Revised CMS Hospital QAPI Worksheet and New Standards: Compliance Update

Learn the Ten new CAH Quality Assessment and Performance Improvement provisions starting at tag 1300, besides all the QAPI standards that have been rewritten in the final Hospital Improvement Rules by CMS.

It is a must attend Compliance program for any hospital especially critical access hospitals. This is because it is one of only three sections with a CMS worksheet. There are over 2,158 deficiencies and many of these relate to patient safety. This program will also cover the final changes to QAPI that were effective November 29, 2019. CMS implement similar QAPI standards for critical access hospitals in the final Hospital Improvement Rule so all CAHs should listen to this presentation. Critical access hospitals (CAHs) have an additional 18 months to implement since this rewrites all the CAHs QAPI standards. There are ten new CAH QAPI provisions starting at tag 1300.

The QAPI (Quality Assessment and Performance Improvement) worksheet is designed to help surveyors assess compliance with the hospital CoPs for QAPI.  The worksheet is used by State and Federal surveyors on all survey activity in hospitals when assessing compliance with the QAPI standards including validation and certification surveys. CMS may also just show up at your door to assess the three worksheets. If CMS showed up at your door tomorrow would you be able to show that you are in compliance with the QAPI standards? Did you know there is a section in the QAPI standards that address patient safety and risk management? It requires hospitals to have 3 root cause analysis.

Every hospital that accepts Medicare and Medicaid must be in compliance. The CMS QAPI worksheet is an excellent communication tool so that the hospital will know what the expectations are from CMS. This program expert speaker, Sue Dill Calloway, will discuss the memo that CMS issued regarding the AHRQ common formats. CMS states that there are several reports that show that adverse events are not being reported. In fact, it is estimated that 86% of adverse event are never reported to the hospital’s PI (Performance improvement) program.  Hospitals were also cited for not having a number of required policies and procedures.

Session Agenda

CMS Final QAPI Worksheet

  • Number of deficiencies hospitals received

  • Final worksheet

  • Use by surveyors in assessing compliance with standards

  • Indicators selected

  • Evidence quality indicator is related to outcomes

  • Scope of data collection, and Collection methodology

  • Number of projects - Focus on severity, high volume, etc.

  • RCA and causal analysis tracers, Interventions etc.

  • TJC Sentinel Events and framework for doing RCA

  • PI requirements and leadership, Board responsibility for PI

CMS CoP Manual Standards on QAPI

  • 34 standards to 8, and 7 completely rewritten

  • Revised QAPI requirements November 29, 2019

  • CAH FINAL QAPI under the Hospital Improvement Rule

  • CAH has ten new tag numbers for QAPI in 2021

  • CMS memo on reporting into the QAPI system

  • Ongoing Performance Improvement program, Number of PI projects

  • CMS Memo on reporting to internal PI program

  • Program scope, Program data, Measurable improvements

  • Analyze and tracking of performance indicators

  • Tracking adverse events, and reduction of medical errors

  • Identifying opportunities for improvement, and Ensuring compliance

  • Board responsibilities for PI, and PI priorities

  • QIO projects and changes in QIO functions

  • Issues to improve patient safety, reduce medical errors and ADEs

  • Three RCAs or root cause analysis; Documentation requirements

  • Executive responsibilities - Providing adequate resources

  • Resources: TJC, CMS compare, CMS VBP, AHRQ PI toolkit, patient safety indicators, National Quality Forum etc.

Session Objectives

  • Review CMS worksheet on QAPI

  • Understand the section on QAPI in the CMS hospital CoP manual that any hospital that accepts Medicare or Medicaid reimbursement must follow

  • Discuss that the board is ultimately responsible for the QAPI program and must ensure adequate resources for PI

  • Recall why hospitals are receiving a high number of deficiencies in QAPI

  • Discuss that CMS has completely rewritten the QAPI requirements for CAHs

Who Should Attend

  • Performance Improvement Director and Staff

  • Risk Management Personnel

  • Quality Personnel, Compliance officer

  • Chief Nursing Officer CNO, Chief Medical Officer CMO

  • Patient Safety Officer, Infection Preventionist

  • Nurse Educator, Staff Nurses, Nurse Managers

  • Leadership personnel, Board members, Department Directors

  • Accreditation Staff

  • Anyone else who is responsible to ensure the CMS CoPs for PI, risk management and patient safety

Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.

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Webinar Information

Date / Time : 19 Jun 2020 @ 12:00 PM EST

Duration : 120 Mins

Number Of Attendees

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Speaker Detail

Sue Dill Calloway RN, Esq. CPRHM CCMSCP AD, BSN, MSN, JD

Alt Text Sue Dill Calloway, R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She is also the past Chief Learning Officer for the Emergency Medicine Patient Safety Foundation and a board member. She was a director for risk management and patient safety for readmore...


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Webinar Information

Date / Time : 19 Jun 2020 @ 12:00 PM EST

Duration : 120 Mins

Number Of Attendees

Avail Discount At Checkout

For Group Registration
Contact 1888-437-7218 or
Email us at