Strategies for Meeting CMS QAPI Standards 2024

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QAPI StandardsHOSPITAL CONDITIONS
OF PARTICIPATION (COPS) 2024

• Presented By
• Laura A. Dixon
• BS, JD, RN, CPHRM

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Speaker

• Laura A. Dixon, Esq.
• BS, JD, RN, CPHRM
• President, Healthcare Risk Education and
  Consulting, LLC
• 303-955-8104
• ldesq_at_comcast.net
• Email questions to CMS
  Critical Access Hospitals
  qsog_CAH_at_cms.hhs.gov. Acute
  hospitals QSOG_Hospital_at_cms.hhs.gov.

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How it Works

• Regulation published in the Federal Register
• CMS publishes the regulation in a transmittal
• Will develop Interpretive guidelines and survey
  procedures
• Updates the hospital CoP manual
• Types of surveys
• Certification
• Complaint
• Validation survey
• If out of compliance CMS may issue a statement of
  deficiency and will have to do a plan of
  correction

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How to Keep Up with Changes

• Subscribe to the Federal Register 1.
• Confirm current CoP 2.
• If new manual check CMS transmittal page 3.
• Check the survey and certification website
  monthly 4.
• 1 https//public.govdelivery.com/accounts/USGPOOF
  R/subscriber/new
• 2, http//www.cms.hhs.gov/manuals/downloads/som107
  _Appendicestoc.pdf
• 3 http//www.cms.gov/Transmittals
• 4 http//www.cms.gov/SurveyCertificationGenInfo/P
  MSR/list.aspTopOfPage

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CMS Changes and Updates

• Hospital Improvement Rule
• Interpretive Guidelines and Survey Procedures

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How QAPI Started

• Hospital underwent a validation survey
• Cited for not following manufacturers
  instructions for use in sterilizing equipment
• Asked what data they were collecting and
  analyzing on this
• When said none - cited for not monitoring a
  high-risk process
• This is sort of like playing whack a mole
• Hospital Accreditation Setting Priorities for
  Your QAPI Program.
• CIHQ at http//www.cihq-blog.org/blog.asp

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Hospital Improvement Rule

• Formal name Regulatory Provision to Promote
  Program Efficiency, Transparency and Burden
  Reduction
• Includes a section on HPs but not applicable to
  CAHs
• Applies to all hospitals that accept Medicare or
  Medicaid reimbursement
• Intended to improve the quality of care to
  patients and reduce barriers to care
• QSO-20-07-ALL 680 pages
• https//www.cms.gov/files/document/burden-reductio
  n-discharge-planning-som-package.pdf

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CoPs Quality Assessment Performance Improvement

• Acute Hospitals
• Tag Nos. 263 310

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Why QAPI?

• Third most frequently cited of the 24 Conditions
  of Participation
• CMS A well-designed and maintained QAPI program
  fully engaged in hospital-wide continuous
  assessment and improvement efforts can
• Significantly enhance ability to provide high
  quality and safe care
• Reduce incidence of medical errors and adverse
  events throughout the hospital

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QAPI CoPs

• 11 Tag numbers
• Covers
• Data Collection and Analysis
• Quality Improvement Activities
• Patient Safety, Medical Errors and Adverse Events
• Performance Improvement Projects
• Executive Responsibilities
• Unified and integrated systems

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Focus of QAPI

• Determine if a hospital has
• An effective, ongoing system in place
• For identifying problematic events, policies or
  practices
• Taking action to remedy the problem areas
• With follow up to determine
• Were actions effective in improving performance
  and quality

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QAPI and Other Areas Evaluated

• Surveyor may assess QAPI when other
  non-compliance identified
• EX Infection prevention and control
• Pharmacy CoPs
• Will cite under those sections
• May investigate tracking of errors and adverse
  events
• Will investigate analyses and actions taken
• Follow up evaluations in process

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Overall What Must Demonstrate

• QAPI must maintain and demonstrate evidence of
  QAPI program
• Including effectiveness
• Must provide surveyors access to QAPI program
  information without disclosing PSWP
• Be prepared to provide evidence of relationship
  with a PSO
• Surveyors will verify if relationship exists

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Quality Improvement Activities 283

• Hospital must use collected data to identify
  opportunities for improvement
• Plus mechanisms for change to improve
  safety/quality
• Hospital must set priorities that
• Focus on high risk, high volume, or problem prone
  areas
• Consider incidence, prevalence, and severity of
  problems in those areas
• Issues that affect health outcomes, patient
  safety and quality of care

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Patient Safety, Medical Errors, AE 286

• PI program must include indicators to identify
  and reduce medical errors measurable
  improvements
• Track medical errors and adverse events
• Analyze causes and implement preventive actions
• EX Root Cause Analysis
• Board responsible for the operations of the
  hospital
• Medical staff and administrative staff
  accountable to ensure clear expectations for
  safety

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QAPI and QIOs

• QIO Quality Improvement Organization
• Can participate in a QIO project or do one that
  is of comparable effort
• QIO advance quality of care for Medicare
  patients
• Every state has a QIO under contract by CMS
• Also 2 BFCC QIOs Livanta and KePro

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Critical Access Hospitals
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QAPI 2019 Changes

• New Tag numbers
• 1302, 1306, 1309, 1311, 1315, 1319, 1321 and 1325
• Previous tag numbers were C-330 343
• Requirements new but similar to Appendix A
• Interpretive guidelines and survey procedures
  pending

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QAPI and Adverse Event Reporting
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In Summary

• Focus on high volume, high risk, and problem
  prone areas
• Clearly document the actions you take to improve
  performance
• Document how you will ensure actions to improve
  are sustained and sustainable
• Governing Body must ensure you are implementing
  an effective QAPI program
• Consider providing the board a report
  demonstrating such
• Show measurable improvements indicators show
• Improving health outcomes and making a difference
• Reducing and identifying medical errors and
  adverse events
• Tracking adverse patient events
• Focus on patient safety and ensure adequate
  resources

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In Summary continued

• Review your QAPI plan and policy annually
• Collected data should be
• Relevant
• Aggregated
• Analyzed
• Acted upon to identify opportunities for
  improvement
• Train your staff that collect data so is done
  correctly
• Use the QAPI worksheet
• Use for a gap analysis with the QAPI standards
• Ensure every department/service reporting data
• Includes inpatient and outpatient departments
• Both clinical and non-clinical areas security
• Review contracted services and ensure board
  reviews same
• Include the performance indicators for each
  contract

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The End Questions???

• Laura A. Dixon, Esq.
• BS, JD, RN, CPHRM
• President, Healthcare Risk Education and
  Consulting, LLC
• 303-955-8104
• ldesq_at_comast.net

Register Now
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