Tackle Hospital Compliance Challenges: CMS QAPI Worksheet & Standards

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

Ensure Compliance with CMS QAPI CoP Standards for Hospitals

The Centers for Medicare & Medicaid Services (CMS) has got its eagle eye on your hospital’s patient safety and risk management. That’s why you must maintain—and potentially improve—your compliance with the Quality Assessment and Performance Improvement (QAPI) standards. Recently, CMS identified over 1,700 deficiencies related to patient safety. Is your hospital guilty of any of these?

Get a needed quality check-up by joining hospital compliance consultant Sue Dill Calloway as she walks you through CMS hospital QAPI standards, required policies and procedures for every hospital, and the three root cause analyses you are required to conduct. She will review the section in the QAPI standards that addresses patient safety and risk management, and you’ll go over the QAPI worksheet used by state and federal surveyors to assess QAPI standards compliance. With this worksheet as a communication tool, you’ll know exactly what CMS expects from you – and how to prepare.

After attending this webinar, you’ll have a solid grasp on everything you must report to remain compliant. You’ll understand what CMS requires of you in terms of the Agency for Healthcare Research and Quality’s common formats. And, most importantly, you’ll have a solid grasp of what data you must report.

CMS recently found that 86% of adverse events are never reported to the hospital’s performance improvement program. Don’t let this be said of your hospital – get the tools you need to tighten your compliance program!

Session Highlights

Here is a taste of what you will uncover:

  • The program scope of QAPI, and how QAPI standards address patient safety and risk management
  • CMS’s proposed changes to QAPI
  • The role of your hospital board in the QAPI process
  • TJC Sentinel Events and framework for doing root cause analysis (RCA)
  • How surveyors assess compliance with QAPI standards and the scope of survey data collection
  • Best practices for reducing medical errors and reporting adverse events
  • Key ways you can improve opportunities for improvement in your hospital
  • The ways the Hospital Improvement Rule will affect critical access hospitals (CAHs)
  • Access to resources, such as:
    • CMS Compare
    • CMS Value-Based Purchasing (VBP)
    • AHRQ PI toolkit
    • Patient Safety Indicators
    • National Quality Forum

Session Agenda

  • The Conditions of Participation (CoPs)
  • CMS  Transmittals
  • Number of deficiencies for QAPI
  • Updated deficiency data reports
  • QAPI deficiencies
  • Areas cited by CMS under QAPI
  • Hospital CoPs for QAPI
  • Adverse event reporting
  • 9 modules in the common formats
  • CMS proposed changes to the hospital improvement rule
  • QAPI program proposed changes
  • CAH QAPI program
  • CMS worksheets – infection control, discharge planning and QAPI
  • QAPI & PI tracer data collection & analysis
  • CMS Hospital CoPs – What PPS hospitals need to know about the QAPI section
  • Changes to the tag numbers
  • What is the scope of your PI program?
  • Pediatric quality measures ED
  • Scope of activities of the PI plan
  • TJC performance measurement
  • CMS hospital acquired conditions

Who Should Attend:

This program will benefit anyone responsible for ensuring the hospital meets CMS Conditions of Participation (COPs) related to performance improvement, including:

  • Performance Improvement directors and staff
  • Risk management staff
  • Quality improvement personnel
  • Compliance officers
  • Chief Nursing officers
  • Chief medical officers
  • Patient safety officers
  • Nurse educators, staff nurses, and nurse managers
  • Leadership staff
  • Hospital board members
  • Accreditation staff
  • Department directors
  • Infection preventionists

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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