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Division of Quality Assurance: Notifications & Updates |
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Attn: Federally Certified Hospitals
CMS issues QSO-23-09-Hospital - Revision to State Operations Manual (SOM), Hospital Appendix A - Interpretive Guidelines for 42 CFR 482.21, Quality Assessment & Performance Improvement (QAPI) Program
Memorandum Summary
CMS issued QSO-23-09-Hospital (PDF) providing updated interpretive guidance for State Operations Manual (SOM) Hospital Appendix A for the QAPI CoP. The QAPI CoP requires a hospital to “maintain and demonstrate evidence of its QAPI program for review by CMS, as well as the governing body oversight of the program in an effort to deliver safe, quality patient care and prevent adverse events and patient harm.” (42 CFR 482.21).
QAPI CoP deficiencies are the third most frequently cited of the 24 CoPs for Medicare-certified hospitals. A hospital with a well-designed and well-maintained QAPI program, fully engaged in hospital-wide continuous assessment and improvement efforts, can significantly enhance its ability to provide high quality and safe care to its patients, and thereby, reduce the incidence of medical errors and adverse events throughout the hospital.
In its ongoing effort to promote and advance a proactive culture of safety in our nation’s hospitals, CMS has developed this updated interpretive guidance to provide surveyors with a consistent approach for assessing whether a hospital’s QAPI program fully complies with the CoP requirements to improve performance, patient safety, and overall quality of care.
Questions
For questions or concerns relating to this memorandum, please contact QSOG_Hospital@cms.hhs.gov.
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