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Catalog Number : ngd1903
Title : CMS PI Standards and Worksheet
Speaker : Sue Dill

Duration : 90 minutes

Webplay Recording Date : 5-11-2015
Webplay Price : $ 125 for two weeks viewing

Webinar Description:

This webinar will discuss the March 15, 2013 memo that CMS issued regarding the AHRQ common formats. CMS states that there are several reports that show that adverse events are not being reported. In fact, it is estimated that 86% of adverse event 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.

Target Audience:

It should be mandatory for the Performance Improvement Director and staff to attend. Others include the 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, and anyone else who is responsible to ensure the CMS CoPs related to performance improvement are met.

Webinar Objectives:

  • Recall that CMS has a worksheet on QAPI
  • Describe that there is a section on QAPI in the CMS hospital CoP manual that any hospital that accepts Medicare or Medicaid reimbursement must follow
  • Discuss that the Board is ultimately responsible for the PI program and must ensure there are adequate resources for PI

A few of the topics to be discussed:

  • CMS QAPI Worksheet
    • Indicators selected
    • Evidence quality indicator is related to outcomes
    • Scope of data collection
    • Collection methodology
    • Number of projects
    • Focus on severity, high volume, etc.
    • RCA and causal analysis tracers
    • TJC Sentinel Events and framework for doing RCA
    • Interventions etc.
    • PI requirements and leadership
    • Board responsibility for PI
  • CMS CoP Manual Standards on QAPI
    • Ongoing PI program
    • CMS Memo on reporting to internal PI program
    • Hospital wide PI program
    • Prevention and reduction of medical errors
    • Program scope
    • Measureable improvements
    • Analyze and tracking of performance indicators
    • Tracking adverse events
    • Ensuring compliance with program data requirements
    • Identifying opportunities for improvement
    • Board responsibilities for PI
    • QIO projects
    • PI priorities
    • Issues to improve patient safety

Contact Hours:

  • Nursing participants: Instruct-online has approved this program for 1.8 contact hours, Iowa Board of Nursing Approved Provider Number 339.
  • All other participants: Must attend the entire Webinar and complete a Webinar critique to receive a 1.5 Hour Attendance Certificate for each program.

Completion of offering required prior to awarding certificate.

Refund Policy:

Full tuition is refunded immediately on request if the participant has not been sent the program materials and instructions. Once the instructions (including access codes) have been sent, a full refund will be issued only after the program runs and it is verified that the participant did not access the program.