CMS issued the Hospital Improvement Rule in November 2019 which included changes to Quality Assessment Performance Improvement (QAPI) standards. This program will discuss the revised CMS hospital QAPI standards for Critical Access Hospitals. CMS implemented similar QAPI standards applicable to acute hospitals for critical access hospitals.

The QAPI worksheet was designed to help surveyors assess compliance with the hospital CoPs for QAPI.  Though the worksheet was never utilized in a CAH and is no longer utilized by State and Federal surveyors on survey activity, it is an excellent self-assessment and/or gap analysis tool any size hospital can utilize to assist with compliance. The CMS QAPI worksheet is also an excellent communication tool so that the hospital will know what the expectations are from CMS.

This program will discuss the memo that CMS issued regarding the AHRQ Common Formats. CMS stated there are several reports that show that adverse events are not being reported. It is estimated that 86% of adverse events are 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.

Learning Objectives:-

• Recall deficiencies with QAPI
• Discuss the changes to QAPI requirements for CAH
• Discuss that the Board is ultimately responsible for the QAPI program
• Recall that CMS has a worksheet on QAPI

Agenda:-

• CMS Manual
• CMS memos and updates to regulations
• Deficiencies hospitals received
• Changes that affect CAH
• New tag numbers for CAH QAPI
• Hospital Care Compare
• QAPI Conditions of Participation
• Definitions in the regulation
• Program design and scope
• Examples of questions to ask
• Program activities – improve health outcomes
• Activity examples
• Governance and leadership responsibilities
• Quality indicators
• Previous interpretive guidelines and survey procedures
  • Quality assessment
  • Healthcare policies
  • Elements of an effective program
  • Evaluation of patient care
  • Quality assessment requirements and options
  • Recommendations of QIO and follow-up actions
• Acute hospital QAPI standards and interpretive guidelines
• QAPI worksheet
• Other resources
  • NQF
  • AHRQ
  • TJC
  • CMS Acquire conditions

Appendix and Resources

Who Should Attend:-

• Performance improvement director and staff
• Risk management
• Quality staff
• Compliance officer
• Chief nursing officer
• Chief medical officer
• Patient safety officer
• Nurse educator
• Staff nurses
• Nurse managers
• Leadership staff
• Board members
• Accreditation staff
• Department directors
• Anyone responsible to ensure the CMS CoPs related to performance improvement.