2019 - CMS Hospital QAPI Worksheet and Standards

CMS Final QAPI Worksheet
CMS CoP Manual Standards on QAPI
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
Collection methodology
Number of projects
Focus on severity, high volume, etc.
RCA and causal analysis tracers
TJC Sentinel Events and framework for doing RCA
Interventions etc.
PI requirements and leadership
Board responsibility for PI
34 standards to 8 and 7 completely rewritten
CAH proposed QAPI under the Hospital Improvement Rule
CMS memo on reporting into the QAPI system
Number of deficiencies in the QAPI standards
Ongoing PI program
CMS Memo on reporting to internal PI program
Hospital wide QAPI program
Prevention and reduction of medical errors
Program scope
Measurable improvements
Analyze and tracking of performance indicators
Program data
Tracking adverse events
Ensuring compliance with program data requirements
Identifying opportunities for improvement
Board responsibilities for PI
QIO projects and changes in QIO functions
PI priorities
Issues to improve patient safety, reduce medical errors and ADEs
Three RCAs or root cause analysis
Number of PI projects
Documentation requirements
Executive responsibilities
Providing adequate resources
Resources; TJC, CMS compare, CMS VBP, AHRQ PI toolkit, patient safety indicators, National Quality Forum etc.