CMS Hospital QAPI Worksheet and Standards 2021

Date : March 23, 2021
Time: 01:00 PM ET
Duration: 120 Minutes
Speaker : Laura A. Dixon

$0.00

 

Description

Overview

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 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. CMS implement similar QAPI standards for critical access hospitals in thefinal 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 analysis. 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 event 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

  • Number of deficiencies hospitals received
  • Final worksheet
  • Recent changes
  • Use by surveyors in assessing compliance with standards
  • Indicators selected
  • Evidence quality indicator is related to outcomes
  • Scope of data collection
  • Collection methodology
  • Number of projects
  • Focus on severity, high volume, etc.
  • RCA and causal analysis tracers
  • TJC Sentinel Events and framework for doing RCA
  • Interventions etc.
  • PI requirements and leadership
  • Board responsibility for PI

CMS CoP Manual Standards on QAPI

  • 34 standards to 8 and 7 completely rewritten
  • Revised QAPI requirements November 2019
  • CAH final QAPI under the Hospital Improvement Rule
  • New tag numbers for QAPI for CAH
  • CMS memo on reporting into the QAPI system
  • Number of deficiencies in the QAPI standards
  • Ongoing PI program
  • CMS Memo on reporting to internal PI program
  • Hospital wide QAPI program
  • Prevention and reduction of medical errors
  • Program scope
  • Measureable improvements
  • Analyze and tracking of performance indicators
  • Program data
  • Tracking adverse events
  • Ensuring compliance with program data requirements
  • Identifying opportunities for improvement
  • Board responsibilities for PI
  • QIO projects and changes in QIO functions
  • PI priorities
  • Issues to improve patient safety, reduce medical errors and ADEs
  • Three RCAs or root cause analysis
  • Number of PI projects
  • Documentation requirements
  • Executive responsibilities
  • Providing adequate resources
  • Resources; TJC, CMS compare, CMS VBP, AHRQ PI toolkit, patient safety indicators, National Quality Forum etc.

Objectives

  • Recall that CMS has a worksheet on QAPI
  • Describe that there is a section on QAPI in the CMS hospital CoP manual that any hospital that accepts Medicare or Medicaid reimbursement must follow
  • Discuss that the Board is ultimately responsible for the QAPI program and must ensure there are adequate resources for PI
  • Recall that hospitals are receiving a high number of deficiencies in QAPI
  • Discuss that CMS has completely rewritten the QAPI requirements for CAHs

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.

Speaker

Laura A. Dixon

Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020.  In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners and staff in multiple states.  Such services included creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.
Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services and pain management.  Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California.  In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States.
Ms. Dixon’s legal experience includes representation of clients for Social Security Disability Insurance providing legal counsel and representation at disability hearings and appeals, medical malpractice defense and representation of nurses before the Colorado Board of Nursing.
As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa.  She is licensed to practice law in Colorado and California.