Webinar - QAPI Worksheet for CAH Pt. 5 of 5
Offered Through Partnership with Georgia Hospital Association
Critical Access Hospital CoPs Series: Part 5 QAPI Worksheet for CAH
The fee for each session is $200/member and $250/nonmember. If you register for all five sessions of either the Critical Access Hospital CoPs series or the Acute Care Hospital CoPs series, you will get the fifth session of the respective series free! Contact Cynthia Grinston at [email protected] for assistance in registering for the full series to ensure you receive the discounted offer.
Please note our new pricing! To support social distancing and remote work, a single registration provides unlimited lines for all employees and trustees of your hospital or system, including a link to view the recording. Please register just one person from your facility and have that person share the access information with others who wish to participate.
Not sure if you’ll be able to make the live session? Everyone who registers will receive a link to the recording of the webinar to view at your convenience at no additional charge.
Overview
This program is a must attend for critical access hospitals as Critical Access Hospitals have until March 2021 to comply with the QAPI standards. Additionally, QAPI is one of only three CMS survey sections with a worksheet. The program will discuss the revised CMS hospital QAPI standard and the final changes to QAPI that were effective November 29, 2019. CMS implemented a similar QAPI standards for critical access hospitals in the final Hospital Improvement Rule and Interpretive Guidelines are still pending. Nonetheless, Critical access hospitals (CAHs) had an additional 18 months to implement the new standards – or until March 2021.
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.
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 to 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 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.
Detailed Agenda
CMS Final QAPI Worksheet
• Number of deficiencies hospitals received
• Final worksheet
• 2020 changes
• Indicators selected
• Scope of data collection
• Collection methodology
• Number of projects
• Focus – 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
• Revised QAPI requirements November 29, 2019
• CAH final QAPI under the Hospital Improvement Rule
• CAH 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
• No hospital wide QAPI program for CAH
• 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
• 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.
Objectives
1. Recall that CMS has a worksheet on QAPI
2. 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
3. Discuss the rewritten the QAPI requirements CMS implemented for CAHs
4. Discuss the Governing Board’s ultimately responsible for the QAPI program and must ensure there are adequate resources for PI
5. Recall that hospitals are receiving a high number of deficiencies in QAPI
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.