence of its QAPI program for review by Centers for Medicare & Medicaid Services.

(2)

As part of performance improvement, leaders (including the governing body) do the following: - Set priorities for performance improvement activities related to health outcomes that are shown to be predictive of desired patient outcomes, patient safety, and quality of care - Give priority to high-volume, high-risk, or problem-prone processes for performance improvement activities and consider the incidence, prevalence, and severity of problems in those areas - Identify the frequency and detail of data collection for performance improvement activities

(3)

The hospital's governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for the following: - An ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained - The hospitalwide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and all improvement actions are evaluated - Clear expectations for safety are established - Adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and reducing risk to patients - The determination of the number of distinct improvement projects is conducted annually