For many hospice leaders, the hardest part of launching a QAPI initiative isn’t the planning—it’s knowing where to start.
That’s where real examples come in.
At Solutions for Care, our hospice consulting team helps agencies develop survey-ready Performance Improvement Projects (PIPs) based on real documentation, audit, or clinical issues. These projects aren’t theoretical—they’re grounded in the real-world pressures hospices face every day.
Here are 4 fully outlined, CMS-aligned PIP examples your agency can learn from, adapt, or use as inspiration in your QAPI program.
📘 PIP Example 1: Improving Physician Narrative Quality
**Trigger:**A TPE review found that 30% of certification narratives lacked individualized documentation supporting terminal prognosis.
**SMART Goal:**Reduce incomplete physician narratives from 30% to 10% within 60 days.
**Root Cause:**Lack of standardized communication between intake, clinical, and physician teams.
Action Steps:
Create standardized eligibility packets (intake + compliance)
Train clinicians to provide supporting data (PPS, FAST, weight loss, etc.)
Educate physicians on narrative expectations
Conduct weekly chart audits with feedback
**Monitoring Method:**Track compliance via random chart reviews weekly for 60 days.
**Outcome:**Improved compliance to 92%; transitioned to quarterly monitoring.
📘 PIP Example 2: Reducing Missed RN Visits
**Trigger:**Audit revealed frequent missed skilled nursing visits without adequate documentation or rescheduling.
**SMART Goal:**Reduce missed RN visits by 50% in 90 days.
**Root Cause:**Poor internal communication and lack of visit prioritization protocol.
Action Steps:
Implement missed visit reporting workflow in EMR
Add RN visit tracking to daily team huddle
Educate field nurses on rescheduling protocol
Assign one leader to review all missed visits weekly
**Monitoring Method:**Weekly report of scheduled vs. completed visits.
**Outcome:**Achieved 60% reduction; added to monthly IDG metrics review.
📘 PIP Example 3: Enhancing Family Satisfaction with Communication
**Trigger:**HHCAHPS revealed below-average scores in "family communication" domain.
**SMART Goal:**Improve communication-related HHCAHPS scores from 72% to 85% over two survey periods.
**Root Cause:**Inconsistent documentation and lack of structured family updates.
Action Steps:
Establish weekly call schedule to families with RN or SW
Add “family update” field to visit notes
Create a call log template to track contact attempts
Train staff on grief-sensitive communication techniques
**Monitoring Method:**Audit visit notes and call logs; follow up with post-bereavement family interviews.
**Outcome:**Scores increased to 88% in 6 months; ongoing initiative to support agency branding and retention.
📘 PIP Example 4: Improving Timeliness of Initial Plan of Care (POC)
**Trigger:**Survey found multiple POCs were not initiated within the required 5-day window.
**SMART Goal:**Achieve 100% compliance with initial POC submission within 5 days of admission over 90 days.
**Root Cause:**Delays in RN scheduling and incomplete assessments at admission.
Action Steps:
Adjust RN schedules to allow time for same-day documentation
Revise intake checklist to prioritize POC elements
Train new nurses on compliance timeframes and EMR workflows
Flag POCs due in dashboard alerts
**Monitoring Method:**Track admission and POC submission dates weekly.
**Outcome:**100% compliance in final 30 days; issue closed and moved to audit rotation.
💡 Why Real PIPs Matter
Whether you're facing survey pressure, internal quality concerns, or a desire to improve patient experience, a good PIP turns challenges into measurable outcomes.
And with hospice consulting support, these initiatives become faster to implement, easier to track, and more effective in changing behavior and culture.
💬 Need help developing a PIP for your agency? Our Hospice Consulting team helps agencies identify key issues, plan realistic projects, and ensure compliance with CMS expectations.
