CMS Hospital QAPI Worksheet and QAPI CoP Standards

Event Information
Product Format
Prerecorded Event
Sue Dill Calloway, RN, MSN, JD
90 minutes
Product Description

Ensure Compliance with CMS QAPI CoP Standards for Hospitals

Every hospital that accepts Medicare and Medicaid must be in compliance with the QAPI (Quality Assessment and Performance Improvement) Conditions of Participation (CoP) standards. QAPI is an important issue to CMS and an increased area of focus in 2017. The CMS QAPI worksheet, which is designed to help surveyors assess compliance with the hospital CoPs for QAPI, is also an excellent communication tool for hospitals to know what the expectations are from CMS.  State and federal surveyors use the worksheet in all their 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.

If CMS showed up at your hospital’s door tomorrow, would you be able to show that you’re 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 three root cause analyses. CMS has cited hospitals for not having a number of these required policies and procedures. Performance improvement is very important to CMS, and the hospital CoPs require many things to be measured.

This session with expert speaker Sue Dill Calloway will discuss the CMS hospital QAPI standards. It is a must-attend for hospitals, as QAPI is one of the three sections within the critical CMS worksheet used by surveyors. Sue will discuss the high number of possible deficiencies, including over 380 deficiencies that relate to patient safety alone. This session will also cover some proposed changes to QAPI. CMS is going to implement similar QAPI standards for critical access hospitals under the Hospital Improvement Act. Sue will also discuss the memo CMS issued regarding the AHRQ’s 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 adverse event are never reported to hospitals’ PI programs. Is your hospital gambling in this critical area? Sue’s presentation will help you find out.

Session Highlights

  • CMS fínal QAPI worksheet
    • Number of deficiencies hospitals received
    • Fínal worksheet
    • Use by surveyors in assessing compliance with standards
    • Indicators selected
    • How the evidence quality indicator is related to outcomes
    • Scope of data collectíon
    • Collectíon 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 Act
    • 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
    • Measureable improvements
    • Analyze and tracking of performance indicators
    • Program data
    • Tracking adverse events
    • Ensuring compliance with program data requirements
    • Identifying opportuníties 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 like TJC, CMS compare, CMS VBP, AHRQ PI toolkit etc.

Session Agenda

  • Conditions of participation (CoPs)
  • Subscribing to the Federal Register
  • Location of CMS hospital CoP manuals
  • Accessing hospital complaint data
  • Number of deficiencies for QAPI
  • Updated deficiency data reports
  • Hospital CoPs for QAPI
  • Reporting adverse events to PI
  • Adverse event reporting
  • 9 modules in the common formats
  • Hospital Improvement Act
  • QAPI program
  • CMS worksheets
    • History
    • Fínal 3 worksheets QAPI
  • Quality indicator tracers
  • Patient safety AE and medical errors
  • Scope of your PI Program
  • CMS hospital acquired conditions

Session Objectives

  • Review CMS’s worksheet on QAPI
  • Understand the section on QAPI in the CMS hospital CoP manual that any hospital that accepts Medicare or Medicaid reimbursement must follow
  • Review the board’s ultimate responsibility for the QAPI program and ensure there are adequate resources for PI
  • Learn why hospitals are receiving a high number of deficiencies in QAPI

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, which include requirements on risk management and patient safety, are met

Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.

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About Our Speaker

Sue Dill Calloway - Hospital Coding Expert

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a focus on medical-legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of...   More Info
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