* The following alert was originally published in California Healthcare News (CHN). To read it on the CHN website, click here.

CMS has finalized surveyor worksheets for assessing a hospital’s compliance Quality Assessment and Performance Improvement (QAPI). This worksheet will be used by State and Federal surveyors on all survey activity in hospitals when assessing compliance the Conditions of Participation regarding QAPI. As of late 2014, the Final Worksheets were made publicly available. This article will briefly describe the finalized QAPI Worksheet and what this Guidance means for hospitals and providers that render lower levels of care.

QAPI Worksheet

By way of background, in 2003, CMS issued a final rule requiring all hospitals that participate in the Medicare/Medicaid programs to develop and maintain as a condition of participation a QAPI program. In essence, the regulation requires that hospitals must establish a data-driven QAPI program that involves all hospital departments and services and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. See 42 C.F.R. §482.21.

The finalized QAPI Worksheet is a detailed 15 pages, broken down into separate parts, of items that will be assessed during on-site surveys for QAPI compliance. Below is a brief description of each subsection of the QAPI Worksheet:

  • Part 1: Hospital Characteristics. This part contains general information to be filled out by the surveyor.
  • Part 2: Data Collection and Analysis – Quality Indicator Tracers. To complete this portion of the assessment, the surveyor will select 3 distinct quality indicators that are not related to patient safety, but are related to QAPI activities or projects, and answer multipart questions regarding those indicators. The questions relate to the frequency of, scope of, and methods employed by the hospital, regarding its QAPI data collection. The surveyor needs to see evidence that the hospital timely and accurately collects data. Additionally, CMS wants evidence that the hospital actually analyzed the data collected, and provide evidence to show that the hospital institutes interventions to address any areas that need improvement, and whether these interventions were successful.
  • Part 3: Applying Quality Indicator Information – Activities and Projects. CMS wants to see evidence that the hospital is conducting distinct performance improvement projects focusing on areas that are high risk (severity), high volume (incidence or prevalence), or problem-prone. The hospital has to have evidence of the scope and number of projects as it relates to the hospital’s services and operations, and evidence explaining why each project was selected.
  • Part 4: Patient Safety – Adverse Events and Medical Errors. This section focuses on whether there is evidence that the hospital provides staff training or communication regarding conveying its expectations for patient safety and reporting requirements for adverse patient events, medical errors, near misses/close calls, etc. CMS also wants to see that the hospital employs methods, in addition to staff incident reporting, to identify possible adverse patient events, medical errors, near misses/close calls, etc. CMS also wants to know whether the hospital has instituted the following QAPI programs: (1) a program in collaboration with infection control officer(s) to identify and track avoidable healthcare-acquired infections; (2) a program process for staff to report blood transfusion reactions, and reviews of reported blood transfusion reactions to identify medical errors. CMS also wants to know if the hospital conducted QAPI reviews regarding implementing preventative actions for all serious preventable adverse events or adverse patient events it has identified. There is also a subset of questions relating to identified adverse patient events.
  • Part 5: Broad QAPI Requirements and Leadership Responsibilities. In this section, CMS wants to see that the hospital has a formal QAPI program with written policies and procedures, budgeted resources, and clearly identified staff responsible for the program. CMS also wants to see evidence that the QAPI manager has been monitoring these programs. With regard to the hospital’s governing body, CMS wants to see evidence that they are involved in planning and implementation of the QAPI program, and in particular, wants to know if the CEO of the hospital is accountable for the effectiveness of the QAPI program.

For the complete QAPI Worksheet, please refer to:https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-12-Attachment-2.pdf.

What This QAPI Worksheet Means for Providers

Document everything! As you can see, other than developing a QAPI program that adheres to all of the requirements in the QAPI Worksheets, the hospitals mustdocument everything so it can provide the surveyor tangible evidence to show it complied with each item in the QAPI Worksheet.

As with any guideline that CMS issues to the public, the guidelines are not mandatory, per se. However, it would be prudent for hospitals to develop its QAPI program to follow these guidelines as these will be the criteria surveyors use when assessing whether the hospital is in compliance with CMS’ rules and regulations. Regarding the newly finalized QAPI worksheets, CMS states, “[t]he hospital industry is encouraged, but not required, to use the worksheets as part of their self-assessment tools to promote quality and patient safety.”

Note that this QAPI Worksheet currently only applies to hospitals. However, it is safe to assume that these requirements will trickle down to facilities that provide lower levels of care. Therefore, it is never too early to start developing a QAPI program that incorporates the requirements in CMS’ QAPI Worksheet.