Hospice QAPI Data Collection and PIP Documentation Inspection

Inspection template for reviewing hospice QAPI data collection, trend analysis, and performance improvement project (PIP) documentation for completeness, traceability, and surveyor readiness.

Inspection Scope and QAPI Record Set

• Inspection period is defined and matches the reviewed QAPI cycle
• QAPI committee or leadership review records are available for the selected period
• List of quality measures, dashboards, and PIPs included in the inspection
• Data sources are identified for each measure or PIP
• Surveyor-ready file index or document map is present

Data Collection Design and Integrity

• Each measure has a written definition, numerator, denominator, and data collection frequency
• Sampling method is documented when full-population review is not used
• Data abstraction tool or worksheet is standardized across reviewers
• Inter-rater review or validation of abstraction accuracy is documented
• Missing data, exclusions, and late entries are tracked and explained

Trend Analysis and Performance Review

• Trend charts or run charts show performance over time
• Performance is compared against a target, benchmark, or internal goal
• Analysis identifies variation, recurring defects, or high-risk patterns
• Root cause or contributing factor analysis is documented when performance is below target
• Leadership or QAPI committee review notes include decisions and follow-up actions

Performance Improvement Project Documentation

• PIP aim statement is specific, measurable, and time-bound
• Baseline performance is documented before interventions begin
• Interventions, owners, and implementation dates are documented
• PDSA or similar improvement cycle is documented with test results
• Post-intervention results are compared to baseline and aim

Monitoring, Sustainment, and Corrective Actions

• Sustainment monitoring plan is documented after initial improvement
• Ongoing monitoring frequency is appropriate to the risk and measure type
• Corrective actions are assigned when performance remains below target
• Re-audit or follow-up review date is documented
• Evidence of closed-loop follow-up is present for prior deficiencies

Documentation Quality and Survey Readiness

• Documents are dated, version-controlled, and attributable to the correct review period
• Supporting evidence is legible and complete
• Any gaps, non-conformances, or missing records are clearly explained
• Inspector signature
• Inspector comments and summary of findings