WEBINAR: CMS Hospital QAPI Standards and Worksheet

This webinar is a must attend for any hospital. This is because it is one of only three sections with a CMS worksheet. It will also discuss the CMS hospital QAPI standards and some of the proposed changes.

Webinar Objectives:
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

Target Audience

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.

Webinar Topics:
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 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
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 
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.

Sue Dill Calloway, RN, Esq. CPRHM, AD, BA, BSN, MSN, JD, Attorney at Law
President of Patient Safety, Healthcare Consulting and Education Company

Sue Dill Calloway, R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She was the past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer. She worked for over 8 years as the Director of Risk Management and Health Policy for the Ohio Hospital Association. She was also the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus area for five years. She does frequent lectures on legal and risk management issues and writes numerous publications.

Ms. Calloway has given many presentations locally and nationally to nurses, physicians and attorneys on medical and legal issues. She has authored numerous articles and over 1000 articles and 100 books, including the 2009 Joint Commission Leadership Standard (HCPro), Nursing and the Law (PESI, 1986 and 1987), Ohio Nursing Law (West Publishing), Nursing Ethics and the Law (PESI, 1986), Legal Issues in Supervising Nurses (PESI, 1988), Medicine Made Easy (PESI, 1992) and The Law for Nurses Who Supervise/Manage Others (PESI, 1993), Legal Issues in Obstetrics (PESI, 1997) and JC Leadership Standards (HCPro, 2004), and the Compliance Guide to the CMS and the Joint Commission Patient Rights Standards (HCPro, 2005), and the 2009 book on the Joint Commission Leadership Standards (HCPro). She often writes articles called the “CMS Corner” in Briefings on the Joint Commission. Ms Calloway is a 1996 recipient of PESI's Excellence in Education Award.

Nursing CEU Credits: 
Nursing participants: This program has been approved this program for 2.4 contact hours by the Iowa Board of Nursing Approved Provider Number 339. Completion of offering required prior to awarding certificate.
All other participants: Must attend the entire Webinar and complete a Webinar critique to receive a 2 Hour Attendance Certificate.
4/24/2017 9:00 AM - 4/24/2017 11:00 AM
United States


Monday, 24 April 2017

4/24/2017 9:00 AM
9:00 AM - 11:00 AM
4/24/2017 9:00 AM
4/24/2017 9:00 AM
9:00 AM - 11:00 AM
4/24/2017 9:00 AM

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