CMS Hospital QAPI Standards 2024

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