SlideShare a Scribd company logo
1 of 22
Download to read offline
QAPI Standards
HOSPITAL CONDITIONS OF
PARTICIPATION (COPS) 2024
Presented By
Laura A. Dixon
BS, JD, RN, CPHRM 1
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.
2
2
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
3
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
4
CMS Changes and Updates
Hospital Improvement Rule
Interpretive Guidelines and Survey Procedures
5
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
6
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
7
CoPs: Quality Assessment
Performance Improvement
Acute Hospitals
Tag Nos. 263 – 310
8
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”
9
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
10
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
11
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
12
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
13
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
14
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
15
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
16
Critical Access Hospitals
17
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
18
QAPI and Adverse Event
Reporting
19
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
20
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
22
The End Questions???
•Laura A. Dixon, Esq.
• BS, JD, RN, CPHRM
• President, Healthcare Risk Education
and Consulting, LLC
• 303-955-8104
• ldesq@comast.net
22
22
Register Now

More Related Content

Similar to Implementing CMS Hospital QAPI Guidelines for 2024

Medicare Advantage
Medicare AdvantageMedicare Advantage
Medicare AdvantageBen Quirk
 
Medicare Advantage
Medicare Advantage Medicare Advantage
Medicare Advantage Ben Quirk
 
3rd Homecare Conference Presentation - Dr. Amer Alata
3rd Homecare Conference Presentation - Dr. Amer Alata3rd Homecare Conference Presentation - Dr. Amer Alata
3rd Homecare Conference Presentation - Dr. Amer AlataDr. Amer Alata
 
9 Compliance Tips to Start the Year Right
9 Compliance Tips to Start the Year Right9 Compliance Tips to Start the Year Right
9 Compliance Tips to Start the Year RightMD Ranger, Inc.
 
PYA Looks Beyond Meaningful Use at AHIMA
 PYA Looks Beyond Meaningful Use at AHIMA PYA Looks Beyond Meaningful Use at AHIMA
PYA Looks Beyond Meaningful Use at AHIMAPYA, P.C.
 
Performance and Reimbursement under MIPS for Orthopedics
Performance and Reimbursement under MIPS for OrthopedicsPerformance and Reimbursement under MIPS for Orthopedics
Performance and Reimbursement under MIPS for OrthopedicsWellbe
 
Quality assurance cycle
Quality assurance cycle Quality assurance cycle
Quality assurance cycle Ankita Kunwar
 
A Step-by-Step Approach to A Clinically Integrated Network
A Step-by-Step Approach to A Clinically Integrated NetworkA Step-by-Step Approach to A Clinically Integrated Network
A Step-by-Step Approach to A Clinically Integrated NetworkConifer Health Solutions
 
Quality Management in the Philadelphia EMA
Quality Management in the Philadelphia EMAQuality Management in the Philadelphia EMA
Quality Management in the Philadelphia EMAOffice of HIV Planning
 
How to Engage Physicians in Quality/Safety Improvement Using Metrics
How to Engage Physicians in Quality/Safety Improvement Using MetricsHow to Engage Physicians in Quality/Safety Improvement Using Metrics
How to Engage Physicians in Quality/Safety Improvement Using MetricsWellbe
 
Quality assurance in nursing, (nursing audit).pptx
Quality assurance in nursing, (nursing audit).pptxQuality assurance in nursing, (nursing audit).pptx
Quality assurance in nursing, (nursing audit).pptxTulsiDhidhi1
 
medical audit in hospital
medical audit in hospital medical audit in hospital
medical audit in hospital Hari dagal
 
PLCO_Indicators_0606.pptx
PLCO_Indicators_0606.pptxPLCO_Indicators_0606.pptx
PLCO_Indicators_0606.pptxAfrim Alili
 
Implementing ICD-10 In Five Simple Steps
Implementing ICD-10 In Five Simple StepsImplementing ICD-10 In Five Simple Steps
Implementing ICD-10 In Five Simple StepsHarold Gibson
 
Quality and safety: lessons from the Francis Report
Quality and safety: lessons from the Francis ReportQuality and safety: lessons from the Francis Report
Quality and safety: lessons from the Francis ReportPMolyneux
 
Health IT Summit Denver 2014 - "Anatomy of a Health System"
Health IT Summit Denver 2014 - "Anatomy of a Health System"Health IT Summit Denver 2014 - "Anatomy of a Health System"
Health IT Summit Denver 2014 - "Anatomy of a Health System"Health IT Conference – iHT2
 

Similar to Implementing CMS Hospital QAPI Guidelines for 2024 (20)

Medicare Advantage
Medicare AdvantageMedicare Advantage
Medicare Advantage
 
Medicare Advantage
Medicare Advantage Medicare Advantage
Medicare Advantage
 
Blank clinical audit report template
Blank clinical audit report templateBlank clinical audit report template
Blank clinical audit report template
 
nursing audit
nursing auditnursing audit
nursing audit
 
3rd Homecare Conference Presentation - Dr. Amer Alata
3rd Homecare Conference Presentation - Dr. Amer Alata3rd Homecare Conference Presentation - Dr. Amer Alata
3rd Homecare Conference Presentation - Dr. Amer Alata
 
9 Compliance Tips to Start the Year Right
9 Compliance Tips to Start the Year Right9 Compliance Tips to Start the Year Right
9 Compliance Tips to Start the Year Right
 
PYA Looks Beyond Meaningful Use at AHIMA
 PYA Looks Beyond Meaningful Use at AHIMA PYA Looks Beyond Meaningful Use at AHIMA
PYA Looks Beyond Meaningful Use at AHIMA
 
Performance and Reimbursement under MIPS for Orthopedics
Performance and Reimbursement under MIPS for OrthopedicsPerformance and Reimbursement under MIPS for Orthopedics
Performance and Reimbursement under MIPS for Orthopedics
 
Quality assurance cycle
Quality assurance cycle Quality assurance cycle
Quality assurance cycle
 
A Step-by-Step Approach to A Clinically Integrated Network
A Step-by-Step Approach to A Clinically Integrated NetworkA Step-by-Step Approach to A Clinically Integrated Network
A Step-by-Step Approach to A Clinically Integrated Network
 
Quality Management in the Philadelphia EMA
Quality Management in the Philadelphia EMAQuality Management in the Philadelphia EMA
Quality Management in the Philadelphia EMA
 
How to Engage Physicians in Quality/Safety Improvement Using Metrics
How to Engage Physicians in Quality/Safety Improvement Using MetricsHow to Engage Physicians in Quality/Safety Improvement Using Metrics
How to Engage Physicians in Quality/Safety Improvement Using Metrics
 
surgical audit
surgical auditsurgical audit
surgical audit
 
191009OHSC.pptx
191009OHSC.pptx191009OHSC.pptx
191009OHSC.pptx
 
Quality assurance in nursing, (nursing audit).pptx
Quality assurance in nursing, (nursing audit).pptxQuality assurance in nursing, (nursing audit).pptx
Quality assurance in nursing, (nursing audit).pptx
 
medical audit in hospital
medical audit in hospital medical audit in hospital
medical audit in hospital
 
PLCO_Indicators_0606.pptx
PLCO_Indicators_0606.pptxPLCO_Indicators_0606.pptx
PLCO_Indicators_0606.pptx
 
Implementing ICD-10 In Five Simple Steps
Implementing ICD-10 In Five Simple StepsImplementing ICD-10 In Five Simple Steps
Implementing ICD-10 In Five Simple Steps
 
Quality and safety: lessons from the Francis Report
Quality and safety: lessons from the Francis ReportQuality and safety: lessons from the Francis Report
Quality and safety: lessons from the Francis Report
 
Health IT Summit Denver 2014 - "Anatomy of a Health System"
Health IT Summit Denver 2014 - "Anatomy of a Health System"Health IT Summit Denver 2014 - "Anatomy of a Health System"
Health IT Summit Denver 2014 - "Anatomy of a Health System"
 

More from Conference Panel

The 2024 Prior Authorization Process For Medical Providers
The 2024 Prior Authorization Process For Medical ProvidersThe 2024 Prior Authorization Process For Medical Providers
The 2024 Prior Authorization Process For Medical ProvidersConference Panel
 
Protecting Patient Privacy: Navigating HIPAA in Digital Landscapes
Protecting Patient Privacy: Navigating HIPAA in Digital LandscapesProtecting Patient Privacy: Navigating HIPAA in Digital Landscapes
Protecting Patient Privacy: Navigating HIPAA in Digital LandscapesConference Panel
 
HIPAA Guidelines and Electronic Communication: What Healthcare Professionals ...
HIPAA Guidelines and Electronic Communication: What Healthcare Professionals ...HIPAA Guidelines and Electronic Communication: What Healthcare Professionals ...
HIPAA Guidelines and Electronic Communication: What Healthcare Professionals ...Conference Panel
 
Nursing Standards in Hospital Accreditation: CMS Guidelines 2024
Nursing Standards in Hospital Accreditation: CMS Guidelines 2024Nursing Standards in Hospital Accreditation: CMS Guidelines 2024
Nursing Standards in Hospital Accreditation: CMS Guidelines 2024Conference Panel
 
Exploring the Revised Medicare 855 Enrollment Form for 2024
Exploring the Revised Medicare 855 Enrollment Form for 2024Exploring the Revised Medicare 855 Enrollment Form for 2024
Exploring the Revised Medicare 855 Enrollment Form for 2024Conference Panel
 
Demystifying Shared Care and "Incident To" Billing: 2024 Updates
Demystifying Shared Care and "Incident To" Billing: 2024 UpdatesDemystifying Shared Care and "Incident To" Billing: 2024 Updates
Demystifying Shared Care and "Incident To" Billing: 2024 UpdatesConference Panel
 
Understanding CPT Code Revisions in 2024
Understanding CPT Code Revisions in 2024Understanding CPT Code Revisions in 2024
Understanding CPT Code Revisions in 2024Conference Panel
 
Breaking Down the Latest HIPAA Modifications: What's New in 2024 and Beyond
Breaking Down the Latest HIPAA Modifications: What's New in 2024 and BeyondBreaking Down the Latest HIPAA Modifications: What's New in 2024 and Beyond
Breaking Down the Latest HIPAA Modifications: What's New in 2024 and BeyondConference Panel
 
Decoding the Latest Changes in the 2024 Medicare Physician Fee Schedule (MPFS...
Decoding the Latest Changes in the 2024 Medicare Physician Fee Schedule (MPFS...Decoding the Latest Changes in the 2024 Medicare Physician Fee Schedule (MPFS...
Decoding the Latest Changes in the 2024 Medicare Physician Fee Schedule (MPFS...Conference Panel
 
Provider Enrollment Excellence: A Strategic Program Guide
Provider Enrollment Excellence: A Strategic Program GuideProvider Enrollment Excellence: A Strategic Program Guide
Provider Enrollment Excellence: A Strategic Program GuideConference Panel
 
What Physicians Need to Know: CMS Final Rules 2024
What Physicians Need to Know: CMS Final Rules 2024What Physicians Need to Know: CMS Final Rules 2024
What Physicians Need to Know: CMS Final Rules 2024Conference Panel
 
A Deep Dive into 2023: Hospital CoPs and Best Practices for History and Physi...
A Deep Dive into 2023: Hospital CoPs and Best Practices for History and Physi...A Deep Dive into 2023: Hospital CoPs and Best Practices for History and Physi...
A Deep Dive into 2023: Hospital CoPs and Best Practices for History and Physi...Conference Panel
 
Demystifying the 2024 OIG Audit Selection Criteria
Demystifying the 2024 OIG Audit Selection CriteriaDemystifying the 2024 OIG Audit Selection Criteria
Demystifying the 2024 OIG Audit Selection CriteriaConference Panel
 
Medicare Preventive Care: A CMS Perspective
Medicare Preventive Care: A CMS PerspectiveMedicare Preventive Care: A CMS Perspective
Medicare Preventive Care: A CMS PerspectiveConference Panel
 
Part B Unpacking the 2023 CMS Hospital Infection Prevention Mandates
Part B Unpacking the 2023 CMS Hospital Infection Prevention MandatesPart B Unpacking the 2023 CMS Hospital Infection Prevention Mandates
Part B Unpacking the 2023 CMS Hospital Infection Prevention MandatesConference Panel
 
Part A Unpacking the 2023 CMS Hospital Infection Prevention Mandates
Part A Unpacking the 2023 CMS Hospital Infection Prevention MandatesPart A Unpacking the 2023 CMS Hospital Infection Prevention Mandates
Part A Unpacking the 2023 CMS Hospital Infection Prevention MandatesConference Panel
 
Key Elements of CMS Emergency Preparedness Regulations
Key Elements of CMS Emergency Preparedness RegulationsKey Elements of CMS Emergency Preparedness Regulations
Key Elements of CMS Emergency Preparedness RegulationsConference Panel
 
2023 Proposed HIPAA Amendments: What You Need to Know
2023 Proposed HIPAA Amendments: What You Need to Know2023 Proposed HIPAA Amendments: What You Need to Know
2023 Proposed HIPAA Amendments: What You Need to KnowConference Panel
 
Prepare for October 2023: ICD-10 Coding Changes Ahead
Prepare for October 2023: ICD-10 Coding Changes AheadPrepare for October 2023: ICD-10 Coding Changes Ahead
Prepare for October 2023: ICD-10 Coding Changes AheadConference Panel
 
Navigating the CMS Physician Proposed Rule 2024: What You Need to Know
Navigating the CMS Physician Proposed Rule 2024: What You Need to KnowNavigating the CMS Physician Proposed Rule 2024: What You Need to Know
Navigating the CMS Physician Proposed Rule 2024: What You Need to KnowConference Panel
 

More from Conference Panel (20)

The 2024 Prior Authorization Process For Medical Providers
The 2024 Prior Authorization Process For Medical ProvidersThe 2024 Prior Authorization Process For Medical Providers
The 2024 Prior Authorization Process For Medical Providers
 
Protecting Patient Privacy: Navigating HIPAA in Digital Landscapes
Protecting Patient Privacy: Navigating HIPAA in Digital LandscapesProtecting Patient Privacy: Navigating HIPAA in Digital Landscapes
Protecting Patient Privacy: Navigating HIPAA in Digital Landscapes
 
HIPAA Guidelines and Electronic Communication: What Healthcare Professionals ...
HIPAA Guidelines and Electronic Communication: What Healthcare Professionals ...HIPAA Guidelines and Electronic Communication: What Healthcare Professionals ...
HIPAA Guidelines and Electronic Communication: What Healthcare Professionals ...
 
Nursing Standards in Hospital Accreditation: CMS Guidelines 2024
Nursing Standards in Hospital Accreditation: CMS Guidelines 2024Nursing Standards in Hospital Accreditation: CMS Guidelines 2024
Nursing Standards in Hospital Accreditation: CMS Guidelines 2024
 
Exploring the Revised Medicare 855 Enrollment Form for 2024
Exploring the Revised Medicare 855 Enrollment Form for 2024Exploring the Revised Medicare 855 Enrollment Form for 2024
Exploring the Revised Medicare 855 Enrollment Form for 2024
 
Demystifying Shared Care and "Incident To" Billing: 2024 Updates
Demystifying Shared Care and "Incident To" Billing: 2024 UpdatesDemystifying Shared Care and "Incident To" Billing: 2024 Updates
Demystifying Shared Care and "Incident To" Billing: 2024 Updates
 
Understanding CPT Code Revisions in 2024
Understanding CPT Code Revisions in 2024Understanding CPT Code Revisions in 2024
Understanding CPT Code Revisions in 2024
 
Breaking Down the Latest HIPAA Modifications: What's New in 2024 and Beyond
Breaking Down the Latest HIPAA Modifications: What's New in 2024 and BeyondBreaking Down the Latest HIPAA Modifications: What's New in 2024 and Beyond
Breaking Down the Latest HIPAA Modifications: What's New in 2024 and Beyond
 
Decoding the Latest Changes in the 2024 Medicare Physician Fee Schedule (MPFS...
Decoding the Latest Changes in the 2024 Medicare Physician Fee Schedule (MPFS...Decoding the Latest Changes in the 2024 Medicare Physician Fee Schedule (MPFS...
Decoding the Latest Changes in the 2024 Medicare Physician Fee Schedule (MPFS...
 
Provider Enrollment Excellence: A Strategic Program Guide
Provider Enrollment Excellence: A Strategic Program GuideProvider Enrollment Excellence: A Strategic Program Guide
Provider Enrollment Excellence: A Strategic Program Guide
 
What Physicians Need to Know: CMS Final Rules 2024
What Physicians Need to Know: CMS Final Rules 2024What Physicians Need to Know: CMS Final Rules 2024
What Physicians Need to Know: CMS Final Rules 2024
 
A Deep Dive into 2023: Hospital CoPs and Best Practices for History and Physi...
A Deep Dive into 2023: Hospital CoPs and Best Practices for History and Physi...A Deep Dive into 2023: Hospital CoPs and Best Practices for History and Physi...
A Deep Dive into 2023: Hospital CoPs and Best Practices for History and Physi...
 
Demystifying the 2024 OIG Audit Selection Criteria
Demystifying the 2024 OIG Audit Selection CriteriaDemystifying the 2024 OIG Audit Selection Criteria
Demystifying the 2024 OIG Audit Selection Criteria
 
Medicare Preventive Care: A CMS Perspective
Medicare Preventive Care: A CMS PerspectiveMedicare Preventive Care: A CMS Perspective
Medicare Preventive Care: A CMS Perspective
 
Part B Unpacking the 2023 CMS Hospital Infection Prevention Mandates
Part B Unpacking the 2023 CMS Hospital Infection Prevention MandatesPart B Unpacking the 2023 CMS Hospital Infection Prevention Mandates
Part B Unpacking the 2023 CMS Hospital Infection Prevention Mandates
 
Part A Unpacking the 2023 CMS Hospital Infection Prevention Mandates
Part A Unpacking the 2023 CMS Hospital Infection Prevention MandatesPart A Unpacking the 2023 CMS Hospital Infection Prevention Mandates
Part A Unpacking the 2023 CMS Hospital Infection Prevention Mandates
 
Key Elements of CMS Emergency Preparedness Regulations
Key Elements of CMS Emergency Preparedness RegulationsKey Elements of CMS Emergency Preparedness Regulations
Key Elements of CMS Emergency Preparedness Regulations
 
2023 Proposed HIPAA Amendments: What You Need to Know
2023 Proposed HIPAA Amendments: What You Need to Know2023 Proposed HIPAA Amendments: What You Need to Know
2023 Proposed HIPAA Amendments: What You Need to Know
 
Prepare for October 2023: ICD-10 Coding Changes Ahead
Prepare for October 2023: ICD-10 Coding Changes AheadPrepare for October 2023: ICD-10 Coding Changes Ahead
Prepare for October 2023: ICD-10 Coding Changes Ahead
 
Navigating the CMS Physician Proposed Rule 2024: What You Need to Know
Navigating the CMS Physician Proposed Rule 2024: What You Need to KnowNavigating the CMS Physician Proposed Rule 2024: What You Need to Know
Navigating the CMS Physician Proposed Rule 2024: What You Need to Know
 

Recently uploaded

Incentive spirometry powerpoint presentation
Incentive spirometry powerpoint presentationIncentive spirometry powerpoint presentation
Incentive spirometry powerpoint presentationpratiksha ghimire
 
Information about acne, detail description of their treatment by topical and ...
Information about acne, detail description of their treatment by topical and ...Information about acne, detail description of their treatment by topical and ...
Information about acne, detail description of their treatment by topical and ...mauryashreya478
 
lupus quiz.pptx for knowing lupus thoroughly
lupus quiz.pptx for knowing lupus thoroughlylupus quiz.pptx for knowing lupus thoroughly
lupus quiz.pptx for knowing lupus thoroughlyRitasman Baisya
 
Low Vision Case (Nisreen mokhanawala).pptx
Low Vision Case (Nisreen mokhanawala).pptxLow Vision Case (Nisreen mokhanawala).pptx
Low Vision Case (Nisreen mokhanawala).pptxShubham
 
Artificial Intelligence Robotics & Computational Fluid Dynamics
Artificial Intelligence Robotics & Computational Fluid DynamicsArtificial Intelligence Robotics & Computational Fluid Dynamics
Artificial Intelligence Robotics & Computational Fluid DynamicsParag Kothawade
 
Leading big change: what does it take to deliver at large scale?
Leading big change: what does it take to deliver at large scale?Leading big change: what does it take to deliver at large scale?
Leading big change: what does it take to deliver at large scale?HelenBevan4
 
Innovations in Nephrology by Dr. David Greene Stem Cell Potential and Progres...
Innovations in Nephrology by Dr. David Greene Stem Cell Potential and Progres...Innovations in Nephrology by Dr. David Greene Stem Cell Potential and Progres...
Innovations in Nephrology by Dr. David Greene Stem Cell Potential and Progres...Dr. David Greene Arizona
 
Learn Tips for Managing Chemobrain or Mental Fogginess
Learn Tips for Managing Chemobrain or Mental FogginessLearn Tips for Managing Chemobrain or Mental Fogginess
Learn Tips for Managing Chemobrain or Mental Fogginessbkling
 
Back care and back massage. powerpoint presentation
Back care and back massage. powerpoint presentationBack care and back massage. powerpoint presentation
Back care and back massage. powerpoint presentationpratiksha ghimire
 
办理西安大略大学毕业证成绩单|购买加拿大UWO文凭证书
办理西安大略大学毕业证成绩单|购买加拿大UWO文凭证书办理西安大略大学毕业证成绩单|购买加拿大UWO文凭证书
办理西安大略大学毕业证成绩单|购买加拿大UWO文凭证书zdzoqco
 
Medisep insurance policy , new kerala government insurance policy for govrnm...
Medisep insurance policy , new  kerala government insurance policy for govrnm...Medisep insurance policy , new  kerala government insurance policy for govrnm...
Medisep insurance policy , new kerala government insurance policy for govrnm...LinshaLichu1
 
Advance Directives and Advance Care Planning: Ensuring Patient Voices Are Heard
Advance Directives and Advance Care Planning: Ensuring Patient Voices Are HeardAdvance Directives and Advance Care Planning: Ensuring Patient Voices Are Heard
Advance Directives and Advance Care Planning: Ensuring Patient Voices Are HeardVITASAuthor
 
Preventing Common Nutritional Deficiencies In Poultry Flocks (PPT).pdf
Preventing Common Nutritional Deficiencies In Poultry Flocks (PPT).pdfPreventing Common Nutritional Deficiencies In Poultry Flocks (PPT).pdf
Preventing Common Nutritional Deficiencies In Poultry Flocks (PPT).pdfAditiAlishetty
 
Single Assessment Framework - What We Know So Far
Single Assessment Framework - What We Know So FarSingle Assessment Framework - What We Know So Far
Single Assessment Framework - What We Know So FarCareLineLive
 
Professional Ear Wax Cleaning Services for Your Home
Professional Ear Wax Cleaning Services for Your HomeProfessional Ear Wax Cleaning Services for Your Home
Professional Ear Wax Cleaning Services for Your HomeEarwax Doctor
 
Local Advanced Esophageal Cancer (T3-4N0-2M0): Artificial Intelligence, Syner...
Local Advanced Esophageal Cancer (T3-4N0-2M0): Artificial Intelligence, Syner...Local Advanced Esophageal Cancer (T3-4N0-2M0): Artificial Intelligence, Syner...
Local Advanced Esophageal Cancer (T3-4N0-2M0): Artificial Intelligence, Syner...Oleg Kshivets
 

Recently uploaded (20)

Incentive spirometry powerpoint presentation
Incentive spirometry powerpoint presentationIncentive spirometry powerpoint presentation
Incentive spirometry powerpoint presentation
 
Information about acne, detail description of their treatment by topical and ...
Information about acne, detail description of their treatment by topical and ...Information about acne, detail description of their treatment by topical and ...
Information about acne, detail description of their treatment by topical and ...
 
lupus quiz.pptx for knowing lupus thoroughly
lupus quiz.pptx for knowing lupus thoroughlylupus quiz.pptx for knowing lupus thoroughly
lupus quiz.pptx for knowing lupus thoroughly
 
Low Vision Case (Nisreen mokhanawala).pptx
Low Vision Case (Nisreen mokhanawala).pptxLow Vision Case (Nisreen mokhanawala).pptx
Low Vision Case (Nisreen mokhanawala).pptx
 
Artificial Intelligence Robotics & Computational Fluid Dynamics
Artificial Intelligence Robotics & Computational Fluid DynamicsArtificial Intelligence Robotics & Computational Fluid Dynamics
Artificial Intelligence Robotics & Computational Fluid Dynamics
 
Leading big change: what does it take to deliver at large scale?
Leading big change: what does it take to deliver at large scale?Leading big change: what does it take to deliver at large scale?
Leading big change: what does it take to deliver at large scale?
 
Innovations in Nephrology by Dr. David Greene Stem Cell Potential and Progres...
Innovations in Nephrology by Dr. David Greene Stem Cell Potential and Progres...Innovations in Nephrology by Dr. David Greene Stem Cell Potential and Progres...
Innovations in Nephrology by Dr. David Greene Stem Cell Potential and Progres...
 
Learn Tips for Managing Chemobrain or Mental Fogginess
Learn Tips for Managing Chemobrain or Mental FogginessLearn Tips for Managing Chemobrain or Mental Fogginess
Learn Tips for Managing Chemobrain or Mental Fogginess
 
Back care and back massage. powerpoint presentation
Back care and back massage. powerpoint presentationBack care and back massage. powerpoint presentation
Back care and back massage. powerpoint presentation
 
办理西安大略大学毕业证成绩单|购买加拿大UWO文凭证书
办理西安大略大学毕业证成绩单|购买加拿大UWO文凭证书办理西安大略大学毕业证成绩单|购买加拿大UWO文凭证书
办理西安大略大学毕业证成绩单|购买加拿大UWO文凭证书
 
Medisep insurance policy , new kerala government insurance policy for govrnm...
Medisep insurance policy , new  kerala government insurance policy for govrnm...Medisep insurance policy , new  kerala government insurance policy for govrnm...
Medisep insurance policy , new kerala government insurance policy for govrnm...
 
Advance Directives and Advance Care Planning: Ensuring Patient Voices Are Heard
Advance Directives and Advance Care Planning: Ensuring Patient Voices Are HeardAdvance Directives and Advance Care Planning: Ensuring Patient Voices Are Heard
Advance Directives and Advance Care Planning: Ensuring Patient Voices Are Heard
 
DELIRIUM psychiatric delirium is a organic mental disorder
DELIRIUM  psychiatric  delirium is a organic mental disorderDELIRIUM  psychiatric  delirium is a organic mental disorder
DELIRIUM psychiatric delirium is a organic mental disorder
 
Kidney Transplant At Hiranandani Hospital
Kidney Transplant At Hiranandani HospitalKidney Transplant At Hiranandani Hospital
Kidney Transplant At Hiranandani Hospital
 
Preventing Common Nutritional Deficiencies In Poultry Flocks (PPT).pdf
Preventing Common Nutritional Deficiencies In Poultry Flocks (PPT).pdfPreventing Common Nutritional Deficiencies In Poultry Flocks (PPT).pdf
Preventing Common Nutritional Deficiencies In Poultry Flocks (PPT).pdf
 
Dr Sujit Chatterjee Hiranandani Hospital Kidney.pdf
Dr Sujit Chatterjee Hiranandani Hospital Kidney.pdfDr Sujit Chatterjee Hiranandani Hospital Kidney.pdf
Dr Sujit Chatterjee Hiranandani Hospital Kidney.pdf
 
Coping with Childhood Cancer - How Does it Hurt Today
Coping with Childhood Cancer - How Does it Hurt TodayCoping with Childhood Cancer - How Does it Hurt Today
Coping with Childhood Cancer - How Does it Hurt Today
 
Single Assessment Framework - What We Know So Far
Single Assessment Framework - What We Know So FarSingle Assessment Framework - What We Know So Far
Single Assessment Framework - What We Know So Far
 
Professional Ear Wax Cleaning Services for Your Home
Professional Ear Wax Cleaning Services for Your HomeProfessional Ear Wax Cleaning Services for Your Home
Professional Ear Wax Cleaning Services for Your Home
 
Local Advanced Esophageal Cancer (T3-4N0-2M0): Artificial Intelligence, Syner...
Local Advanced Esophageal Cancer (T3-4N0-2M0): Artificial Intelligence, Syner...Local Advanced Esophageal Cancer (T3-4N0-2M0): Artificial Intelligence, Syner...
Local Advanced Esophageal Cancer (T3-4N0-2M0): Artificial Intelligence, Syner...
 

Implementing CMS Hospital QAPI Guidelines for 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. 2 2
  • 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 3
  • 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 4
  • 5. CMS Changes and Updates Hospital Improvement Rule Interpretive Guidelines and Survey Procedures 5
  • 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 6
  • 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 7
  • 8. CoPs: Quality Assessment Performance Improvement Acute Hospitals Tag Nos. 263 – 310 8
  • 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” 9
  • 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 10
  • 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 11
  • 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 12
  • 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 13
  • 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 14
  • 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 15
  • 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 16
  • 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 18
  • 19. QAPI and Adverse Event Reporting 19
  • 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 20
  • 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
  • 22. 22 The End Questions??? •Laura A. Dixon, Esq. • BS, JD, RN, CPHRM • President, Healthcare Risk Education and Consulting, LLC • 303-955-8104 • ldesq@comast.net 22 22 Register Now