HCAHPS Action Plan Review

Quarterly EPMS template for reviewing HCAHPS domain performance, action plan progress, unit-level results, and next-quarter priorities.

HCAHPS Domain Performance

No items.

Goal Achievement and Action Plan Progress

• HCAHPS Improvement Goals
  Document quarterly goals, measures, progress, and ratings for HCAHPS improvement work.
• Action Plan Progress Summary
  Summarize completed actions, in-progress items, and any missed milestones with evidence.
• Barriers and Escalations
  Capture operational barriers, resource gaps, or escalations needed to keep the action plan on track.

Unit-Level Results and Root Cause Review

• Unit-Level Results Summary
  Summarize the unit's HCAHPS results, trend direction, and notable changes from the prior quarter.
• Root Cause Analysis
  Identify the most likely drivers of performance changes using observable evidence and operational data.
• Stakeholder Feedback Reviewed
  Select the feedback sources used to assess unit performance.

Next-Quarter Priorities and Development Plan

• Next-Quarter Priorities
  List the top priorities for the next quarter with measurable outcomes and ownership.
• Development Plan
  Capture development actions using a 70-20-10 approach, including on-the-job practice, coaching, and formal learning.

Overall Summary and Sign-Off

• Overall Performance Summary
  Summarize overall quarterly performance using specific evidence from goals, HCAHPS results, and action plan execution.
• Employee Reflection
  Employee comments on results, barriers, and support needed for the next quarter.
• Manager Signature
• Employee Signature