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Run: CASPER Quality Measure Report Review

Review CASPER quality measure reports each month, flag measures above threshold, drill into resident-level drivers, and hand off issues to QAPI with clear fo...

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Review Identification

Review month and year documented critical (required)

Record the month and year covered by this CASPER review.

Facility or unit identified critical (required)

Identify the facility, campus, or unit included in the review.

Reviewer name and role documented critical (required)

Identify the person completing the review and their role.

CASPER report version or source noted

Document the report source, export date, or report version used for the review.

Review completed within monthly schedule

Confirm the review was completed according to the monthly run schedule.

Yes No N/A

Measure Threshold Screening

Measures above threshold identified critical (required)

Confirm whether any CASPER quality measures were above the facility threshold.

Yes No N/A

Number of measures above threshold

Count the number of measures exceeding threshold.

Measures requiring QAPI handoff listed critical (required)

Select each measure that requires QAPI follow-up.

Threshold source documented

Document the internal threshold, benchmark, or comparison source used to determine whether a measure was above threshold.

Trend Analysis

Trend direction assessed critical (required)

Select the overall trend direction for the measure(s) reviewed.

Trend period reviewed

Document the comparison period used for trend review, such as 3-month or 6-month trend.

Persistent pattern identified

Indicate whether the measure shows a persistent pattern rather than a one-time spike.

Yes No N/A

Trend summary narrative

Summarize the observed trend, including any seasonal, census-related, or process-related factors.

Resident-Level Drill-Down

Resident-level drill-down completed critical (required)

Confirm that the review included resident-level analysis for the affected measure(s).

Yes No N/A

Number of residents reviewed

Count the residents included in the drill-down review.

Primary contributing factors identified

Select the factors most associated with the elevated measure.

Resident-level examples documented

Summarize resident-level findings without entering unnecessary personally identifiable information.

Immediate risk issues escalated critical (required)

Indicate whether any immediate resident safety or clinical risk issues were escalated.

Yes No N/A

QAPI Handoff and Follow-Up

QAPI handoff completed critical (required)

Confirm the measure review was formally handed off to QAPI when thresholds were exceeded.

Yes No N/A

QAPI owner assigned critical (required)

Identify the QAPI owner or department responsible for follow-up.

Corrective action plan documented

Document the planned intervention, monitoring method, or process change.

Follow-up due date documented

Record when the next review or follow-up is due.

Escalation to leadership or committee completed if needed

Indicate whether escalation beyond QAPI was required based on severity or persistence.

Yes No N/A

Reviewer Attestation

Reviewer signature critical (required)

Signature confirming the review is complete and accurate.

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