Quality Assessment and Performance Improvement (QAPI) Conditions of Participation deficiencies are the third most frequently cited of the 24 Conditions for Medicare-certified hospitals. The Centers for Medicare & Medicaid Services (CMS) believes that a hospital with a well-designed and well-maintained QAPI program can significantly enhance its ability to provide high quality and safe care to its patients while reducing the incidence of medical errors and adverse events throughout the hospital.
In 2020, CMS published updated QAPI standards, but the interpretive guidelines for the regulation were delayed. Some of the changes included a section in the QAPI standards that address patient safety and risk management. In March 2023, CMS issued new interpretive guidelines with information and directions for surveyors on assessing a hospital’s QAPI program.
This program will discuss the revised CMS hospital QAPI standards and the new applicable interpretive guidelines. Included will be a discussion on CMS expectations for hospital leadership and the governing body with respect to oversight and execution of the QAPI.
Laura A. Dixon, BS, JD, RN, CPHRM
Laura A. Dixon 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, facility patient safety and risk management and operations for COPIC from 2014 to 2020. In her role, she provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states.
Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the director, 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, Dixon holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.
At the conclusion of this session, participants should be able to:
Discuss that the governing body and hospital leadership are responsible for the QAPI program, its implementation and completion.
Recite key requirements for a QAPI program that will be reviewed and assessed during a survey.
Describe areas to be assessed during a survey and what surveyors will be reviewing.
Recall that CMS surveyors will review policies in place and observe for implementation of such policies and procedures.
The Georgia Hospital Association Research & Education Foundation is an approved provider of nursing home administrator credits as a professional trade association in long term care under Ga. Comp. R. & Regs. 393-13-.02, (1) (a). Approved for 2 contact hours.
By attending CMS Hospital QAPI Standards 2024 offered by Georgia Hospital Association, participants may earn up to 2 ACHE Qualifying Education Hours toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation. Attendees who wish to have the hours applied toward ACHE Qualifying Education credit must self-report their participation by logging into their MyACHE account and selecting ACHE Qualifying Education Credit.