CMS Hospital QAPI Worksheet and New Standards 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 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 on 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? 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 for 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.

• 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

CMS Final QAPI Worksheet

• Number of deficiencies hospitals received
• Final worksheet 
• 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 the 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 29, 2019
• CAH final QAPI under the Hospital Improvement Rule
• CAH has ten new tag numbers for QAPI in 2021
• 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 
• Measurable 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.

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.