QAPI for CAHs: Conditions of Participation 2023


Date: June 22, 2023 | Time: 01:00 PM (ET)
Duration: 120 Minutes | Speaker: Laura A. Dixon

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CMS issued the Hospital Improvement Rule in November 2019 which included changes to Quality Assessment Performance Improvement (QAPI) standards. This program will discuss the revised CMS hospital QAPI standards for Critical Access Hospitals. CMS implemented similar QAPI standards applicable to acute hospitals for critical access hospitals.

The QAPI worksheet was designed to help surveyors assess compliance with the hospital CoPs for QAPI. Though the worksheet was never utilized in a CAH and is no longer utilized by State and Federal surveyors on survey activity, it is an excellent selfassessment and/or gap analysis tool any size hospitals can utilize to assist with compliance. The CMS QAPI worksheet is also an excellent communication tool so that the hospital will know what the expectations are from CMS.

This program will discuss the memo that CMS issued regarding the AHRQ Common Formats. CMS stated there are several reports that show that adverse events are not being reported. It is estimated that 86% of adverse events 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.


  1. Recall deficiencies with QAPI
  2. Discuss the changes to QAPI requirements for CAH
  3. Discuss that the Board is ultimately responsible for the QAPI program
  4. Recall that CMS has a worksheet on QAPI


  • CMS Manual
  • CMS memos and updates to regulations
  • Deficiencies hospitals received
  • Changes that affect CAH
  • New tag numbers for CAH QAPI
  • Hospital Care Compare
  • QAPI Conditions of Participation
  • Definitions in the regulation
  • Program design and scope
  • Examples of questions to ask
  • Program activities – improve health outcomes
  • Activity examples
  • Governance and leadership responsibilities
  • Quality indicators
    • Previous interpretive guidelines and survey procedures
      - Quality assessment
      - Healthcare policies
      - Elements of an effective program
      - Evaluation of patient care
      - Quality assessment requirements and options
      - Recommendations of QIO and follow up actions
  • Acute hospital QAPI standards and interpretive guidelines
  • QAPI worksheet
  • Other resources
              - NQF
              - AHRQ
              - TJC
              - CMS Acquire conditions
    Appendix and Resources

Who Should Attend

  • Performance improvement director and staff
  • Risk management
  • Quality staff
  • Compliance officer
  • Chief nursing officer
  • Chief medical officer
  • Patient safety officer
  • Nurse educator
  • Staff nurses
  • Nurse managers
  • Leadership staff
  • Board members
  • Accreditation staff
  • Department directors
  • Anyone responsible to ensure the CMS CoPs related to performance improvement.

Ask your question directly from our expert during the Q&A session following the live event.


Laura A. Dixon

Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided consultation and resources to clinical staff. Prior to joining Kaiser, she served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Such services included creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States. Ms. Dixon’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing.

As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.


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