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Pilot-Test: Focused Quality Assessment and Performance Improvement (F-QAPI) Surveys for Organ Transplant Programs – Informational Only
Memo #
13-51-Transplant Programs
Posting Date
Fiscal Year
• Pilot F-QAPI Surveys: The Centers for Medicare & Medicaid Services (CMS) developed the F-QAPI survey to enhance assessment of the Transplant Program Quality Assessment and Performance Improvement (QAPI) Condition of Participation (CoP). • Purpose: These initial F-QAPI surveys will pilot-test stand-alone surveys focused on QAPI. We will use the pilot to determine the extent to which a more in-depth review of QAPI may (a) improve surveyor ability to identify weaknesses in a QAPI program, (b) enable surveyors to offer improved feedback to hospitals, (c) provide tools that hospitals may use for internal risk assessment, and (d) offer CMS an option for a more focused survey for some transplant hospitals in lieu of more frequent, full, onsite surveys. • Educational Approach: During the pilot-test phase, F-QAPI surveys will be educational. They will assess the risks that a transplant program’s QAPI may not be in compliance with CMS requirements, but will not involve the issuance of deficiency citations. And CMS will learn more about the manner in which QAPI elements relate to program outcomes.