A key component to a successful transplant program is a comprehensive, well-designed, active quality assurance and performance improvement program. Quality is the most cited area of deficiency during CMS surveys. Programs frequently find that quality slip-ups cost them on both their CMS and UNOS surveys. Having Guidry & East perform a review of the quality program prior to surveys can help avoid those pitfalls.
In 2013, CMS announced and implemented a pilot Focused QAPI two-day stand-alone survey. Although a number of programs participated in the pilot, this survey never became widespread and dropped off the landscape by about 2015. However, what remained was an increased emphasis on quality.
A gap analysis of the program’s policies as outlined in the Medicare Conditions of Participation can be completed by one or more of Guidry & East’s clinical partners. A written report with gaps identified and recommendations to be completed is provided. This analysis and implementation of recommendations will position a program well for regulatory surveys.
QAPI Assessment/Gap Analysis may be performed in 2-3 days, depending upon the number of organ programs being reviewed, in one of the following engagements:
- Stand alone
- Combined with an Operational Assessment/Cost Review
- Combined with an Independent Peer Review
If your program was cited for quality infractions on your last survey, consider investing in a QAPI assessment 9-12 months ahead of your next anticipated survey.