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Validity : 18th Apr'24 to 28th Apr'24
CMS Hospital QAPI Worksheet and Standards
CMS Final QAPI Worksheet:
- Number of deficiencies hospitals received
- Final worksheet
- Use by surveyors in assessing compliance with standards
- Indicators selected
- Evidence quality indicator is related to outcomes
- Scope of data collection
- Collection methodology
- Number of projects
- Focus on severity, high volume, etc
- RCA and causal analysis tracers
- TJC Sentinel Events and framework for doing RCA
- Interventions etc
- PI requirements and leadership
- Board responsibility for PI
CMS CoP Manual Standards on QAPI:
- 34 standards to 8 and 7 completely rewritten
- CAH proposed QAPI under the Hospital Improvement Rule
- CMS memo on reporting into the QAPI system
- Number of deficiencies in the QAPI standards
- Ongoing PI program
- CMS Memo on reporting to internal PI program
- Hospital-wide QAPI program
- Prevention and reduction of medical errors
- Program scope
- Measurable improvements
- Analyze and tracking of performance indicators
- Program data
- Tracking adverse events
- Ensuring compliance with program data requirements
- Identifying opportunities for improvement
- Board responsibilities for PI
- QIO projects and changes in QIO functions
- PI priorities
- Issues to improve patient safety, reduce medical errors and ADEs
- Three RCAs or root cause analysis
- Number of PI projects
- Documentation requirements
- Executive responsibilities
- Providing adequate resources
- Resources; TJC, CMS compare, CMS VBP, AHRQ PI toolkit, patient safety indicators, National Quality Forum etc
Overview of the webinar
This program is a must attend for any hospital. This is because it is one of only three sections of a CMS worksheet. It will also discuss the CMS hospital QAPI standards. There is a high number of deficiencies and these will be discussed. There are over 1,700 deficiencies of these that relate to patient safety. This program will also cover some proposed changes to QAPI. CMS is going to implement similar QAPI standards for critical access hospitals in the proposed Hospital Improvement Rule.
If CMS showed up at your door tomorrow would you be able to show that you are in compliance with the QAPI standards? Did you know there is a section in the QAPI standards that address patient safety and risk management? It requires hospitals to have 3 root cause analysis. Hospitals were also cited for not having a number of required policies and procedures.
The QAPI (Quality Assessment and Performance Improvement) worksheet is designed to help surveyors assess compliance with the hospital CoPs for QAPI. The worksheet is used by State and Federal surveyors on all survey activity in hospitals when assessing compliance with the QAPI standards including validation and certification surveys. CMS may also just show up at your door to assess the three worksheets.
Every hospital that accepts Medicare and Medicaid must be in compliance. The CMS QAPI worksheet is an excellent communication tool so that the hospital will know what the expectations are for CMS. QAPI is an important issue to CMS and an increased area of focus.
This program will discuss the memo that CMS issued regarding the AHRQ common formats. CMS states that there are several reports that show that adverse events are not being reported. In fact, it is estimated that 86% of the adverse event is never reported to the hospital’s PI program. Performance improvement is very important to CMS and the hospital conditions of participation require many things to be measured.
Who should attend?
- Performance Improvement Director and Staff
- Risk Management Personnel
- Quality Personnel
- Compliance Officer
- Chief Nursing Officer
- Chief Medical Officer
- Patient Safety Officer
- Nurse Educator
- Staff Nurses
- Nurse Managers
- Leadership Personnel
- Board Members
- Accreditation Staff
- Department Directors
- Infection Preventionist
- Anyone else who is responsible to ensure the CMS CoPs related to performance improvement are met which includes requirements for risk management and patient safety
Why should you attend?
- Recall that CMS has a worksheet on QAPI
- Describe that there is a section on QAPI in the CMS hospital CoP manual that any hospital that accepts Medicare or Medicaid reimbursement must follow
- Discuss that the Board is ultimately responsible for the QAPI program and must ensure there are adequate resources for PI
- Recall that hospitals are receiving a high number of deficiencies in QAPI
Faculty - Ms.Sue Dill Calloway
Sue Dill Calloway, R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She is also the past Chief Learning Officer for the Emergency Medicine Patient Safety Foundation and a board member. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer. She worked for over 8 years as the Director of Risk Management and Health Policy for the Ohio Hospital Association. She was also the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus area for five years. She does frequent lectures on legal, patient safety, and risk management issues and writes numerous publications.
Sue has been a medico-legal consultant for over 30 years. She has done many educational programs for nurses, physicians, and other healthcare providers on topics such as nursing law, ethics and nursing, malpractice prevention, HIPAA medical record confidentiality, emergency department patient safety and risk, EMTALA anti-dumping law, Joint Commission issues, CMS issues, documentation, medication errors, medical errors, documentation, pain management, federal laws for nursing, sentinel events, MRI Safety, Legal Issues in Surgery, patient safety and other similar topics. She is a leading expert in the country on CMS hospital CoPs issues and does over 250 educational programs per year. She was the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program.