Marketing and Empathy Psychology
CMS Hospital QAPI Standards 2024

By - Laura A. Dixon, BS, JD, RN, CPHRM

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Quality Assessment and Performance Improvement (QAPI) Conditions of Participation deficiencies are the third most frequently cited of the 24 Conditions for Medicare-certified hospitals. CMS believes that a hospital with a well-designed and well-maintained QAPI program, 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 2020 CMS published updated standards for QAPI but the interpretive guidelines for the regulation were delayed. Some of the changes to the regulation included a section in the QAPI standards that address patient safety and risk management. Hospitals were cited for not having required policies and procedures.

In March 2023, CMS issued new interpretive guidelines with information and direction 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.

CMS has found several reports that show that adverse events are not being reported. It is estimated that 86% of adverse events are never reported to the hospital’s PI program. Performance improvement is very important to CMS to improve patient safety.


  • 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.
  • Recall 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


  • Conditions of Participation overview
  • QAPI deficiencies
  • General history and background of QAPI
  • CMS memos
    • Reporting into the QAPI system
    • QAPI and adverse event reporting
  • QAPI standards for hospitals with new interpretive guidelines
  • Scope of program
  • Program data
  • Tracking of quality indicators
  • Quality improvement activities
  • Performance improvement projects
  • Program and hospital services, population
  • PI requirements and leadership
  • Protected records
  • Board responsibility for PI
  • Unified and integrated QAPI
  • Critical Access Hospitals
  • Resources available
  • 2019 changes – new tag numbers
  • Program design and scope
  • Responsibilities of governing body and leadership
  • Program activities
  • Data collection and analysis
  • QAPI and Adverse Event Reporting
  • Appendix and Resources

Who Should Attend

  • Performance improvement director and staff
  • Risk management
  • Quality staff
  • Compliance officer
  • Chief nursing officer
  • Chief medical officer
  • Patient safety officer
  • Nurse educator
  • Staff nurses
  • Nurse managers
  • Leadership staff
  • Accreditation staff
  • Department directors
  • Infection preventionist

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Speaker Detail

Laura A. Dixon, BS, JD, RN, CPHRM

Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided consultation and resources to clinical staff. 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, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Such services included creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products. Ms. Dixon has more than twenty 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, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States. Ms. Dixon’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing. As a registered nurse and attorney, Laura 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.

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