QAPI Standards and Expectations for Hospitals – What Trustees Need to Know


Quality Assessment and Performance Improvement (QAPI) Conditions of Participation deficiencies are the third most frequently cited of the 24 Conditions for Medicare-certified hospitals. CMS believes that a hospital with a well-designed and well-maintained QAPI program, fully engaged in hospital-wide continuous assessment and improvement efforts can significantly enhance its ability to provide high quality and safe care to its patients, reduce the incidence of medical errors and adverse events throughout the hospital.

In 2020 CMS published updated standards for QAPI but the interpretive guidelines for the regulation were delayed. In March 2023, CMS issued new interpretive guidelines with information and direction for surveyors on assessing a hospital’s QAPI program.  Included in the updated guidance was specific reference to a hospital’s leadership’s oversight and execution of the hospital wide QAPI program including evaluation of how QAPI priorities are established, how data is used to monitor quality and safety.

This program will discuss the revised CMS hospital QAPI standards and the new applicable interpretive guidelines. Included will be a discussion on CMS expectations for hospital leadership and the governing body with respect to oversight and execution of the QAPI. 

CMS has found several reports that show that adverse events are not being reported. It is estimated that 86% of adverse events are never reported to the hospital’s PI program. Performance improvement is very important to CMS to improve patient safety.

Registration Pricing

Member Group (Unlimited connections from your organization): $125
Non-Member Group (Unlimited connections from your organization): $175

Register via PDF

Who should attend:

Trustees, Board Chairs, CEOs, and administrative assistants.

Continuing Education:

American College of Healthcare Executives

By attending the QAPI Standards and Expectations for Hospitals – What Trustees Need to Know Webinar offered by Texas Hospital Association participants may earn up to 1.0 ACHE Qualified Education Hours toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation.

Certified Healthcare Trustees Education
The Texas Healthcare Trustees designates this continuing certified healthcare trustee education activity for up to 1.0 contact hours. For more information about the CHT program, please contact THT at 512-465-1071.

Continuing Education Public Accountancy CPE
The Texas Hospital Association has registered with the Texas State Board of Public Accountancy as a CPE sponsor. This registration does not constitute an endorsement by the board as to the quality of the program. This course may be submitted to the Texas State Board of Public Accountancy for up to 1.2 contact hours.

Learning Objectives:

  • Discuss that the governing body and hospital leadership are responsible for the QAPI program, its implementation and completion.
  • Recall key requirements for a QAPI program and areas to be assessed during a survey and what surveyors will be reviewing.
  • Recall the impact of adverse event reporting on QAPI.
  • Discuss key elements of Board involvement with QAPI and recommendations from Office of Inspector.


Laura A. Dixon, BS, JD, RN, CPHRM, President, Healthcare Risk Education and Consulting, LLC, Denver, CO

Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided consultation and resources to clinical staff. Prior to joining Kaiser, she served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Such services included creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States. Ms. Dixon’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing.

Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management.

As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.