Take a look at your QAPI CoP compliance

The recent report from the Office of the Inspector — "Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries" — recommends that the Centers for Medicare & Medicaid Services (CMS) focus on the Quality Assurance and Performance Improvement (QAPI) Condition of Participations in its survey and certification processes.

"This report really stresses that CMS is not only going to incentivize from a financial standpoint the reduction of adverse events, but they also are going to hold hospitals accountable through that survey and certification enforcement process for adverse events... And when hospitals start getting condition-level violations, it will be a wake-up call," Katherine A. Kuchan, RN, attorney with Hall, Render, Killian, Heath & Lyman PC, says.

It's important for hospitals to review the QAPI elements and shore up compliance, she says.

According to the OIG report, the CoP states hospitals must:

  • develop, implement, and maintain an effective, ongoing, hospitalwide, data-driven QAPI;
  • show measurable improvements in indicators for which there is evidence that it will improve health outcomes and identify and reduce medical errors;
  • measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care;
  • incorporate quality indicator data to monitor effectiveness and safety of services and quality of care; identify opportunities for improvement and changes that will lead to improvement;
  • set priorities for performance improvement activities that: focus on high-risk, high-volume, or problem-prone areas; affect health outcomes, patient safety, and quality of care; track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning;
  • annually conduct and document performance improvement projects. The hospital must provide a rationale for conducting them, and must document the measurable progress made through them. The number and scope of practices must be proportionate to the scope and complexity of the hospital services and operations;
  • governing body/medical staff/administrative officials have executive responsibilities to ensure that QAPI programs are ongoing, reduce medical errors, and improve quality of care and patient safety.

Kuchan adds that because the governing body is responsible for oversight, if CMS finds an inadequate response to events, that could lead to another condition-level finding and hospitals would then have to submit a plan "that not only addresses how they're going to improve their quality improvement, quality performance efforts but how will they then, at the same time, keep their key leaders, both in administration and on the medical staff, informed."

(For the entire interpretive guidelines on the QAPI CoP, go to https://www.cms.gov/manuals/downloads/som107ap_a_hospitals.pdf and see page 140.)