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CMS Updates QAPI Program Evaluation Guidance

Faridat Animashaun
March 13, 2023

The Centers for Medicare & Medicaid Services (CMS) on March 10, 2023, updated interpretive guidance for surveyors to determine if a hospital’s Quality Assessment and Performance Improvement (QAPI) program meets Medicare Conditions of Participation.

Notably, the updated guidance highlights the importance of sustaining a QAPI program over time and an increased focus on engagement by the hospital’s governing body in the QAPI program.

Surveyors use a systematic review process of evidence provided by the hospital through documentation, interviews, and observations of the hospital-wide QAPI program. During the assessment, surveyors will determine whether a hospital has an effective, ongoing system in place for identifying problematic events, policies, or practices and is taking sustainable and integrated actions to remedy these problems.

Contact Director of Policy Rob Nelb, MPH, at rnelb@essentialhospitals.org or 202.585.0127 with questions.

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