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Quality Assurance (QA) and Performance Improvement (PI) is one of three CoP sections with a correlating CMS worksheet. State and federal surveyors use the worksheet on all survey activities in hospitals when assessing compliance with the QAPI standards, including validation and certification surveys.
This program will cover the CMS QAPI CoPs and proposed changes, QAPI standards on patient safety and risk management, root cause analysis, and the CMS memo on Agency for Healthcare Research and Quality (AHRQ) Common Formats. The Common Formats define a systematic process for reporting adverse events, near misses, and 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 is why QAPI is an area of focus for surveyors. Our expert will guide attendees through the QAPI worksheet and prepare them for an upcoming survey.
|- Interventions||- Board responsibility||- Root cause analysis|
|- Data collection||- Selected indicators||- Causal analysis tracers|
|- Final worksheet||- Number of projects||- Quality indicators|
|- PI requirements||- TJC Sentinel Event Alerts||And more!|
|- CMS deficiencies||- Ongoing PI programs||- Tracking performance indicators|
|- Rewritten standards||- Improve patient safety||- Quality improvement projects|
|- Board responsibilities||- Reduce medical errors||- Hospital-wide QAPI program|
|- Adequate resources||- Documentation requirements||- Tracking adverse events|
|- Ensuring compliance||- Measurable improvements||- CMS Compare|
|- AHRQ PI toolkit||- Program data requirements||And there's more!|
Anyone involved with or interested in QAPI worksheet compliance regulations and standards, including but not limited to: CEOs, CFOs, COOs, CMOs, CNOs, CE Directors, Department Directors, Quality Improvement Staff, Physicians, Nurses (all levels), Compliance Officers, CMS Liaisons, TJC Liaisons, Registration Staff, Safety Officers and Staff, Pharmacy Staff, Ethics Committee Members, Consumer Advocates, Risk Managers, Legal Counsel, Behavioral Health Staff, Psychiatry Staff, Discharge Planners, Hospice Staff, Regulatory Affairs Staff, and anyone involved in QAPI administration.