CMS Hospital QAPI Worksheet and Standards 2021
Live Webinar | Speaker : Laura A. Dixon
From: May 27, 2021 - To: May 27, 2021
This program is a must-attend for any hospital especially critical access hospitals. This is because it is one of only three sections with a CMS worksheet. It will also discuss the revised CMS hospital QAPI standards. There is a high number of deficiencies and these will be discussed. There are over 2,158 deficiencies and many of these relate to patient safety.
This program will also cover the final changes to QAPI that were effective November 29, 2019. CMS implements similar QAPI standards for critical access hospitals in the final Hospital Improvement Rule so all CAHs should listen to this presentation. Critical access hospitals (CAHs) have an additional 18 months to implement since this rewrites all the CAHs QAPI standards. There are ten new CAH QAPI provisions starting at tag 1300.
If CMS showed up at your door tomorrow would you be able to show that you are in compliance with the QAPI standards? Have you implemented the 2020 changes? Did you know there is a section in the QAPI standards that address patient safety and risk management? It requires hospitals to have 3 root cause analyses. Hospitals were also cited for not having a number of required policies and procedures.
The QAPI (Quality Assessment and Performance Improvement) worksheet is designed to help surveyors assess compliance with the hospital CoPs for QAPI. The worksheet is used by State and Federal surveyors on all survey activity in hospitals when assessing compliance with the QAPI standards including validation and certification surveys. CMS may also just show up at your door to assess the three worksheets.
Every hospital that accepts Medicare and Medicaid must be in compliance. The CMS QAPI worksheet is an excellent communication tool so that the hospital will know what the expectations are from CMS. QAPI is an important issue to CMS and an increased area of focus.
This program will discuss the memo that CMS issued regarding the AHRQ common formats. CMS states that there are several reports that show that adverse events are not being reported. In fact, 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.
CMS Final QAPI Worksheet
CMS CoP Manual Standards on QAPI
Who Should Attend?
It should be mandatory for the performance improvement director and staff to attend. Others include the 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, infection preventionist, and anyone else who is responsible to ensure the CMS CoPs related to performance improvement are met which includes requirements on risk management and patient safety.