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On March 9, the Centers for Medicare & Medicaid Services (CMS) issued new interpretive guidelines that explain what hospitals must do to comply with the Condition of Participation for Quality Assessment and Performance Improvement (QAPI).
The interpretive guidelines are written by CMS headquarters and sent to all state agency surveyors to help them understand how to evaluate a hospital’s compliance with the Medicare/Medicaid Conditions of Participation. Although written for surveyors, the interpretive guidelines provide valuable insight for hospitals to help them meet CMS expectations. The new guidelines focus on:
- The difference between performance improvement activities and performance improvement projects
- Data collection and analysis
- Engagement and oversight by the hospital’s governing body
- Sustainable QAPI program for all locations, services, and departments
- How deficiencies will be cited
- Surveyors’ access to peer review documents and root cause analyses
To help hospitals understand state and federal licensing and certification requirements and processes, CHA has published the California Hospital Survey Manual. This publication — free for CHA members — explains the survey process, how to prepare for a survey, the laws surveyors consult to assess compliance, and how to respond to a statement of deficiencies.
