CMS updates guidance for assessing hospital compliance with Medicare quality requirement

The Centers for Medicare & Medicaid Services yesterday released updated interpretive guidance for surveyors assessing whether a hospital’s Quality Assessment & Performance Improvement Program complies with Medicare requirements, emphasizing the integral role hospital leadership and governance play in advancing quality improvement throughout the hospital. Medicare-certified hospitals are required to have a QAPI program, and surveyors will now be looking for evidence of hospital leadership involvement and governance involvement in the prioritization and oversight of the program. 

“CMS does not prescribe a particular QAPI program that all hospitals must use,” the guidance notes. “Rather, each hospital is provided with the flexibility to develop its own program based on its unique needs, priorities, clinical programs, as well as its own considerations for the health equity needs of its patient population.”