CMS Final QAPI Worksheet and Revised QAPI Hospital CoP Standards

Event Information
Product Format
Prerecorded Event
Sue Dill Calloway, RN, MSN, JD
90 minutes
Product Description

Review of the Deficiencies that Hospitals have Received in the QAPI Area from CMS


The final QAPI (Quality Assessment and Performance Improvement) worksheet by the CMS 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.

These are problematic standards with CMS with over 800 hospital receiving deficiencies. CMS is placing a high priority on improving patient safety and the quality of care. Hospitals have also received a high number of deficiencies under tag number 283 on QAPI activities, and were also cited for not having a number of required policies and procedures. Every hospital that accepts Medicare and Medicaid must be in compliance with this section.

Join expert speaker Sue Dill Calloway, RN, MSN, JD in this informative session, where she will shed light on the CMS final QAPI worksheet and the revised QAPI standards. 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 in 2015. Sue will also highlight the deficiencies that hospitals have received in the QAPI area from CMS.

This session 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. 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.

Objectives of the session:

  • Review of the CMS QAPI worksheet
  • Get insights on the section on QAPI in the CMS hospital CoPs manual that any hospital that accepts Medicare or Medicaid reimbursement must follow
  • Understand why the Board is ultimately responsible for the QAPI program and must ensure there are adequate resources for PI
  • Review of why hospitals are receiving a high number of deficiencies in QAPI

Session Highlights

CMS Final QAPI Worksheet

  • Information on number of deficiencies received by hospitals
  • The Final QAPI worksheet for 2015
  • Use by surveyors in assessing compliance with standards
  • Indicators selected
  • Evidence quality indicator related to outcomes
  • Scope of data collection and 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

  • As revised on March 21, 2014
  • 34 standards to 8 and 7 completely rewritten
  • Review of CMS memo on reporting into the QAPI system
  • Insights on ongoing PI program
  • Review of CMS Memo on reporting to internal PI program
  • Discussion on Hospital wide QAPI program
  • Learn more on 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 in  2014
  • PI priorities, number of PI projects
  • Issues to improve patient safety, reduce medical errors and ADEs
  • Documentation requirements
  • Executive responsibilities
  • Providing adequate resources
  • Resources; TJC, CMS compare, CMS VBP, AHRQ PI toolkit, patient safety indicators, National Quality Forum etc.

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, 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.

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About Our Speaker

Sue Dill Calloway - Hospital Coding Expert

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a focus on medical-legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the...   More Info
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