CMS Hospital QAPI Standard

CMS Hospital QAPI Standards 2022 will cover the final changes to QAPI that were effective November 29, 2021. CMS implemented similar QAPI standards for acute hospitals for the critical access hospitals in the final Hospital Improvement Rule. Critical Access Hospitals (CAHs) had an additional 18 months to implement the changes. Ten new CAH QAPI provisions are starting at tag 1300.

CMS Hospital QAPI Standards 2022 will discuss the memo that CMS issued regarding the AHRQ Common Formats. CMS stated several reports 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.

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.

This will cover the key updates in CMS Hospital QAPI Standards, including the delayed interpretive guidelines, focusing on patient safety and risk management. Understand the implications of deficiencies in required policies and procedures—Discover CMS's issuance of new interpretive guidelines in March 2023, aiding surveyors in assessing QAPI programs. Learn about the QAPI worksheet's significance as a self-assessment tool, briefly covered in this program to assist hospitals with compliance.

Quality Assessment and Performance Improvement (QAPI) Conditions of Participation deficiencies are the third most frequently cited of the 24 Conditions for Medicare-certified hospitals. In 2020, CMS published updated standards for QAPI, but the interpretive guidelines for the regulation were delayed. 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 to oversee and execute the QAPI.

• Recall that CMS has a worksheet on QAPI
• 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
• Acknowledging that hospitals are facing an increase in QAPI deficiencies and common citations.
• Review key requirements of the QAPI program evaluated during surveys.
• Understand the areas and aspects assessed by surveyors during evaluations.
• CMS surveyors will scrutinize existing policies and observe their implementation.

• Discuss that the governing body and hospital leadership are responsible for the QAPI program's implementation and completion. 
• Recall key requirements for a QAPI program that will be reviewed and assessed during a survey.
• Recall areas to be assessed during a survey and what surveyors will be reviewing
• Recall that CMS surveyors will review policies in place and observe the implementation of such policies and procedures.

• Number of deficiencies hospitals received
• Recent changes in QAPI requirements
• Use of the final worksheet by surveyors for compliance assessment
• Focus on severity and high-volume areas in QAPI projects
• Board responsibilities for PI and leadership in QAPI initiatives

• Conditions of Participation Overview
• Hospital Improvement Rule and its implications
• CMS memo on QAPI reporting and adverse event reporting
• QAPI standards for hospitals with new interpretive guidelines
• Board responsibility and leadership in PI efforts

• CoP overview and its impact on QAPI implementation.
• Understanding QAPI common issues and areas needing improvement.
• General history and background of QAPI with evolution and context of quality assessment and performance improvement.
• CMS memos on reporting into the QAPI system and adverse event reporting
• Coordination of QAPI program activities, including PI requirements, leadership, and board responsibilities.