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Quality Assurance (QA) and Performance Improvement (PI) is one of only 3 CoP sections with a correlating CMS Worksheet. State and federal surveyors use the worksheet on all survey activity in hospitals when assessing compliance with the QAPI standards, including validation and certification surveys. There have been more than 1,100 recent deficiencies in this section alone.
In addition to the five elements of QAPI and what the worksheet covers, our expert will discuss the CMS memo regarding the Agency for Healthcare Research and Quality (AHRQ) systematic process for reporting adverse events, near misses, unsafe conditions, and allow a hospital to report harm from all causes. CMS estimated that 86% of adverse events are never reported to the hospital’s PI program, which makes it very hard to correct errors before the surveyor shows up.
|- Final worksheet||- Number of projects||- Quality indicators|
|- Data collection||- Selected indicators||- Causal analysis tracers|
|- Interventions||- Board responsibility||- Root cause analysis|
|- PI requirements||- TJC Sentinel Event Alerts||And more!|
|- Ensuring compliance||- Measurable improvements||- CMS Compare|
|- Board responsibilites||- Reduce medical errors||- Hospital-wide QAPI program|
|- Rewritten standards||- Improve patient safety||- Quality improvement projects|
|- Adequate resources||- Documentation requirements||- Tracking adverse events|
|- CMS deficiencies||- Ongoing PI programs||- Tracking performance indicators|
|- AHRQ PI toolkit||- Program data requirements||And there's more!|