Est1 Task 1

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Federal Regulation The federal regulation is Centers for Medicare and Medicaid Services, HHS: Subpart C—Basic Hospital Functions § 482.21 Condition of participation: Quality assessment and performance improvement program. The DRHA Pediatric Oncology and Bone Marrow (BMT) Unit proposal is in compliance with §482.21 in development, implementation, and maintenance of a data driven quality assessment and performance improvement plan. The business plan outlines measuring quality and safety indicators in evaluating pediatric oncology treatments, infection control, and patient and family satisfaction. The DRHA Pediatric Oncology and BMT unit reports the required information from the Quality Assurance & Performance Improvement (QAPI) worksheet into the hospital database to assure reimbursement requirements by the Centers for Medicare & Medicaid Services (CMS) (CMS, Department of Health and …show more content…

The evaluation will include a regression model to measure the central line associated bloodstream infections (CLABS) using evidence – based practice norms to identify variations which allows the unit to improve and reduce CLABS. The plan also includes training the oncology pediatric nurses in safe administration of chemotherapeutic agents and passing the Oncology Nursing Society (ONS), Oncology Nursing Certification Corporation (ONCC) to meet national standards. To further improve the implementation of the indicator measurement process in treatment guidelines, it is recommended that the quality improvement and infection control teams will improve assessments using the QAPI worksheet to meet the CMS requirements for safe and quality outcomes, and reimbursement (Legal Information Institute, Cornell Law School,

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