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CMS Hospital QAPI Worksheet and Standards - Webinar

  • Webinar
  • 120 Minutes
  • April 2019
  • Compliance Online
  • ID: 4899965
Why Should You Attend:

This program 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. There is high number of deficiencies and these will be discussed. There are over 1,600 deficiencies any many that relate to patient safety. This program will also cover some proposed changes to QAPI. CMS is going to implement similar QAPI standards for critical access hospitals in the proposed Hospital Improvement Rule.

If CMS showed up at your door tomorrow would you be able to show that you are in compliance with the QAPI standards? Did you know there is a section in the QAPI standards that address patient safety and risk management? It requires hospitals to have 3 root cause analysis. Hospitals were also cited for not having a number of required policies and procedures.

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.

Areas Covered in the Webinar:
CMS Final QAPI Worksheet

CMS CoP Manual Standards on QAPI

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

34 standards to 8 and 7 completely rewritten
CAH proposed QAPI under the Hospital Improvement Rule
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
Measurable 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 is a nurse attorney, a medical legal consultant and the past chief learning officer for the Emergency Medicine Patient Safety Foundation. She is the immediate past director of Hospital Patient Safety and Risk Management for The Doctors Company. She is currently president of Patient Safety and Health Care Education and Consulting. She was a medical malpractice defense attorney for many years and a past director of risk management for the Ohio Hospital Association. She was in-house legal counsel for a hospital in addition to being the privacy officer and compliance officer. She has done many educational programs for nurses, physicians, and other health care providers. She has authored over 102 books and numerous articles. She is a frequent speaker and is well known across the country in the area of healthcare law, risk management, and patient safety. She has taught many educational programs and written many articles on compliance with the CMS and Joint Commission restraint standards.