MASTER CLASS SERIES
Guidance from Top Industry Experts
Learn from the best.
Industry specialists from across the nation lead master classes designed to take your organization to the next level.
Each master class series is designed to give you a set of practical ideas and actions to improve your organization, and you’ll also gain access to a master educator to answer your questions at the end of each session.
Live Virtual Classes
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Building a Compliant and Impactful QAPI Program Master Class
$399
Included with this training is the QAPI Policy and Annual Plan Tool — a $199 value.
Creating and maintaining a successful Quality Assessment and Performance Improvement (QAPI) program is more than a regulatory requirement—it’s a cornerstone of delivering high-quality, patient-centered care. Yet many hospitals struggle with sustaining meaningful improvement, avoiding common deficiencies, and fully engaging leadership and staff. This two-part master class series is designed for healthcare professionals looking to build or refine a QAPI program that meets CMS Conditions of Participation (§482.21, §485.641) and drives measurable results. From foundational compliance and documentation to performance improvement projects and root cause analysis, this series delivers actionable strategies for hospitals of all sizes. In this series, you will learn how to:- Develop a sustainable, hospital-wide QAPI plan that aligns with CMS expectations.
- Identify and avoid common pitfalls that lead to citations.
- Launch effective performance improvement projects using PDCA and DMAIC models.
- Conduct structured root cause analyses and respond to adverse events.
- Build a culture of safety, accountability, and transparency across all departments.
Designed for Your Busy ScheduleEach class includes a presentation and Q&A session. Attend live or view recordings of each session at your convenience. On-demand classes will be available at the conclusion of the live series.
Taught by Donna Gorby, MLD, RN, an ACHC Standards Interpretation Specialist.
Before joining ACHC in 2024, Donna’s career spanned key leadership roles, including Vice President of Quality and Medical Staff Services, Director of Nursing, and Regulatory Compliance Officer. Her strategic vision and hands-on experience in both acute and long-term care settings have made her a respected voice in the industry.
Donna holds a Master’s in Leadership Development, a Bachelor’s in Nursing, and a Lean Six Sigma Black Belt—credentials that underscore her commitment to continuous improvement and effective leadership. Her passion for shaping healthcare standards and fostering a culture of safety continues to inspire those around her.
Class 1 | 11:00 a.m. to 12:30 p.m. ET Tuesday, November 11, 2025 (available on demand)
Foundations of QAPI: Building a Compliant and Sustainable Program
This session sets the foundation for creating a high-performing QAPI program that meets CMS (§482.21, §485.641) requirements while engaging staff across all departments.
Topics Covered:
- What CMS requires: Scope, design, and governing body responsibilities.
- Elements of an effective, ongoing, hospital-wide, data-driven QAPI program.
- Integrating contracted services and all departments into your QAPI plan.
- Common deficiencies and how to avoid them.
- Defining performance indicators and using dashboards to centralize data.
- Strategies for documenting QAPI plans, meeting minutes, and annual summaries.
- Creating SMARTER goals and building accountability across leadership and staff.
Interactive Component:
- Walk through a sample QAPI plan and dashboard.
- Discuss case studies of frequently cited deficiencies.
Nursing contact hours available for this session: 1.5
Included with this training is the QAPI Policy and Annual Plan Tool — a $199 value.
Class 2 | 11:00 a.m. to 12:30 p.m. ET Tuesday, November 18, 2025 (available on demand)
Driving Improvement: Performance Projects, Root Cause Analysis, and Culture of Safety
This session builds on foundational QAPI knowledge to focus on implementing performance improvement projects (PIPs) and conducting root cause analysis (RCA), utilizing structured methods to drive measurable improvement and foster transparency and safety.
Topics Covered:
- PIPs: PDCA and DMAIC methods.
- How to select high-risk, high-volume, and problem-prone areas for PIPs.
- Using data to drive corrective actions and measure success.
- RCA: Steps, tools (five whys, fishbone diagram, affinity diagrams), and best practices.
- Lessons learned from adverse events: Responding to patients, families, and staff.
- Building a culture of trust, transparency, and shared accountability.
- Reporting outcomes to governing bodies and committees.
Interactive Component:
- Walk through an RCA case study.
- Write a performance improvement plan with goals, metrics, and a reporting strategy.
Nursing contact hours available for this session: 1.5
Included with this training is the QAPI Policy and Annual Plan Tool — a $199 value.
