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Quality Assessment and Performance Improvement (QAPI) Conditions of Participation deficiencies are the third most frequently cited of the 24 Conditions for Medicare-certified hospitals. CMS believes that a hospital with a well-designed and well-maintained QAPI program, fully engaged in hospital-wide continuous assessment and improvement efforts, can significantly enhance its ability to provide high-quality and safe care to its patients and reduce the incidence of medical errors and adverse events throughout the hospital.
In 2020, CMS published updated standards for QAPI, but the interpretive guidelines for the regulation were delayed. Some of the changes to the regulation included a section in the QAPI standards that addressed patient safety and risk management. Hospitals were cited for not having the required policies and procedures. In March 2023, CMS issued new interpretive guidelines with information and direction for surveyors on assessing a hospital’s QAPI program.
This program will discuss the revised CMS hospital QAPI standards and the new applicable interpretive guidelines. Included will be a discussion on CMS expectations for hospital leadership and the governing body for oversight and execution of the QAPI.
CMS has found several reports showing that adverse events are not 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 to improve patient safety.
Learning Objectives:-
Agenda:-
Critical Access Hospitals
QAPI and Adverse Event Reporting
Appendix and Resources
Who Should Attend?