What does “Effectiveness review” mean?
Short answer
An effectiveness review checks that a fix worked and the problem did not return. A measure and a date set in advance let the action close.
Also known as: effectiveness check, effectiveness verification
What it checks
CMS expects providers to measure success after they act and to track results so gains last (42 CFR 483.75(d)(1), 482.21(c)(3)). Nursing home governing bodies must make sure fixes are judged for effect (483.75(f)(5)). So must surgery center governing bodies (416.43(e)(2)).
The Joint Commission asks for system-wide improvement with measurable results. The VA gives each action a measure. A process measure shows the action was done. An outcome measure shows whether it worked.
How to do it
- Set the measure with the action, like falls with injury per 1,000 resident days.
- Set a review date far enough out to see a trend.
- Collect data and compare it to the baseline, the starting numbers.
- Decide: effective, partly effective or not effective. Reopen the action if it failed.
- File the proof so a surveyor can see it.
CMS also expects an acceptable plan of correction to say how the facility will monitor results so fixes last. Mix-up: finishing the task is not the review. Installing alarms shows it was done. Fewer falls shows it worked.
Frequently asked questions
How long after implementation should the review happen?
CMS sets no number of days. Pick a window long enough to show a trend, and record the baseline.
What counts as evidence of effectiveness?
Data tied to your measure: event rates before and after, audit results, or watching the new process in use. Keep both process and outcome measures.
What if the action did not work?
Reopen it. Go back to the causes, choose a stronger action and set a new review date. Recording the failed try shows the system learns.
Sources
- 42 CFR 483.75: Nursing home QAPI
- 42 CFR 482.21: Hospital QAPI condition of participation
- 42 CFR 416.43: ASC QAPI condition for coverage
- Joint Commission: Sentinel Event Policy (SE chapter), Comprehensive Accreditation Manual, Update 1, July 2026
- VHA National Center for Patient Safety: Root cause analysis (page and Guide to Performing a Root Cause Analysis, rev. 02/05/2021)
- CMS State Operations Manual, Chapter 7: Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities
Reviewed against the sources above on Oct 5, 2026. Rules change: confirm current requirements with the issuing body or your counsel before relying on any summary.
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