CMS tackles quality and performance improvement

Dear Medical Staff Leader,

Last week, the Centers for Medicare & Medicaid Services (CMS) published a long-awaited revision to the Medicare Conditions of Participation for Hospitals (COP). The final rule addresses the agency's hospital quality assessment and performance improvement (QAPI) program. (CMS is making changes to the COP in many areas, but chose to finalize changes to this portion ahead of all the others.)

The new rule addresses five aspects of the QAPI program--scope, activities, data collection and use, selection and implementation of performance improvement (PI) projects, and "executive responsibilities." These new requirements, for the most part, should already be incorporated into a well-designed PI program. The rule requires hospitals to measure indicators that reasonably relate to clinical outcomes, and to use collected data to identify and implement opportunities to improve patient care. In addition, hospitals must use traditional criteria-high-risk, high-volume, and problem-prone activities--to prioritize PI opportunities. In addition, hospitals must implement PI projects and document the rationale for and impact of the projects.

Perhaps the most important of the new QAPI standards are those that relate to "executive responsibilities." These standards clearly place responsibility for patient safety and PI in the hands of the governing body, medical staff, and senior management. The standards state that these leaders are responsible for ensuring that "adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital's performance and reducing risk to patients." In this time of resource constraints, CMS has gone on record as requiring hospital leaders to allocate those scarce resources to QAPI programs to improve quality of care and patient safety.

This message is consistent with the Greeley governance model, which I shared with you several months ago. As some of you will recall, this model asserts that hospital governing boards have two primary fiduciary responsibilities--to preserve and enhance the hospital's financial assets, and to ensure the delivery of quality patient care. The new COP rule places the responsibility of balancing dollars and quality on the governing board, medical staff, and administrative leadership.

To assist with the task of balancing these two critical priorities, The Greeley Company has developed a new monograph to guide governing boards, medical staff leadership, and senior management to meet these challenging, and at times conflicting, fiduciary responsibilities. If you would like to receive a free electronic copy of this monograph, please send us your email address to: josborn@hcpro.com

That's all for this week.

All the best,

Rick Sheff, MD