QAPI Standards and Expectations for Hospitals – What Trustees Need to Know Webinar

Date: 6/6/2024, 1:00 PM - 2:00 PM

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, 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. In March 2023, CMS issued new interpretive guidelines with information and direction for surveyors on assessing a hospital’s QAPI program. Included in the updated guidance was specific reference to a hospital’s leadership’s oversight and execution of the hospital wide QAPI program including evaluation of how QAPI priorities are established, how data is used to monitor quality and safety.

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 with respect to oversight and execution of the QAPI.
CMS has found several reports that 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. Performance improvement is very important to CMS to improve patient safety.

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