CMS Hospital QAPI Worksheet and New Standards


April 21, 2020


Sue Dill Calloway

  1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes

* Not able to attend the live session? We can arrange an on-demand session for You. Please call 1-951-801-2324


This program is a must attend for any hospital especially CAHs. This is because it is one of only three sections with a CMS worksheet. It will also discuss the CMS hospital QAPI standards. There are over 2,158 deficiencies and many of these relate to patient safety and these will be discussed in this webinar.

This program will also cover the final changes to QAPI that were effective November 29, 2019. CMS implement similar QAPI standards for CAHs in the final Hospital Improvement Rule so all CAHs should listen to this presentation.. There are ten new CAH QAPI provisions starting at tag 1300 and so CAHs have an additional 18 months to implement since this rewrites all the CAHs QAPI standards.

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. Hospitals were also cited for not having a number of required policies and procedures.

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.

The CMS QAPI worksheet is an excellent communication tool so that the hospital will know what the expectations are from CMS. QAPI is an important issue to CMS and an increased area of focus.

This program will discuss the memo that CMS issued regarding the AHRQ common formats. As per CMS, it is estimated that 86% of adverse event are never reported to the hospital’s PI program. Performance improvement is very important to CMS and the hospital conditions of participation require many things to be measured.

Learning Objectives:

  • Recall that CMS has a worksheet on QAPI
  • Describe that there is a 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 there are adequate resources for PI
  • Recall that 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 and Quality Staff
  • Compliance Officer
  • Chief Nursing Officer, Nurse Educator, Staff nurses, Nurse Managers, 
  • Chief Medical Officer
  • Patient Safety Officer
  • Leadership Staff and Board Members
  • Accreditation staff
  • Infection preventionist