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The QAPI (Quality Assessment and Performance Improvement) worksheet is designed to help surveyors assess compliance with the hospital CoPs for QAPI. The worksheet is used by State and Federal surveyors on all survey activity in hospitals when assessing compliance with the QAPI standards including validation and certification surveys. CMS may also just show up at your door to assess the three worksheets.
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 1,700 deficiencies and many of these 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.
|- Scope of data collection||- Collection methodology|
|- RCA and causal analysis tracers||- PI requirements and leadership|
|- Number of deficiencies in the QAPI standards||- Hospital wide QAPI program|
|- Analyze and tracking of performance indicators||- Identifying opportunities for improvement|
|- Documentation requirements||And that's just the beginning!|
It should be mandatory for the performance improvement director and staff to attend. Others include the risk management, quality staff, compliance officer, chief nursing officer, chief medical officer, patient safety officer, nurse educator, staff nurses, nurse managers, leadership staff, board members, accreditation staff, department directors, infection preventionist and anyone else who is responsible to ensure the CMS CoPs related to performance improvement are met which includes requirements on risk management and patient safety.
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