Update CMS Quality Standards for Hospital Boards

In its updated guidance for Quality Assessment and Performance Improvement, CMS highlights the governing board's responsibility in oversight of the QAPI program.


The Centers for Medicare & Medicaid (CMS) recently issued updated guidelines for the Quality Assessment and Performance Improvement (QAPI) Program, which is a part of the Medicare Conditions of Participation. These guidelines emphasize the critical role of governing boards in overseeing the QAPI program’s effectiveness. Boards are tasked with ensuring the establishment and periodic review of the QAPI program, determining data collection frequency and detail, developing implementation plans, and annually evaluating projects under the program.

CMS outlined the board’s specific QAPI responsibilities as:

  • Ensuring a program is in place along with its periodic review;
  • Determine the frequency and detail of data collection;
  • Development of a plan to implement and maintain the QAPI program;
  • Annual determination of projects under the program and the review process for these projects;
  • Evaluation of the effectiveness of improvement activities;
  • Ensuring expectations for quality and patient safety are clearly communicated across the organization (including off-site clinics and outpatient services), including informing staff of roles and responsibilities in QAPI; and
  • Allocate resources to support the needs of QAPI program activities.

Evidence of these governance activities should show:

  • What data will be collected, what is the purpose, what areas the data cover, and the collection frequency.
  • That the board has an active role in the developing and planning of QAPI data collection.
  • How governing boards must show that they are engaged in oversight of the program for all services provided by the hospital, including those provided under contract. The board must also ensure contractors are compliant to CMS’ COPs and how it is determined to use contractors for services under the QAPI program.
  • Improvement activities are focused on high-risk, high-volume and problem-prone areas and what actions were initiated based on data tracking/reporting.
  • The completion of performance improvement projects as well as ongoing projects and their demonstrated success. Board members may be asked how projects are selected and their alignment with the organization’s complexity and scope of services.
  • That the organization’s QAPI program is enterprise-wide, meaning efforts are also conducted at all affiliated and off-site locations, and expectations are clearly stated, including those providing contract services.
  • Clear communication about safety expectations and an understanding of roles and responsibilities from all staff, including contractors.
  • How contractors are included in the QAPI program. This may be done through assessment of contracted services, contractor resources that are allocated to QAPI activities, the contractor directly participating in QAPI activities via quality reporting, attending planning meetings, and/or participating in performance improvement projects.
  • Resource allocation for QAPI program activities.

Specific types of evidence may include:

  • Meeting minutes with attendance rosters, including board and committee meetings and/or budget meetings that discuss QAPI resource planning.
  • Meeting minutes that show QAPI as a standing agenda item.
  • Sample of data collected and board interviews to confirm utilization.
  • Medical error/adverse event reporting system and related policies.
  • A QAPI plan.
  • Signatures on annual QAPI project reviews and approvals.
  • Contracts stating safety expectations and requirements.
  • Documentation showing safety expectations and requirements, including documentation of training, posters, staff newsletters, etc.
  • Samples of quality data/reports from contractors, as applicable.

Board members should consult and collaborate with their organization’s leadership to strengthen their understanding of these new requirements and to ensure proper compliance with the QAPI Program’s governance responsibilities. These responsibilities encompass a wide range of activities aimed at enhancing the quality and safety of healthcare services provided by the organization, both within its facilities and through contractors, emphasizing the importance of effective oversight and transparency in quality improvement efforts.