I am looking at the data that we track for our QAPI (Quality Assessment/Performance Improvement) relating to the Volunteer Program.  What we are currently tracking is:

  • The % of volunteers (ie, are we meeting the required 5% to stay compliant with Medicare)  Related to this, I also have questions as to how often other programs tabulate this percentage-weekly, monthly, quarterly, annually?  (I do it weekly as of this writing)  Also, if you utilize interns, do are you allowed to count their hours toward your 5% or do you have to break them out separately?

Any suggestions on other things to track?  Ways to fine tune what I am tracking?  I just don't think I am getting a good picture of what to track and I have found little data when I try to find resources on this.  Thanks!

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  • Some additional information on the QAPI program can be found in the Regulatory - Medicare Group. While the basic focus is on improving patient care, the extent of the data tracking requirements generally reflects the nature of the specific hospice organization.  One of the key points in the CoPs is that the rule (i.e. Federal Register / Vol. 73, No. 109 / Thursday, June 5, 2008 / Rules and Regulations) does not require hospices to use any specific patient outcome measures or data elements. Therefore the data collected will be dependent upon the nature of the organization and the way it implements its specific plan of care.

    The key focus of the QAPI is:

    "...hospices are required to identify patient outcome measures that they will apply to all patients. These measures should help the hospice identify areas of strength and weakness in patient and family care delivery. Once the measures are identified, hospices must choose which data elements they will collect in order to measure their performance."

    What I would suggest is getting more familiar with the specific outcome measures your hospice has identified and the corresponding data collection requirements.  Based upon that, identify related items you might that you might track in your volunteer programs.  For example, beyond just the % of volunteer hours would be to measure the number of hours being provided against the Plan of Care for each patient. Other options might be whether alternative services that can be provided by volunteers are useful such as a music therapy program.  How a patient and/or family perceives the value of these services is also very important.

    Hope that is helpful.

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