Accreditation

CMS adopts new requirement for hospitals to develop and maintain a QA/PI program

Accreditation Connection, February 3, 2003

Get ready to show state surveyors how you collect data to forge improvements, compare the data over time, and take actions based on the comparison.

The Centers for Medicare & Medicaid Services (CMS) last month adopted new Conditions of Participation (COP) that require hospitals to develop and maintain a data-driven quality assessment and performance improvement (QAPI) program, published in the Federal Register at http://a257.g.akamaitech.net/7/257/2422/14mar20010800/edocket.access.gpo.gov/2003/03-1293.htm

The COP take effect March 25.

"The fundamental purpose of the COP is to set a clear expectation that hospitals must take a proactive approach to improve their performance and focus on improved patient care," states the CMS final rule.

All Medicare and Medicaid participating hospitals must comply with the new COP (Tag 482.21), regardless of their accreditation status.

CMS acknowledges that JCAHO standards mirror its new COP. "Their standards require hospitals to collect data to monitor performance of processes that involve risks or may result in sentinel events," the final rule says. "Similarly, (Tag 482.21) requires hospitals to consider prevalence and severity of identified problems and to give priority to improvement activities that affect clinical outcomes."

Many of your colleagues agree that their facilities already adopted such quality improvement programs, although the heightened demand for a rigorous, data-driven process will challenge them, as will presenting findings with graphs and charts.

Since many state surveyors are more "gotcha" oriented than the JCAHO, read the 21-page final rule to ensure your quality/PI program meets the requirements, a quality professional advises.

The new QAPI program extends the current COP to hold medical staff accountable to the governing body for monitoring quality care to an organization-wide function, says Steve Bryant, practice director, accreditation and regulatory compliance for The Greeley Company, a division of HCPro, in Marblehead, MA.

"This new COP looks at overall quality of care, so it's not just a medical staff function anymore," he says.

Therefore, organizations that take PI to heart and have adopted an organizational leadership priority should not face challenges with the new COP, Bryant says. "But if your senior administrative leaders are not knowledgeable about quality methodology and prioritization, then this COP will raise the bar for those organizations."

CMS backed down from its original proposal that required hospitals to evaluate performance in 12 specific areas since, based on public comment, that measure was too prescriptive. CMS initially proposed the QAPI rule in 1997.

CMS also recognizes that hospitals will face additional costs associated with data collection and that "it is not feasible nor desirable to collect data on everything."

Therefore, CMS gives hospitals the flexibility to establish-based on priorities and needs-the areas on which to focus. However, CMS suggests that facilities use hospital-specific data (such as medical record and committee information) as part of their QAPI program. The governing body must determine priorities on which processes to monitor with data collection and the subsequent development of planned improvement efforts.

Other details include the following:

  • Focus on indicators related to improved health outcomes and the prevention and reduction of medical errors
  • Set priorities based on high-risk, high-volume, or problem-prone areas

From a Briefings on JCAHO fax express.

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