Explore the significance of Quality Assessment and Performance Improvement (QAPI) programs in Medicare-certified hospitals, focusing on the updated CMS standards and interpretive guidelines. Learn about essential requirements, assessment areas, and hospital leadership's role in ensuring compliance and enhancing patient safety. Title: Understanding CMS Hospital QAPI Standards and Guidelines: Key Elements for Implementation and Compliance Description: Explore the significance of Quality Assessment and Performance Improvement (QAPI) programs in Medicare-certified hospitals, focusing on the updated CMS standards and interpretive guidelines. Learn about essential requirements, areas of assessment, and the role of hospital leadership in ensuring compliance and enhancing patient safety. Quality Assessment and Performance Improvement (QAPI) Conditions of Participation deficiencies rank among the top three cited issues for Medicare-certified hospitals, highlighting the critical need for robust QAPI programs. CMS emphasizes the pivotal role of well-designed and maintained QAPI initiatives in enhancing patient care quality, reducing medical errors, and fostering a safer healthcare environment. Register, https://conferencepanel.com/conference/cms-hospital-qapi-standards-2024

1. QAPI Standards
HOSPITAL CONDITIONS OF
PARTICIPATION (COPS) 2024
Presented By
Laura A. Dixon
BS, JD, RN, CPHRM 1

2. 2
Speaker
•Laura A. Dixon, Esq.
• BS, JD, RN, CPHRM
• President, Healthcare Risk Education
and Consulting, LLC
• 303-955-8104
• ldesq@comcast.net
• Email questions to CMS:
Critical Access Hospitals: qsog_CAH@cms.hhs.gov.
Acute hospitals: QSOG_Hospital@cms.hhs.gov.
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3. How itWorks
• Regulation published in the Federal Register
• CMS publishes the regulation in a transmittal
• Will develop Interpretive guidelines and survey procedures
• Updates the hospitalCoP manual
• Types of surveys
• Certification
• Complaint
• Validation survey
• If out of compliance CMS may issue a statement of
deficiency and will have to do a plan of correction
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4. How to Keep Up with Changes
• Subscribe to the Federal Register 1.
• Confirm current CoP 2.
• If new manual – check CMS transmittal page 3.
• Check the survey and certification website monthly 4.
• 1 https://public.govdelivery.com/accounts/USGPOOFR/subscriber/new
• 2, http://www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf
• 3 http://www.cms.gov/Transmittals
• 4 http://www.cms.gov/SurveyCertificationGenInfo/PMSR/list.asp#TopOfPage
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5. CMS Changes and Updates
Hospital Improvement Rule
Interpretive Guidelines and Survey Procedures
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6. How QAPI Started
• Hospital underwent a validation survey
• Cited for not following manufacturers instructions for use in
sterilizing equipment
• Asked what data they were collecting and analyzing on this
• When said “none” - cited for not monitoring a high-risk
process
• This is sort of like playing whack a mole
• Hospital Accreditation: Setting Priorities forYour QAPI Program.
• CIHQ at http://www.cihq-blog.org/blog.asp
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7. Hospital Improvement Rule
• Formal name: “Regulatory Provision to Promote
Program Efficiency,Transparency and Burden
Reduction”
• Includes a section on H&Ps but not applicable to CAHs
• Applies to all hospitals that accept Medicare or
Medicaid reimbursement
• Intended to improve the quality of care to patients
and reduce barriers to care
• QSO-20-07-ALL – 680 pages
• https://www.cms.gov/files/document/burden-reduction-
discharge-planning-som-package.pdf
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8. CoPs: Quality Assessment
Performance Improvement
Acute Hospitals
Tag Nos. 263 – 310
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9. Why QAPI?
• Third most frequently cited of the 24 Conditions of
Participation
• CMS: “A well-designed and maintained QAPI program
fully engaged in hospital-wide continuous assessment
and improvement efforts can:
• Significantly enhance ability to provide high quality and safe
care
• Reduce incidence of medical errors and adverse events
throughout the hospital”
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10. QAPI CoPs
• 11Tag numbers
• Covers:
• Data Collection and Analysis
• Quality Improvement Activities
• Patient Safety, Medical Errors andAdverse Events
• Performance Improvement Projects
• Executive Responsibilities
• Unified and integrated systems
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11. Focus of QAPI
• Determine if a hospital has
• An effective, ongoing system in place
• For identifying problematic events, policies or practices
• Taking action to remedy the problem areas
• With follow up to determine:
• Were actions effective in improving performance and quality
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12. QAPI and Other Areas Evaluated
• Surveyor may assess QAPI when other non-
compliance identified
• EX: Infection prevention and control
• Pharmacy CoPs
• Will cite under those sections
• May investigate tracking of errors and adverse events
• Will investigate analyses and actions taken
• Follow up evaluations in process
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13. Overall –What Must Demonstrate
• QAPI – must maintain and demonstrate evidence of
QAPI program
• Including effectiveness
• Must provide surveyors access to QAPI program
information without disclosing PSWP
• Be prepared to provide evidence of relationship with a
PSO
• Surveyors will verify if relationship exists
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14. Quality Improvement Activities 283
• Hospital must use collected data to identify
opportunities for improvement
• Plus – mechanisms for change to improve safety/quality
• Hospital must set priorities that
• Focus on high risk, high volume, or problem prone areas
• Consider incidence, prevalence, and severity of problems in
those areas
• Issues that affect health outcomes, patient safety and
quality of care
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15. Patient Safety, Medical Errors, AE 286
• PI program must include indicators to identify and
reduce medical errors – “measurable improvements”
• Track medical errors and adverse events
• Analyze causes and implement preventive actions
• EX: Root CauseAnalysis
• Board responsible for the operations of the hospital
• Medical staff and administrative staff – accountable to
ensure clear expectations for safety
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16. QAPI and QIOs
• QIO – Quality Improvement Organization
• Can participate in a QIO project or do one that is of
comparable effort
• QIO – advance quality of care for Medicare patients
• Every state has a QIO under contract by CMS
• Also 2 BFCC QIOs Livanta and KePro
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17. Critical Access Hospitals
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18. QAPI 2019 Changes
• NewTag numbers
• 1302, 1306, 1309, 1311, 1315, 1319, 1321 and 1325
• Previous tag numbers were C-330 – 343
• Requirements new but similar to Appendix A
• Interpretive guidelines and survey procedures pending
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19. QAPI and Adverse Event
Reporting
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20. In Summary
• Focus on high volume, high risk, and problem prone areas
• Clearly document the actions you take to improve performance
• Document how you will ensure actions to improve are sustained
and sustainable
• Governing Body must ensure you are implementing an effective
QAPI program
• Consider providing the board a report demonstrating such
• Show measurable improvements – indicators show:
• Improving health outcomes and making a difference
• Reducing and identifying medical errors and adverse events
• Tracking adverse patient events
• Focus on patient safety and ensure adequate resources
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21. In Summary – continued
• Review your QAPI plan and policy annually
• Collected data should be:
• Relevant
• Aggregated
• Analyzed
• Acted upon to identify opportunities for improvement
• Train your staff that collect data so is done correctly
• Use the QAPI worksheet
• Use for a gap analysis with the QAPI standards
• Ensure every department/service reporting data
• Includes inpatient and outpatient departments
• Both clinical and non-clinical areas – security
• Review contracted services and ensure board reviews same
• Include the performance indicators for each contract 21

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The End Questions???
•Laura A. Dixon, Esq.
• BS, JD, RN, CPHRM
• President, Healthcare Risk Education
and Consulting, LLC
• 303-955-8104
• ldesq@comast.net
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