And now, I would like to introduce our speaker to get us started. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of Facility Patient Safety and Risk Management and Operations for COPEC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPEC, she served as the Director of Western Region Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jewish Prudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and California. Thank you so much for being here with us this morning, Laura, and we invite you to go ahead and get us started. Okay. Thank you very much and welcome, everyone. As Lindsay mentioned, we're talking today about what's called QAPI. And there have been some changes lately to QAPI. Some of them are not in the manual, and I'll explain where we can find those. But nonetheless, we are still required to comply with each and every one of them, even though they're not yet in the manual. I included in here email addresses for CMS. And I would choose the one that said hospital, even if you're a critical access hospital. I'm getting better responses when I go through the hospital one for general questions and also for critical access. So just to kind of save yourself a step, I would just go ahead and send it to the hospital one and keep it, of course, once they reply to you. And of course, we all know I have my disclaimer, and this disclaimer just says that my program today is strictly informational. It is not meant to serve as legal advice or to establish an attorney-client relationship. So please reach out to your own counsel, your in-house counsel, or legal representative, whoever that happens to be, as it relates to advice for your particular hospital and especially for your state. Well, let's go ahead and just start real quick on why we're here. Those of you who've had the experience of going through a CMS or state survey knows you don't want to get one of these, and that's a statement of deficiencies and request for the plan of correction. No facility or any provider ever wants to get notice that they have been involuntarily terminated from their Medicare and Medicaid agreement. This occurs for a couple of reasons, but it's mainly because they didn't respond to the statement of deficiencies or it was inadequate, the problems continued, so that's one thing we never want to get. How does this all work with CMS? Well, first off, the regulation itself, the law, gets published into the Federal Register, and then CMS has a couple responsibilities from there. One is they have to put that regulation into a transmittal, and the transmittal is the information that goes to their surveyors. You have access to it, by the way, I'll show you. Oh, they are also responsible to then look at that regulation and come up with the interpretive guidelines. Now, in short, the interpretive guidelines are just that, they interpret the regulation and come up with the rationale on why this isn't so important. They also have to develop survey procedures. The survey procedures in the manual are not all-inclusive. Again, those of you who've gone through one and you look at the manual, oh, no, they look at a whole bunch more, but it gives you an idea where their focus will be. And then, of course, they have to update the manual. Three types of survey, certification, validation, and complaint, which is hopefully what nobody ever wants to get. How do they keep up with the changes? How would you, how would I suggest you do that? First, subscribe to the Federal Register, because that's where you'll get notice of the new rule. You want to make sure you have the most recent manual, first started in 86, the last one for acute hospitals came out just April of this year. For critical access, yours is still there, pending, and it was 2020 when your last manual was published. If there is a new manual, go to the transmittal page, because that will save time to see what was new, deleted, or revised. And there's a certification site. That is where CMS will put out the memos. Now, this goes to all types of facilities over which they have responsibility, so just be aware, you want to look for what applies to you. On slide number seven here, I have those email, or excuse me, web addresses. You will have to copy paste to your surf engine to get them there. So this is what the overall appendix looks like for the CMS manual, and we're talking today specifically on A, but keep an eye on W for your criticals. Now, for criticals, what they did was they took those standards that they have in A, and pretty much word for word applied it to you. Now, the problem is we don't have the interpretive guidelines in either manual. I'll show you where to get them, but just keep an eye on that for criticals, because I have a feeling once they do get around to it, you're going to have the same interpretive guidelines and survey procedures for you. So the operations manual for your acute hospitals, again, this is where you would find it, and the transmittal page is that blue lettering. So that's what you would click, doesn't matter if you're in A or W, but the transmittal page again shows you the changes, when were the updates, and that's where you want to go. It makes it much easier to follow along. Again, you will see where it says revised, new, or deleted. For the survey memos, this is what the link looks like. It's now in order that they put it out. It used to be you had to triple click the posting date. You don't have to do that anymore. You just pull it up, and it's the most recent one for you, and it's just an example. We're going to talk about this one, by the way, for today. Again, it came out last year, March of 2023, and that has the interpretive guidelines for Appendix A, but again, criticals, please look at that, because I have a feeling they're going to apply it to you also. And of course, I mentioned the deficiency reports. You can access that data, criticals, acute, has the tag numbers, has a brief description of what they found, but it will also have the name, address of where they were. It doesn't have the plan of correction, but you can still request it. It may take them a while. And so for access to the deficiency links, you will go to the provider enrollment certification, scroll to the bottom where it says full text statements. You will come up with two Excel documents that go by years now, so CMS goes now from, I believe it will take you from 2010 to 2016, and then 2017 to current. Save yourself the time, just go to the current one. That's what it comes up when you see it. If you're searching by tag number, for those of you who haven't had an opportunity to listen to these programs, again, put in the letter, that's your appendix letter, and the four-digit number, so you get the right one. And just briefly, here are some ones that I found back in December, again, 2017 to 2023. You can see a lot of it had to do just generally with QAPI. All right, updates. The hospital improvement rule. Back in 2019, CMS did a huge overhaul of all the hospital's acute and criticals, and that's where they developed it, and that included QAPI. And it all started because a hospital underwent a survey and found out that during this survey, they weren't following manufacturer's instructions on sterilizing equipment. It's kind of a big deal, and they didn't have a backup plan either. Well, in response to that, the surveyor asked, okay, what are you collecting to analyze what's going on? And they said, well, none. Now, that's a high-risk process, so needless to say, they got sighted on it. And what they found out in talking just with the folks there at that particular hospital, they're playing whack-a-mole. Okay, where's your problem? How do you address it? Do you know this is a problem? Where is that problem? And so that's how it came to be. And so the hospital improvement rule has a very long name, Regulatory Provision to Promote Program Efficiency, Transparency, and Burden Reduction. There is a section also on history and physicals that doesn't apply to criticals, but it's a very long document, 680 pages worth of it. Now, this applies to all hospitals that accept Medicare and Medicaid reimbursement. And the goal was to improve the quality of care and reduce those barriers. I have the link there if you wanted to download it. The overall benefits, they were trying to, again, burden reduction, reduce that burden to providers and patients. So they did take out some of the repetitive information. Of course, improve quality of care, reduce those hospital readmissions, and also quality data. So that's why QAPI also came around. Now, it does mention these strategies. They go along with the National Quality Strategy that came out in 2011 by AHRQ. So it took them a few years to get around to it. But overall, what they're looking for with this data is you have to look at the quality of your services and then put improvement projects into place on an ongoing basis. It must incorporate what data you are collecting. Remember, that hospital wasn't. And that you either submit yourself or you get from some of the other reporting systems, whether it's Medicare quality reporting, your quality improvement programs, and anything set, for example, on readmissions or your HACs, your hospital acquired conditions. And the rationale behind this was, hey, you're already collecting this data. And so why not use it in a program to improve quality and then continue with your performance projects? So I've just listed a few. You know, that HAC reduction program, your ventilation, preventing those ventilation pneumonias, inpatient outpatient quality. And so I put in here just a couple samples of the links for your hospital acquired conditions. They list them out here. And some you may want to look at. Falls is a big one. We still have so many falls that result in so much injury and cost to the hospital. Aaron Ballas, for pressure ulcers. There's also the readmission reduction program that you can tap into. Now if you're in a system, and I'll touch on this now briefly and then a little bit more in depth later. If you are in a system, you can have a system-wide QAPI. Now it does not mention critical access. If you happen to be a part of that system, you can play along. You can participate. It just, they chose not to include them at this time. They're not going to say, no, you can't. Because I think it's a great benefit for criticals when they have access to all that great information. They call it unified integrated for multi-hospital systems, a couple requirements. You have to be part of a system and under one governing body that is responsible for at least two or more of the hospitals in that system. You don't have to do this, but it is an option. And it has to be consistent with any state law. The board, again, they're responsible. If you're going to do this, the board is responsible that each and every hospital that does participate meets all of those requirements. And each hospital has to show that the program was set up in a way that takes into account their circumstances. What kind of patients are you seeing? What kind of services do you offer? So that can be somewhat of a challenge. But just be aware that is an option out for you. You also have to make sure policy and procedures are in place to address the individual needs. Doesn't matter where they're located or what service they offer. Now CMS is saying this is great because it could incorporate each hospital's program, increase efficiencies, innovations, and flexibility. And again, for criticals, it helps get these best practices out to you where you may not have the luxury of doing that. Now the interpretive guidelines. I want to mention this very quickly. The 2019 rule did not have them. All you had was the regulation. They didn't update them again until March of last year. Now currently they only apply to acute hospitals. They didn't include system-wide programs or critical access. Both of those remain pending. And I want to show you, here is the memo to that. It will show you, now if you have trouble getting it, just go to your surf engine and put in CMS QSO 23-09-hospital, and that should pop up. And it will have the regulation and the interpretive guidelines and survey procedures. There are 16 pages for this. So keep this because I need to let you know, this is not in the 2024 updated manual that I showed you. It's still not in there. But you are still required to comply. And keep that memo, the 2023 memo, and the new manual with you side-by-side because you are required to comply. But they wanted a consistent approach to see and make sure that it fully complies with all of the requirements. So why are we doing this? And I'm going to go through now. There are the tag numbers 263 through 310, Appendix A. And Lindsay mentioned we have questions. These questions, strictly informational. Maybe it will start a conversation within your facility. But I do touch upon this as we go through. So I'll have Lindsay go ahead and put up that first question. Okay. All right. So this question should now be on your screen. It says, our QAPI program includes, and you can select all that apply to your organization Specific projects involving our high-risk areas only. At least one project for each department. Governing board and leadership's involvement. Very few projects. We could do more. Or possibly prefer not to answer. And then for those of you who may have joined after I did our initial introduction this morning, we will have several of these polling questions on the screen, as Laura mentioned. And during the time of these polling questions, we will also reserve a few moments to address any questions that you have for Laura up to this point in the presentation. So at the bottom of your Zoom window, you should see that Q&A option. You can click on and go ahead and type in your questions there. Or if for some reason you don't see that Q&A option, you can, of course, utilize the chat to type in your questions as well. Okay. Looks like we've gotten some good responses here. Laura, I'll go ahead and end this poll and share the results. Okay. Good. Oh, I love seeing the governing board. Thank you. That's wonderful. Because I'll tell you, CMS is really focusing on that these days. Again, this is the third most frequently cited of all 24 conditions of participation. And they're finding when you have a well-designed and maintained program that's fully engaged hospital-wide, that you're going to provide high-quality and safe care and reduce not only errors and adverse events, but really cut down on those repeated visits where you have patients who have unnecessary readmissions. For the conditions, for what we're talking about, there's only 11 tag numbers. I always want to stress that, because when you look at patient rights, restraint and seclusion, there's like 50 of them. Here you've got 11 to cover. This is what it covers. Data collection, activities you're doing, errors, projects, executive responsibilities. That's why I'm so happy to see that those of you who responded, your governing body is heavily involved in it. And then, of course, the unified integrated, which doesn't apply to everybody. But the focus is that, look, you have a good program that's effective, it's ongoing, to where you can identify maybe your problematic areas, policies or practices you want to revisit. Then you can take action on those areas. And then follow up, did they work? Did they improve your quality and your performance? Now as far as the interpretive guidelines, again, these are surveyors' tools. And the idea is to focus that evaluation on compliance with the conditions of participation. So you can improve, you can sustain that process. So you promote safety, you reduce harm, and they really emphasize that integral role of leadership, advancing the program, keeping it going and making sure it happens. Here are the key points of it. One, you have a systematic approach. So you're monitoring all your programs and services. Then what you're doing is, okay, that's an area we can do better in. Or maybe we want to look at it, maybe there is a better way to do it. And then also identifying, analyzing your errors. This includes near misses and adverse events. Because from a patient safety perspective, CMS and others consider near misses to be an error. Here's an example of one. We have a patient who came in, she's new diagnosis, type 1, diabetes mellitus. So at discharge, they had medications for home, put it to her bedside with the idea, okay, we're going to train you. Well, during the routine medication check before she went home, here the physician happened to notice a discrepancy. They set up, instead of the pins and needles that were ordered, they set up a vial of insulin and extra syringes. Well, unfortunately, this person had not had the opportunity to have any training on it. And unfortunately, the provider noticed it and recognized, hey, there's no training. It's a lot different using insulin pen than drawing it up on the vial. And so the physician reaches out and says, hey, what's going on here? Well, the pharmacy said, oh, we're out of stock. So we just substituted it. It's the same thing. What's the big difference? Well, the physician, the provider, wisely said, no, not good enough. We're declining this. Send it back and get me the pins. Now they did work it out. They were able to get some pins until more came in and then made sure the patient had it after she was discharged. Well, they did refer this one over to QAPI because it was a near miss. And they really took this and really improved the process to make sure, OK, maybe we couldn't get the meds, but the physician was aware of it. And then they could take time to train the patient if that's what had happened. So again, the patient wasn't harmed and it was a near miss. So that's why they took this one to it. Here are the key points for your QAPI. You want to put together and put into place actions that really improve our outcomes and either prevent or reduce the number of errors. And this is, again, on a repeated cycle for those where you do your planning, your tracking, getting your feedback, and doing then that formal. There are five elements of QAPI. Now for those of you who may have picked up these slides a couple of days ago, I apologize. I did make an update late last night. Thank you, Lindsay, for working with me. So these are the new slides. There are five elements within QAPI. Design and scope. We're going through these. Governance and leadership, big one. Feedback, system analysis, and monitoring. Then your performance improvement projects. And then again, systematic analysis and systemic action. There's two different things. I have the link there for you. So overall for QAPI, what must you do? You have to develop, implement, and maintain an effective, ongoing, hospital-wide data-driven program. And they really stress that data-driven because they want this not to be anecdotal. They want something that this is what we're working on. We've had five falls in this unit. Why? You've got that data. Then you can put your program into place, go back and revisit, hey, we're down to one fall. That's what they're looking at. Again, the governing body has to make sure this program reflects, of course, your organization and services and involves all departments. And they also say include your contracted services. Focus on those indicators to prove our outcomes. And maintain and demonstrate evidence of the program for CMS review. During the survey, the surveyor is probably going to want to talk to those who are in charge of the QAPI. They may ask the CEO or C-suite, what are you doing here for your QAPI program? How's your involvement? So I've got your new interpretive guidelines. Again, not in the manual. It's in that memo. You must have a way, a mechanism, to systematically examine the quality of your care that you're delivering. Put specific projects in place on an ongoing basis for all services, taking into account the complexity of what you're doing when you're looking at your parameters. Because your parameters for a med-surg unit may be vastly different versus, say, what's on a behavioral health unit or in surgery. They're going to be quite different. What they're looking at is that there's continual study and improved processes within your service delivery, using that proactive approach to improve performance, not a reactive. And then the idea to prevent errors, and especially medical errors. And yes, they do distinguish between the two of them. They don't tell you what program you must use. So you have that opportunity to put together what works for you, what's good for your needs and your programs. And don't forget health equity. You have to take that into consideration. And then ways to continue to identify, maybe we can do better here. Are your changes sustainable over time? Maybe you put into place this great new medication administration process using your automated dispensing process. And then you've got several steps in there, and it worked. But then time gets crunched, and maybe they're doing a workaround, and it didn't work, and we're skipping a step, and now we're back to step one. So that's why maybe you have to go back and revisit the whole process and see what can we do to make it better. They want evidence of what you have done, your data collection and analysis with areas for improvement. And then changes. Did you monitor those changes to make sure they're working? And again, they want to see evidence of oversight by your governing body. That could be in the minutes, the meeting minutes for the governing body. All services, including contracted services. Other expectations, if you have more than one location, then yes, all locations, services, whether it's on campus or off. Now, they understand that not all departments are going to function at the same level. It could be large scale, very small, very focused. But nonetheless, something for continual monitoring, quality, and safety, and then taking action to make sure that we are providing safe, quality care. Contracted services, I mention in here because this is different than the normal tag numbers. So the governing body under 83, that's in the governing body section, they must, not should, must ensure that contractors are providing safe care or safe services to you as a hospital. Because they have to do it in such a way that you comply with the conditions and standards. And so what you have to show, how did you include these services into your QAPI? And that there's an evaluation of what services they're providing. Performance improvement activities related to those contracted services. Now, this could be anything from actual patient care delivery, like maybe you're using radiology, contracted radiology services, or contracted ER services, maybe even contracted dietary services. So those would be something affecting direct patient care. But you might want to consider adding in there, if you're doing any reconstruction, upgrades to your hospital. How are they making sure those contractors that you're complying with infection prevention and control, that your water management program is being maintained, that they're maintaining your air quality, so that those items are addressed and that they're not putting you at risk for any citations. The surveyors, they won't judge the performance, measures you've used. But what they're looking for is, did it work? The success to improve quality and performance. What they're looking at, do you have an effective on-going system to identify these areas? Whether it's events, practices, policies, and then they're stepping up. They're really taking action to remedy those and following up on those remedial actions. Did they work? Are they sustainable? They may assess when they're also coming in for other non-compliance. And I mentioned infection prevention and control, that's one. So they may look, okay, did you take this to your QAPI? Well, why not? What's going on with your QAPI? They will cite you under those sections also. So if they're looking at your program, and they may ask, you know, how about, we see that you've got here in pharmacy for controlled substance control. What are you doing to make sure that that's happening? They'll track your errors, adverse events. Once again, they want to look, has there been an analysis and action taken, and follow up with those events. This is what they should not do. And I always put in there, there's a caveat in that. They should not use your program data and analysis as other violations of the program. As other violations, unless, unless there's evidence of current non-compliance with those requirements. So I know what the last side, I said, you know, you could be cited under those. So let's take infection prevention and control. We just had a situation here in Colorado, where a VA hospital had to cancel up to 500 surgeries in one month or so, and dental procedures too included in there, because their cleaning of their instruments wasn't done appropriately. And there was substances, that's the way they described it, on the equipment. So if CMS would come in and evaluate that, and looking at it from QAP, what do you do for your infection prevention? And they see this, and nothing has been done, then yes, they will go, they will go back and look at your infection prevention and control. And they will probably cite them on that, because they found out it was there and you hadn't done anything to improve it. So that means they may look at additional records, that whether that's error reports, peer review information, and really that's what they have to have to show non-compliance with statutory and regulatory requirements. Rarely, and I almost say rarely, because it has happened, they use that information from the QAPI records to cite you in other conditions of participation. Rarely have they done it. So just a quick example. Here's again that hospital, they identified errors increasing with their ADM. Patients were given oxycodone 15, as opposed to 5, that was ordered, because 15 was more commonly ordered. So they made it closer to the front and easier to access. So they did steps to find out, okay, why are we having this? And that's when they realized that's what happened. Well, sure enough, the state shows up at the same time. Now here, the state agency should not use the QAPI records. Again, they were going through this QAPI process to cite them under medication administration. They should not be doing that. Well, that brings me to question number two. Lindsay. Okay, let's go ahead and get that one up here on the screen. Okay, this question says, on occasion, the state surveyor has asked for documentation on adverse events that include peer review documents. And our hospital responds that we cannot provide, period. We provide redacted copies or explain that we will provide alternative evidence. And it looks like we do have one question that came into the Q&A, Laura. This one says, what is the difference between quality improvement activities and performance improvement projects? They do sound very similar. They do, don't they? And that's a good question. And I believe there is a definition there. Okay, a project. What I always look at, like a project, if I'm going to redesign my kitchen, that's my project. That's what I want to do. I want to make it flow better. My activities are, how do I get there? How am I going to, you know, what plan am I going to draw up to make this thing my dream kitchen? Who am I going to work with? How am I going to contact the contractor? What are the requirements for that contractor? What is my data completion? How much money do I have to spend? So the project is your overall item you're going to do. Your activities, this is how we're going to carry it out. What we're going to do and what we expect that should be. Now, that's what the difference is. That's a good question. Okay, that's the only question I see. I'll go ahead in this poll and share that result. Great. Okay. All right. I bring this up because I had a couple in my past life. There were a couple times when we got calls that the surveyors here and they want our peer review documents. What do we do? We don't usually turn those over. They should be aware of the sensitivity of those records, peer review in particular, because most states protect them. My state protects peer review documents from disclosure, from anything. RCA documents, same thing. We do that because they're supposed to not make copies of that information unless absolutely necessary to support the citation. And of course, make notes that could identify those particular events. What they're doing is to make sure any recommendations that did come out from your peer review, your RCA, that they did have improvements, showed progress. So they may ask for a copy of your overall program documents. They will review them to make sure they're based on and reflect your complexity, that they're hospital-wide, they're data-driven, and really focus on those measures to improve our outcomes and reduce or prevent errors. So with that, they may access your staff and those protected documents. So just make sure that they can assess compliance, give them access to the staff and the program documentation. But if they want that protected document, you can give them alternative information that is not protected from evidence disclosure. So the surveyor does have sole discretion to determine if what you give them in place of that protected information helps them assess compliance. If there is no alternative evidence or you don't give enough evidence to determine you're going to be cited, and that's why please work with your in-house counsel on that when they want it. So they put out a memo late last year, talks about patient safety organizations and the work product. This is similar to like an RCA, but those of you who participate in a PSO, you do know you provide this information. It's pretty sensitive information because your patient safety work product to that organization is protected. They cannot demand disclosure. They can't. So that's why we have to give them alternative information. Again, work with your counsel on that if you're getting pushback from the surveyor. But here's that memo just in a quick nutshell. It's the Patient Safety Quality Improvement Act. And this put together a privileged and confidential status to those materials that you submit to your patient safety organization as work product, whether it's statement, records, analysis, and whatever you come up with that you put into this program. Information that is not patient safety work product that you have to collect and submit to comply with your external organizations or obligations, such as national practitioner data bank, that's not protected. And you must disclose it under the conditions of participation. So what you have to show is that you maintain and demonstrate evidence of your program, including the effectiveness. Give them access to the program information without disclosing the patient safety work product. But you must be ready to show them that you have a signed contract or an agreement with that PSO. And they will verify if that relationship does exist. If so, then you can show here's our alternative documentation to show we are complying. You're not required to turn over that documentation. And lately, I haven't heard of too many surveyors, maybe those of you who have had a recent experience. The surveyors understand, hey, we get this as protected. You're doing what you can. Well, now let's go ahead and start with some of the actual tag numbers. I put the number up in the upper right corner for you. So the program needs to be ongoing, showing improvements in our outcomes. As a hospital, you have to measure, analyze, and track your indicators. You determine those indicators, by the way. Other areas of performance that help you assess the processes of care and put that data, that patient care data into place. That's why you have to incorporate this data also that you get or that you send off to your quality reporting and performance. And that's not limited to readmissions, hacks. By the way, if you see an asterisk, I have information in the appendix for you on that. Have data to show the effectiveness and safety of what you're doing and the frequency and detail of what you're collecting. The governing body here is, they determine that. They determine how often and how much data you're going to collect. So I always want to include in here their hack reduction program to give you an idea where you want to maybe start on it. The interpretive guidelines show that the program must include continuous collection and analysis of that data and that you've taken steps to improve it. With, again, you want to improve your outcomes. As far as the quality indicator data, start with your adverse events. Sometimes that's a good place to start because you get what you need there. But you can also use your Medicare quality reporting, whether it's HCAHPS, maternal morbidity, safe opioid use, whichever one you want to use. But adverse events is always a good place to start. Once again, you know what's happened. Oh man, we got an issue here. What's going on? Use it to determine if what you're providing is effective, that you are delivering safe care. Don't forget your cultural competence when you're developing the measures for that data collection. And have those quality indicators and how data is used to monitor. What information are we using to say, yes, we're washing our hands each and every time that we go into a patient room? And where can you improve those opportunities? Analyze the data. Are you meeting your goals, meeting those quality indicators? I said hand washing is always a big one. Are they compliant with the standards? Central line infections, how have you just able to decrease or even eliminate your CLABSIs? Measurable improvement, that's your quantifiable data. That's something the numbers show you are meeting those. You've had 10 men errors in an ICU over six months. Put changes into place, one in six months. That's your quantifiable measurable data. Again, they won't tell you the thresholds for what's an acceptable improvement. That's up to you. What does your quality indicators tell you? But the hospital, you determine those thresholds. Taking into account those national standards of practice, CMS won't establish them. They leave that to your national societies. So you can develop your own indicators, your own measures to really focus on what you're looking at. Again, they always have stressed lately, health equity in your population. Governing body, they put out the frequency and detail. What are you going to collect? What are you trying to measure? What areas of the hospital are you collecting that data? How often are you going to get various types of data to be collected? Really, they have to have enough descriptive information to determine the requirements that they need to approve and that they've been an active role. They've been part of the development, the planning, the frequency and detail. And again, meeting minutes are a great way to show that, that they've approved it and that they're reviewing the data and maybe identifying, what resources do we need to put into place? From the staff, the surveyor is going to ask them about their quality indicators. They want to see that list of what they're currently tracking, including adverse events and maybe other patient care data and then quality indicators that reflect the population. They want evidence, measurable data of improvements of those indicators you have chosen. Are they ongoing? And if no improvement, have you gone back to revisit that? What are we missing? What can we do different to make this happen? From the governing body, the surveyor wants evidence of the specified frequency and detail of data. Again, meeting minutes is always a good way to do it. And that the hospital is using something to measure safety and quality of care. That's where they'll ask, okay, great, this is what you've done in your minutes. Can I see that data? And they want either a representative or let me ask the entire board, how did you use that collection to monitor the safety and quality of care that you're providing in your hospital? They'll verify you're using data to see opportunities for improvement. And then they want to see a sample of that data. And they're going to go back to leadership and say, okay, how was the data identified and what needed improvement? Because if they can't answer it, that could be a concern. If the board can't say, I don't know, I have no idea what we were collecting. And then they want documentation for those opportunities so that there is a basis for that data that you did collect. So here's just some questions you might want to ask. Is there an overall assessment of your activities with a focus again on continually improving care? Does it look at those indicators for process and outcomes? Are your indicators, what you've used, are they objective? Are they measurable? And have you used current experience and knowledge, and especially from your national societies, the experts in it, to really make this a basis? So I just put an example, whether it's stroke, venous thrombo, thrombolysm, they have a host of them available for you. There's outpatient quality measures also. So if you happen to incorporate outpatient care, say dialysis, infusion therapy, now here's some, or even ER. Other scope examples, excuse me, medication therapy, reconciliation, those dangerous abbreviations, we keep seeing them crop up. Falls, I like to include those. But don't forget others. Active shooter, that's another one you might want to consider for review, because there you can bring in some of your contracted services, such as maybe security, if that's what you're using. Other infection control systems, your patient satisfaction, pathology reports that don't match, unanticipated deaths, blood and blood product components, on, excuse me, those patient experience and satisfaction. You can use those, especially if you're starting to see a trend. Now, most of those are anonymous, granted, but that might give you a heads up on what's going on and what the patient is seeing, because that might help with your HCAHPS scores also. Near misses, environment management, restraint and seclusion, that's a good one. Are we seeing injuries? Maybe we've seen an increased use in our restraints. Invasive procedures, wrong site, wrong patient. Anesthesia, where we have complaints about sedation, maybe a broken tooth or recall. So these are just some examples that you can start to look at. And then don't forget the ER. Maybe you've got somebody who left AMA or left without being seen. Patient flow issues, I sat in ER for four hours, nobody else was there, what's going on? So that's just some areas that you can consider. And our third question, Lindsay. Okay, let's go ahead and launch that one here on the screen. So this one says, our QAPI program includes too many areas for consideration to be practicable. Yes, no, or prefer not to answer. And while you're doing that, looks like there's one question that came in here to the chat this time. And it asks for best practices for documenting QAPI plan and activities and maintaining that documentation. Oh, that's a good one. In fact, at the end, I think there'll be time, CMS has put out some information for you that you can access. And it talks about how do we do this? How do we track it? How do we document it? What's the best ways to do it? Now, understand using those forms and that information they have will not confirm or ensure you absolutely are in compliance, but it's a really good tool to get started. So at the end, Lindsay, I'm gonna go through those couple of slides that I did add and show you where it can locate. Really good information that CMS has put out to try to help us with this. Perfect. Okay, I'll go ahead and end this poll and share those results. Okay, all right. Oh, good, that's good that they're keeping it level so it's not overwhelmed. So as far as the improvement activities, you have to use that collected data to say, where do we need to improve? But also, how are you going to do it? What mechanisms are you gonna put into place? You set your priorities. That's up to you, your governing body. What's high risk, high volume? Now, we know high risk is probably what? Mother, baby, maybe behavioral health, if you have that. Emergency room, you have to determine that based upon your experience. Maybe you want high volume. And by the way, high volume can be dietary. Now, what are you going on with your food services process? Because that reaches everybody, especially if you have a cafeteria. So that reaches not only patients, but visitors and staff. Look at your incident reports. What are the severity of those incident reports? Maybe the frequency that's going on. But again, focus on those health outcomes and safety so we can improve the quality. Activities, of course, you want to make sure what you're doing is aimed at improvement. You measure how they're working, track its performance and that they're sustainable. So again, I had just another exam, very similar to the one I gave where we got a hospital, they put into this detailed process for administration of IV meds, but then they start skipping a beat and skipping a beat because that took up too much time. I didn't have somebody to verify and sure enough, the errors went back up. So this hospital scrapped it and started all over. So in the guidelines, evaluate your program data to make sure you're hitting those priority areas. And it should affect outcomes, safety, and of course, quality of care. And determine those based upon the complexity of what you provide. And they always like separating that because I take the example of you've got a burn unit, you've got a lot more complex patient than say you do for a patient who happens to be in for maybe some home care. Maybe not, but there's a lot more going on in your burn unit than you would on a med search. So they've given you some areas to consider. I've already mentioned L and D, ED, but ICU and your immunocompromised areas. High volume where patients and others could be really affected. And then they always mentioned food, medication administration. We still have those issues. Look at your problem prone areas that your own data shows you still have problems. Whether it's hacks, handoff, medication administration or reconciliation too. On incidents, what is the frequency that occurs? How widespread is it for prevalence? And the degree of injury or significance with that? The surveyor is going to want a list of your current or recent improvement activities. They will talk, as I mentioned to the governing body and staff who oversee this program. They want you to provide evidence that what you're doing are focused on those high risk or volume areas. What data do you have on the incidents, the prevalence, the severity? What evidence, the activities are really hitting those areas? And that you have tracking data for your indicators. How many reactions did you have? How many bad errors occurred, say over a month or a couple of weeks? The scope itself has to include indicators. So we reduce errors. In other words, measurable improvements. Activities, you track your errors, analyze the cause and then put actions into place. Your RCA square, for example. That's a good place where you could start to evaluate and get this information. Governing body, medical staff, C-suite. They're all accountable to make sure clear expectations are established and also communicated down the chain. Now I put in here, this interpretive guideline is very long. I've hit some of the highlights on it. The reporting mechanism, how you're doing this is up to you. And that's why if you have a really good IT system that can pull this data for you, great. That will save you some time. Now they do expect it, that you can track and analyze errors effectively and meaningfully. That's why if you have a really good IT system, that's helpful. And then put the staff, let the staff know what is considered an error and an adverse event, when and how to report. Because we know, those of you who are in risk management know there's some things that go on, you have no idea because they're not being reported. Maybe staff feel no harm, no error, no reason to report it. That's why we have to be very clear. And CMS has taken the definitions from the January, 2003 Quality Interagency Task Force with their definitions. They put them right into this manual. Put them into your policy. Error, fair of a planned action to be completed or the use of the wrong plan. So that can be problems in practice, procedure, products that you're using. Medication administration. These are type of medical errors. These are the ones that hit the patient. Wrong medication, wrong patient. Surgical site, wrong site. Equipment failure, defib battery. Maybe IV pump dosing went haywire. You've got sterile processing issues. Again, just this morning in our Denver Post, they had that issue over at the Veterans Administration Hospital. Blood transfusion issues. Put wrong patient, wrong product. Maybe we had a misdiagnosis we didn't use, indicated test or the tests were misinterpreted. And then the one we've seen a couple of times, we didn't act on those abnormal results. They also included a definition of a near miss. Now from a patient safety perspective, again, they consider this an error. That's an error that we hit before it reaches the patient. And that's why they're tracking, analyzing those. So, hey, what can we do to prevent this in the future? That it doesn't happen again? Or if it is going to happen because we couldn't avoid it, we reduce that harm that does eventually end up. So here, this is the definition of adverse event. It's preventable. And the injury was caused by that error. Adverse event is an untoward, undesirable, unanticipated event that either causes or is at the risk of causing death or serious injury. That's why you want to analyze those errors and those events. What was the cause? How can we prevent it? Those of you who've done root cause, this could take a while. It can be very detailed before you actually get down to find out why did this happen? And then what can we do to make sure it doesn't happen again? After you've done that analysis, then put your actions into place, your preventive actions. So we do improve the quality. Maybe you will need to replace the equipment. Now, trained staff, those, again, who are familiar with this, education tends to be on the lower level of the effectiveness, as opposed to putting in those stopgap measures where you can't go any further until that's done. Again, maybe replacing the equipment where, okay, yeah, it acted up now and then. That's not good enough. We need to make sure patients are safe. Educate your staff and that you've got evidence that the changes were done. Education was documented. You've got your sign-in sheet. You put in the repair invoices and this is what was done. And then Biomed came back, checked it again, and it's all good. As far as evaluating those, you have to have a way to assess did the actions work and are they sustainable? So collect that data so that you have your indicators to show, yep, this is what we did. We dropped our patient falls from six a month to none a month. And that's why I just happened to put that in there. All right, if you're going for initial certification, no, you haven't done it. You're going to do this. You have to be able to show that you at least have a collection and analysis infrastructure because you won't have any data ready usually to present, but at least you have that infrastructure so that when you do have enough data, you can start analyzing it. And you are expected to provide evidence that you are putting actions into place on, say, selected indicators, maybe from outside sources, so that if you're part of a system or maybe you're working within your community and you're working jointly with another hospital, that's a good way to do it too, that you could take those indicators and utilize them for benchmarking also. A surveyor wants evidence of that reporting system. They want a copy of your adverse event reporting policy. And they want to see, how does this work? How do you use the system? Can it organize your data so you can analyze it easily? Whether it's type, dates, maybe you want to go to a shift or a unit so that you can start analyzing that error reporting system. They want evidence that there's been education for all staff and training. So again, training records. They will talk to your staff. This is your frontline staff too, by the way. Can you identify and report an error? What constitutes an error? What's an event? Who do you report it to? How are you going to do that? What happens, you know, have you gotten feedback? Maybe system-wide that, you know, we've identified a couple of our areas of having problem with medication administration or getting meds up in time. So we looked into it and this is what we found. Are you getting any feedback on it too? So they're going to look at least three events or errors that you did track. How did you do it? How'd you analyze it? Then what'd you put into place based upon that identified cause? Did you then do periodic data collection to make sure that the improvements occurred and that they were sustainable over time? Again, it doesn't help if there's a very complex procedure that the staff starts doing workarounds. It's human nature. We want to get it done quick. So that's what we have to be aware of. These are my comments. It's not in the memo. It's not in the manual, but have a way that maybe has feedback and that you can share it throughout the hospital. Of course, we know we have to identify an error. We know they're underreported and we know you can't fix a problem that you don't know is out there. Evaluate that error. What can you put into place to prevent it? And make sure incident reports are filled out for not only errors, but near misses, and keep that non-punitive approach in mind. If they report a near miss, one hospital actually said, hey, thank you, and rewarded the person for reporting that near miss, whether it's a gift card, whatever it is, but they said, thank you. We were not aware that that was happening. Next tag number talks about your improvement projects. So that's where your improvement projects happen. The number and scope, that's up to you to determine. As far as the scope, complexity, just look at to what you're offering. You can use IT to help with that, but don't forget you have to document the project and why you're doing it. And then again, measurable improvement on that. But you have a couple options. You can use a quality improvement organization. Every state has one. You can participate in that project. You can also do one that's comparable to what they are doing. The QIOs are there to really help advance the quality of care to our Medicare patients. Again, every state has one. They're under contract with CMS. I have the link in the appendix for you to find out where it is, but they describe what it is, and then there's a list according to what your state is. And that's the link that you have to copy into your server. So again, mine is the Colorado Foundation for Medical Care. And that's the description. There's the map, there it is. That shows what area and which one particular applies to your particular state. So as far as projects and activities, so the person who asked the question, you're ahead of your time. So here's the difference. The projects, that's the one. Extensive pre-planning. A definitive start and end date. Activities, that's what you're doing. Each continuous ongoing function of the program. Tracking, analysis, changes, follow-up. That's the activities that you do. How much and how many, your decision. CMS won't tell you. The governing body makes that determination based upon your services provided. There is no fixed ratio. CMS won't come up with that. Because smaller hospitals, you're gonna have fewer than your large university-based hospitals. But again, you can participate in a QIO. If you don't, that's fine. But you still have to have your own annual projects that are comparable to one. So again, how many patients do you think would be affected by this? What's your range of services? Is it one specific set of services or can it be set across the whole organization? And what are the benefits to those patients if you're going to do this? Record keeping. How you do it, that's up to you. Electronic, old school paper, that's up to you. But you have to keep those that you completed within the previous six years. And of course, any current ones that happen to go on. What you have to have for each project. Why did you do this one? What data did you collect? Whether you went internal or maybe you went outside. And what led you to believe that this is going to help? It's going to improve your outcomes and going to improve your safety. Now, sometimes you may want to look at that low-hanging fruit. Okay, that's okay. But don't forget to take into account those more involved ones. Because if you can really show you've got a wide band of patient safety improvement, now that goes a long way to help eliminate some of those low-hanging fruits. If you have those in process, great. Just be able to explain what do the activities entail and how are you monitoring them? They want evidence of the baseline data. Where did you start? And then how did you achieve any measurable outcomes? As far as anything you've done, your completed projects, how did you, first off, show measurable improvement that improved quality of care or safety for patients? The surveyor wants a list of those distinctive projects, ones you're currently done, and those you did within the last three years. Now, that's different from the documentation. This is the list of your projects. And they are doing that to make sure, yes, you are doing annual projects. Why did you do it? And what evidence do you have to support progress? In other words, why was it done and how are you monitoring its progress also? From the governing body, how did you select those projects? What was the basis for doing that? Is it in line with your complexity and what you're providing? So again, take into account critical care. Maybe you have transplant, OB, oncology. It could be radiation and chemo. We do have some events that happen there, whether it's over radiation, we get burns, or chemo, where we've overdosed the patient with chemo. And it does reflect the complexity. That's why the governing body determines it. All departments, all services, including contractor. So you have to show evidence so that CMS can review that quality data. Okay, question number three, Lindsey. Okay, I'm gonna read this first part, and then I will put up the question here for you. This says that Mercy Hospital is a 350-bed hospital that provides all services in a competitive market. Each hospital in the community advertises its mother-baby unit as state-of-the-art with patient satisfaction survey data posted on their websites. The governing board at Mercy does not see a need to collect similar data, as census numbers speak for themselves. Mercy has had two infant deliveries with severe injuries. And I'll go ahead and post this question up here for you on the screen. Okay, here we go. So this says, do you agree with the board's decision? Yes, a decision with the board's discretion, or no, gathering more data may lead to finding a care issue or possibly no opinion here. I don't see any pending questions. So if you do have any questions, go ahead and type those into the Q&A option there. Great, okay. Just another couple seconds here. Okay, I'll go ahead and end this and share that result. Okay, great. Okay, yeah, this was a little work to do with our governing body on this one. So here's what the governing body, and they call them executive responsibilities. They encompass not only your governing body or board, however you want to call them, but they include medical staff and your C-suite. They have the responsibility and they're accountable to make sure that this program includes definition that it is implemented, it's maintained to reduce our errors. It is hospital-wide, and again, addresses those priorities. The determination of the number of projects is conducted annually. Now, as far as what they're looking for, because what they're saying, okay, leadership, you can delegate this to maybe medical staff, you're gonna have your medical executive committee, they're in charge of our QAPI, that's fine. As far as the administrative, again, that's your C-suite, but all of them are responsible to make sure these items are done and take into account all locations, because you may have a smaller hospital within your system, but they still have to be part of the development, definition, the implementation and maintenance of this program. So they must make sure, and again, that's tag 309, that they make sure all of those requirements met. They have to show evidence that they're engaged. They're engaged in not only developing, but fulfilling their response QAPI. They're actively engaged in the oversight. They need to know what is this plan? How are we gonna implement? What do we wanna make sure we're collecting? That there's progress on that project. And then, of course, to determining what's going to occur throughout the year. It may be an ongoing process that occurs throughout five years where they're collecting data. But again, also evaluating the effectiveness and improvement activities. So here's some examples. First up, they put together the plan. There's meeting minutes through the governing body, the board minutes, and there's an attendance to show, okay, who was there? Who attended? There's a signature on the project reviews for approvals and minutes from the annual budget because we have to budget this thing. We have to resource it. It just doesn't happen. So that's another thing that shows, yes, the governing body is engaged in it. They have to make sure clear expectations for safety is not only established, but communicated throughout the hospital. And information on staff of what is your responsibility within this QAPI and those under contract. What do we expect from our contractors? And that's what the governing body has to make sure. First off, they're done safely and that they are included in the program. So they have to show that how they're included, maybe periodic assessment, the resource contractor allocated to that QAPI, how they're going to participate. Are they going to give reports, attend meetings, conduct projects, and make sure if they are, you know, giving those reports, the governing body determines how often they want those reports. You want to include that in the contract as an FYI, how often they're required to give the reports and what happens if they don't supply those reports. A budget. Again, that there are resources so this program can be done and done well. Minutes from the meetings. Leadership. They make the program requirement decisions on planning, collection, performance. What do they want to review? The surveyor wants to see evidence of leadership's providing of oversight. Meeting minutes, agendas, minutes that show evidence of QAPI discussion. These don't have to be real long, lengthy ones either. They don't. Documents that yes, indeed, leadership's involved and they're signing off on it. Leadership approved the number of annual projects. They've reviewed the results. They made decisions based upon that. For contractors, are they actively involved in QAPI? Are there reviews of their reports? The contractor, have they been involved in any current or past projects? What are the contractor's expectations? You know, what's their roles, responsibilities with giving you that QAPI? And then, does the data show positive outcomes? In other words, yeah, it's working. And then, of course, the governing body has to have those resources for us to measure, assess, improve, and sustain them so we do the risk. Now, these resources can take a couple different forms. One, enough staff. One, staff has time to do this. That, okay, if you've got a floor nurse who's participating and they're really one of the drivers in getting that particular project implemented on the floor, well, somebody has to step in and take over their job duties while they're doing this. So, again, staff time. IT systems to help collect, measure, so you're not having to do it by hand. And, of course, training, education, so that all of these activities, we know what we're to do. These are the projects, why we're doing it. You know, helping to understand why really will help forward that project. Staff, of course, they should be qualified to participate in those functions as assigned. Experienced training in doing the functions is also crucial. You know, you don't want to take maybe a first-year grad and put them into a highly detailed QAPI program, but maybe a little more experienced staff member would be a better fit. Technical aspects, you can contract those out. You don't have to do everything in-house. But, again, governing body, you're responsible for that ongoing management of the program. So, here's some resources, again. Staff time, IT, so that we even prevent inpatient suicide. That's a resource. Prevention of wrong-site surgery. Maybe they're going to put together bundles. You know, those things cost money in getting them implemented, what you have to have, your tools, your supplies. And then also keeping the equipment up and working. The surveyor, they want evidence of what resources have been provided. They want to make sure that staff is qualified. So, what does that mean? They may look at their HR folders to see, okay, what training did they have to do that? And maybe also staff is trained on error reporting. By the way, you can do that during skills lab and then have your sign-in sheet. That's your evidence. If you're required to collect data and analysis, again, the staff knows what to do. They know how to collect it and how to analyze it. Contractors, they want to get evidence. They're incorporated into the program with oversight. Unified, integrated. This is one area where we don't have any updated survey procedures or interpretive guidelines. I didn't get around to this component. Again, if you're in a system with two or more hospitals under one board, you can share the QAPI. They didn't mention critical access hospitals, but I reached out to CMS and they said, if they participate, this is what they have to show. So, first off, consistent with your state law. Two, the board's responsible and accountable to make sure each hospital is separately certified and meet all of the requirements. The guidelines are still pending. For your unified program, it's established so it takes into account each hospital's circumstances, their patient populations, the services they provide, and that they have to be policy and procedures. They won't get away with that. You have to have policy and procedures that show that the needs of each hospital or site is given due consideration and you have mechanisms to make sure that even if you have a situation going in your 200-bed orthopedic hospital, it's still taken into account and considered and addressed the same it would be in your 580-bed teaching hospital. Again, interpretive guidelines are pending on those. So, criticals. Again, I hope you had an opportunity to listen because the regulation is pretty much word for word with an acute and we just don't have the interpretive guidelines. My fourth question, Lindsey. Okay, let's get that one up here for you. So, this says our critical access hospital has limited resources. As such, our QAPI program, and you can select what all to apply to your organization here, continues to address all departments, addresses most but not all departments, reflects programs in our high-risk areas only, not sure, or may prefer not to answer. I think we just have maybe the final discussion left and we will have some time at the end of the session, but if you do have any questions, make sure you're typing those in for us. Okay, looks like we've gotten good responses here. I'll go ahead and end that and share those results. Okay, good. All right, we're kind of all over the board. That's good. Okay, criticals. Again, 2019 changes. I included in here the page number for that burden reduction memo. It's 680 pages. So, you go right to page 503 and tag. They renumbered all of the tags. So, these are the new tag numbers. They are not in your current manual. If you pull up just the hospital improvement rule, which is different, it's on page 212. So, there's new tag numbers. They are now 1302 through 1325. They left open some of the numbers so they can add additional tag numbers later. The requirements are new, but it's very, very similar to Appendix A. So, overall, what they did was they took the standards under A and put them into critical access, except for the system-wide addressment. They replaced reactive with annual evaluation to proactive approach. So, just like an acute, you have to develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven program. You have to show evidence of the effectiveness of the program. They include the same definitions, whether it's adverse event, an error, or a medical error, exact same definition. So, here's some examples of an adverse. You get a Stevens-Johnson's after antibiotic use for pneumonia. Error, patient got too much radiation therapy, and then a medical error, patient given the wrong blood. Your design and scope, similarly, for the complexity and services you offer. Ongoing, comprehensive, and involve all departments and services, including contracted. Now, sometimes your criticals may have more contracted than an acute, sometimes. Use those objective measures to evaluate what you're doing and your services. Look at your outcome indicators to improve your outcomes and prevent errors. And also, they talk about transitions of care, including readmissions, so that we can reduce those. Your governance, your leadership, they have the same responsibilities. They are responsible for the program. They're accountable for the program. They must make sure that it meets the scope and design of your facility. Look at the measures on improved outcomes. So, those that are predictive for what you can do, that's where your national societies come into play. Use those measures to analyze and track your performance and set priorities. Again, high volume, high risk, or simply a problem-prone area. Data collection, you must incorporate this to include your patient care data, other data to achieve your programs. And the nice thing is, there are some additional resources for critical access hospitals. And they are encouraging, CMS does encourage you to use the technical assistance through your state flex program, Medicare beneficiary QA projects. So, they do have some additional resources for your critical access that perhaps they don't have for an acute hospital. So, now I'm going to talk about some additional information on QAPI and adverse events, those barriers. You are required to track your adverse events. And we know, not just nurses, but others, they're not reporting all adverse events. So, of course, it doesn't get into your system. Office of Inspector General and CMS, they recommend using AHRQ common formats because it is very, it uses similar language. You're not making up the language, and then we're all on the same page with it. And so, the OIG, they found back in November that, even back in 2012, that 86% are never reported. And when you look at, you go back and do a look back, almost half were actually considered preventable. So, I just included what that looks like. So, as far as your adverse reporting, this is really where you can start. That's your foundational capability to determine if you can maintain compliance with the COPs. And that's why those common formats, these are evidence-based to uniformly report the events. It helps you identify and helps the staff identify and report those events. And it includes those, quote, never events, such as falls in your medication errors. And they also talk about triggers from the IHI that can help you identify errors and opportunities for improvement. There's trigger tools for adverse drug events that you can tap into. So, as we start to close out, yes, you get a little extra time, look at what really keeps you awake at night. What are those high volume, high risk, or just those problem-prone areas? Document what you've done, take credit, and really show, you know, that could be dictation, that could be your computer system. How do you make sure these actions are working, that you're improving, that they're sustainable, and you can keep them going? Your governing body, you have to make sure that this program's implemented and effective, and that it's showing measurable improvements. How are you improving your outcomes? How are you reducing errors and events? How do you track them with really focusing on patient safety? Look at your plan and policy annually. I know that sounds like a lot of work, but you may pick up on a few things. Things change. Maybe a new process comes into being. You brought in a new piece of equipment. That's one way you can start. It is relevant. You have aggregated it, you've analyzed it, and then took steps where you can improve and train your staff so that it is done correctly, that they're documenting and looking and really keeping an eye out for what they need to document. Use a worksheet. There is a QAPI worksheet. This one started back prior to implementing the hospital improvement rule. They used it in acute hospitals, never in a critical access, and they used it also to establish the new regulations, and it will go through and show you, okay, these are the questions. Do they have this? Do they not have that? It's a really good gap analysis. Make sure all departments are reporting it, inpatient, outpatient. Maybe it's a non-clinical area. Don't forget your security. Look at those contracted services. Include those indicators in each contract so that if they're not up to measure, that's an area where you can start focusing on. That brings me to my final section. I've got an orthopedic hospital. They do various surgeries, joint replacements, scopes, etc. Non-critical or IF. That's the one where it's not compound fracture and poking through. They have an arthroscopy scheduled, and here our surgeon sees something on the tip of the scope. Well, they said that doesn't look right, so they did actually send it off for pathology, and sure enough, it's human tissue. They get a new instrument tray. They get it up there, contaminated scope, everything. They send it back. Well, they didn't report this. They got busy, and they forgot, and they figured, no harm, no foul. We won't report it. Well, three days later, sure enough, another surgeon sees something in the bottom of the tray. There's something that doesn't look right. What's in there? They had to cancel this one because they didn't have a backup tray. This was later in the afternoon when this surgery happened. This one, they did report, and as a result, they canceled future procedures. This was a huge impact because this is an orthopedic hospital. That's what they live off. So, the governing board said, you know what? This ain't right. We need to do something, so they put together and ordered a program to be put into place. They have central processing. They do all the cleaning and the reprocessing. So, of course, our infection prevention control, they worked with surgery leadership to determine what parameters are we going to look at. They collected data, and that includes observation of standing down and central processing, watch each step as it's done. Well, they did this for one week. There was no apparent cause for any retained material, and so the board said, okay, let's resume them. We got to get back up and running. Four days after they resumed, sure enough, another one came up. This time, it was dry blood on the instruments, and, of course, our state surveyors show up the next day for their routine survey, as luck would have it. So, during the QAPI review, this is when the surveyors are looking at, they found about this contaminated events and asked to see the project assessment and findings. So, do you think River North is going to have any citations based upon what they did, and those are the selections there. Lindsay, I'll let you describe how you want them to respond. Okay, let's see here. I don't know if we had this built in as a, it looks like I do. Okay, yes, perfect. So, these are your possible options here for this final discussion question. What possible citations might River North receive, and if you have any other ideas about what they might get, you can, I guess, what, put it in the chat box. Is that where you'd like them to put it, Lindsay? Okay, great. That would be perfect, and then just if you have any additional questions at all, go ahead and be typing those in as well. So, as we do final comments, we'll make sure to have time to address your questions. For Laura, let's see some of you still putting in your responses here, and as she mentioned, if you have additional comments regarding this final discussion, you can just type those into the chat. And this one did happen prior to our most recent incident at our Veterans Administration Hospital, but it did happen in Denver, this particular situation. Okay, so we've got some good responses there. Yeah, good, good, good. Yeah, insufficient data, love it. Yep, insufficient reporting system, insufficient time frame, correct, insufficient time frame, correct, insufficient assessment of what data they did get. Everybody's got it. You've nailed them all, absolutely. So, this wasn't just, unfortunately, one little thing that they had to go back and look at. One week wasn't long enough. That's not enough, and especially if you're standing over them. We all probably have heard of the Hawthorne effect, where you've got somebody looking over your shoulder. Sure, they're going to follow each and every step. The minute they're gone, you go back to what you were doing before, and you can see it starting to slide downhill, and that's what happened here. So, they did have to shut it down again, and this time for over a month before they figured out what happened, and as it turns out, it was just one step by two of the cleaners, and they simply said, oh, we forgot. We only got a little bit of training. I went back, revised all the training, and beefed it up, especially the oversight of that cleaning. So, I have in here a few of the memos. This happens to be that patient safety work product memo. There are resources. I did mention these. They are great resources. It's on the website. You don't have to use them, and just because you do them doesn't mean you're going to meet compliance. So, they have a self-assessment tool. It's only five pages in length. It is very basic. That's what it looks like. So, not started, and then on our way, etc. Another one is the process tool framework. Three pages long, but this one's nice because it has many more resources, additional links that you can tap into, and there's also a guide for even developing a plan. So, you can see it's got the five elements that go along with it, and then they also include a prioritization worksheet for you. Two pages. Where are you going to start? What are the high priorities within your organization? Is it very low or, oh man, this keeps me awake at night? So, these are really nice resources. Any hospital can use it. It's free. You can download them. Great way to start. So, just a couple additional national quality form. AHRQ, I mentioned there. They have that quality indicator toolkit for you, and the knowledge base. So, I'm not going to go through all of these. Again, there's about 20 some odd pages. If you cannot find that other worksheet, the longer one, CMS utilized, send a message to Lindsey, and I will send the link to Lindsey so she can forward it on to you. Again, they're not using it anymore. Never used in a critical access, but really good place to start, and a lot more information than the five-page assessment tool for the gap analysis. Okay. So, Lindsey, I'll send it back to you and give them a little bit more time in their day for, maybe for coffee break. Perfect. Okay. I did just post some additional information there for you all in the chat. Just a reminder that you will receive an email tomorrow morning, but just note that it does come from educationnoreplyatzoom.us, and those emails that come in from Zoom do very often seem to get caught in spam, quarantine, junk folders. So, if you don't see that in your inbox in the morning, I would encourage you to select or to check those additional boxes there, and then if you still don't see that email, you can always use the same Zoom link that you used to join us for today's live presentation to also access the recording, and you would need to click on that link, type in your information. It will prompt an email to come to us for approval. We try to approve those requests very quickly, but we ask that you give us one business day, and then also included in that email will be a link to the slides that Laura presented today, and then if you are joining us, a member of the Georgia Hospital Association, also pay special attention to the link to the survey that will be included in that email, and that is how you will obtain information regarding continuing education credits for today's session. If you are joining us as a member of a partner state hospital association, I would encourage you to reach out to your contact at your association to obtain any information regarding CEs that may be available for you as well, as GHA is only able to provide CEs to GHA members. I did go ahead and provide a link there to you for the slides in the chat, so you can have that as a resource now, and as Laura mentioned, if you received an email from us yesterday prior to today's live session, the links to the slides from yesterday and then today that's now provided in the chat are slightly different, as she did include some additional resources there for you to have as well, and you do see Laura's content information here on the screen. She is wonderful about answering any additional questions that you have, but you can always reach us at education at gha.org. We'll be happy to pass along questions to her or just help in any other way that we can, and thank you all so much for joining us today, and thank you, Laura, as always for your time and information that you share with us. We hope to have you all back with us for future sessions. I hope you have a wonderful afternoon. Thank you so much, Laura. Thank you, everyone. Thank you, Lindsay. Bye-bye.

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