CMS Hospital QAPI Standards for 2024

Webinar Details

Speaker

Laura A Dixon

Industry

Nursing

Speciality

Nursing

Available

All Days

Duration

90 Minutes


Registration Options

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Description

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 to oversee and execute 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

  • 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.

Agenda

  • Conditions of Participation Overview.
    • QAPI deficiencies.
    • General history and background of QAPI.
  • CMS memos 
  • Reporting into the QAPI system.
  • QAPI and adverse event reporting.
  • QAPI standards for hospitals with new interpretive guidelines.
  • Scope of program.
  • Program data.
  • Tracking of quality indicators.
  • Quality improvement activities.
  • Performance improvement projects.
  • Program and hospital services, population.
  • PI requirements and leadership.
  • Protected records.
  • Board responsibility for PI.
  • Unified and integrated QAPI.

Critical Access Hospitals

  • Resources available.
  • 2019 changes – new tag numbers.
  • Program design and scope.
  • Responsibilities of governing body and leadership.
  • Program activities.
  • Data collection and analysis.

QAPI and Adverse Event Reporting 

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
  • Accreditation staff
  • Department directors
  • Infection prevention
Laura A Dixon
Laura A Dixon

(BS, JD, RN, CPHRM)

Laura Dixon | Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided consultation and resources to clinical staff. Prior to joining Kaiser, she served as the Director, of 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 the creation of presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

Prior to joining COPIC, she served as the Director, of the 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 in the western United States. Ms. Dixon’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing.

Ms. Laura Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management.

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.

Registration Options

Choose Your Options

Save $20 - [ HEALTHCPTI ]

Error Conference Exists In Wish-list.

Congrats Conference Added In Wish-list.


Need Corporate Discount ?


  • * For more than 6 attendee call us at +1-800-803-7592 or mail us at cs@conferencepanel.com
  • * For Check and ACH payment call us at +1-800-803-7592 or mail us at cs@conferencepanel.com
  • * Click to download the Order Form
Laura A Dixon
Laura A Dixon

(BS, JD, RN, CPHRM)

Laura Dixon | Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided consultation and resources to clinical staff. Prior to joining Kaiser, she served as the Director, of 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 the creation of presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

Prior to joining COPIC, she served as the Director, of the 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 in the western United States. Ms. Dixon’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing.

Ms. Laura Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management.

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.