When CMS shows up at a hospital’s door, the hospital staff needs to be able to show that it’s in compliance with a Quality Assurance and Performance Improvement (QAPI) program, which is one of the three sections within the critical CMS worksheet used by surveyors. CMS has increased its focus on QAPI in 2017 and has cited hospitals for not having a number of these required policies and procedures. Performance improvement continues to be very important to CMS, and the Medicare Conditions of Participation (CoPs) for hospitals require compliance with QAPI.
Hospitals can use both the QAPI worksheet and the hospital CoPs to build or reinforce their quality programs as part of an overall effective compliance program and be prepared when surveyors come knocking.
Adverse Events and QAPI
CMS’s oversight of hospitals is broad and includes everything from surveys and accreditation to assessing deficiencies and maintaining quality standards.
The agency’s hospital QAPI standards include the CMS final QAPI worksheet and the CMS CoP Manual Standards on QAPI. The latest QAPI standards that address patient safety and risk management require hospitals to have three root cause analyses (RCAs) for adverse events. Hospitals are required to report adverse events in compliance with QAPI standards.
CMS has indicated concern that adverse events are not being reported. In fact, it’s estimated that 86 percent of adverse events are never reported to hospitals’ performance improvement (PI) programs.
As performance improvement (PI) staff, risk management personnel, compliance officers, nurse managers, leadership personnel and board members know, there are a high number of possible deficiencies, including over 380 deficiencies that relate to patient safety alone. The good news is it’s possible to learn from deficiencies, including those that relate to patient safety, and build that knowledge into a stronger hospital compliance plan at your facility.
Review QAPI Compliance
Eight hospital CoP manual standards address QAPI, and seven of them have been completely rewritten. Hospitals should analyze and track performance indicators using a total of three CMS worksheets, implement a hospital-wide QAPI program, and understand CMS’s latest memo regarding the AHRQ’s common formats.
The following checklist, based on the final QAPI worksheet, can help hospital compliance staff prepare for a visit from CMS:
- Keep track of the number of deficiencies hospital receives
- Review indicators selected
- Provide evidence that quality indicator is related to outcomes
- Establish scope of data collection and collection methodology
- Focus on severity, high volume, etc.
- Establish RCA and causal analysis tracers
- Track The Joint Commission “sentinel events”
- Track interventions
- Review PI requirements and leadership
- Establish board responsibility for PI
- Anticipate CMS’s proposed changes to QAPI
Putting It All Together
Find out more about how CMS measures hospitals’ compliance with QAPI and how you can build a better hospital quality and compliance program in ProfEdOnDemand’s webinar “CMS Hospital QAPI Worksheet and QAPI CoP Standards” with industry veteran Sue Dill Calloway, RN, MSN, JD. Sue thoroughly reviews CMS’s QAPI Worksheet and the CoPs, and she also explains how CMS’s QAPI CoP requirements directly affect your Medicare and Medicaid reimbursements.
