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CMS Hospital QAPI Standards 2025 (ODW5021)
Speaker
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, IowaShe is licensed to practice law in Colorado and California.  

 

This speaker has no real or perceived conflicts of interest that relate to this presentation. 

Description

The Centers for Medicare & Medicaid Services (CMS) believes that a hospital with a well-designed and well-maintained Quality Assessment and Performance Improvement (QAPI) program that is fully engaged in hospital-wide continuous assessment and improvement efforts can significantly enhance its ability to provide high quality and safe care to its patients, reduce the incidence of medical errors and adverse events throughout the hospital. 

 

In March 2023, CMS issued new interpretive guidelines with information and direction for surveyors on assessing a hospital’s QAPI program. Although those guidelines and procedures are not in the current Conditions of Participation manual, hospitals must still comply.  

 

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.  

Continuing Education

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 1.5 contact hours.   

 

By attending Medical Staff and Telemedicine: Meeting CMS CoPs and Overview Webinar offered by Georgia Hospital Association, participants may earn up to 1.5 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. 

Learning Objectives

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.   
  • Recall key requirements for a QAPI program that will be reviewed and assessed during a survey. 

  • Recite areas that surveyors assess during a survey.  

  • Explain that CMS surveyors will review policies in place and look for proof of implementation of such policies and procedures. 

Contact Us
If you need assistance with registration, please contact the education department at education@gha.org or 770-249-4529.
Summary
Availability:
On-Demand
Cost:
FREE
Credit Offered:
1.5 ACHE Qualifying Education Hours Credits
1.5 Certificate of Participation Credits
1.5 Nursing Home Administrator Credits
 
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