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How to Write a Hospice PIP: A Step-by-Step Guide to Performance Improvement Success

In hospice care, quality isn’t just about compassion—it’s about consistency, compliance, and continuous improvement. That’s why every agency is required by CMS to have a QAPI (Quality Assurance and Performance Improvement) program in place—and why knowing how to create an effective Performance Improvement Project (PIP) is so essential.


But let’s be honest: most clinical leaders and administrators were never formally trained in writing PIPs. They’re learning as they go—often during a stressful survey or after receiving a TPE denial or citation.

hospice consulting

As hospice consultants, we work with agencies every day to build strong QAPI programs. Here’s a clear, step-by-step guide to help you write a practical, measurable, and survey-ready PIP that actually improves outcomes.


✅ What Is a PIP (Performance Improvement Project)?

A PIP is a focused, data-driven initiative that addresses a specific problem within your agency’s operations, care quality, or compliance. It includes:

  • A clearly defined problem

  • Root cause analysis

  • A goal

  • Action steps

  • A method for measuring success

  • Ongoing monitoring

CMS expects every hospice QAPI program to identify and execute PIPs as needed—not just during a crisis, but as part of proactive quality improvement.

🧭 Step-by-Step: How to Write a Hospice PIP


1. Define the Problem Clearly

Use data, audit findings, or survey feedback to identify an issue.

📌 Example:

“Recent chart audits showed that 30% of physician narratives lacked sufficient documentation to support eligibility.”

Make sure the problem is:

  • Specific

  • Measurable

  • Relevant to patient care or compliance


2. Conduct a Root Cause Analysis

Ask: Why is this happening?Use the 5 Whys, flowcharts, or team feedback to uncover real causes—not just symptoms.

📋 Example:

  • Why were narratives incomplete? → Because physicians didn’t include recent clinical data.

  • Why not? → Because intake and field staff didn’t provide it consistently.

  • Why? → There’s no standardized process for sharing eligibility documentation.


3. Set a SMART Goal

Your improvement goal should be:

  • Specific

  • Measurable

  • Achievable

  • Realistic

  • Time-bound

📌 Example:

“Reduce incomplete physician narratives from 30% to 10% within 60 days through process improvement and staff training.”

4. Outline Action Steps

Define what you’ll do to fix the problem—and who’s responsible.

🛠 Sample Action Plan:

  • Create a standardized eligibility packet (Compliance RN, Week 1)

  • Train intake and field staff on eligibility communication (Clinical Director, Week 2)

  • Train physicians on individualized narrative writing (Medical Director, Week 3)

  • Start weekly chart audits to monitor progress (QAPI Chair, Ongoing)


5. Define Metrics for Success

Decide how you’ll measure improvement and how often you’ll check progress.

📊 Example Metrics:

  • % of narratives meeting documentation criteria of charts audited weekly

  • Staff participation in training sessions

  • Feedback from medical review or consultant


6. Monitor and Document Progress

Track your results in QAPI meeting minutes. Adjust if needed.

✅ Tip: Use a simple spreadsheet or audit log to document:

  • What’s working

  • Where barriers exist

  • Changes made along the way

📌 Pro Tip: Surveyors love to see that you're learning and adapting—not just checking boxes.


7. Close the Project or Transition to Monitoring

Once the goal is met, either:

  • Close the PIP and document the outcome

  • Or transition to ongoing monitoring to ensure sustainability

📘 Example:

“After 60 days, the incomplete narrative rate dropped to 8%. Monthly audits will continue for 90 days before closing the project.”

🧠 Bonus: When Should You Start a PIP?

Trigger a new PIP when:

  • A survey or TPE identifies a deficiency

  • Your audits show trends (e.g., repeated documentation gaps)

  • There’s a drop in HHCAHPS satisfaction

  • Staff raise concerns about a recurring process failure

  • Leadership wants to improve a system, not just fix a symptom

💡 Conclusion

A well-written PIP isn’t just about satisfying surveyors—it’s about creating real improvements that protect your patients, your team, and your Medicare revenue.

Whether you’re new to performance improvement or looking to refresh your QAPI approach, hospice consultants can provide the structure, feedback, and real-world experience to make your efforts effective and sustainable.

💬 Need help building a PIP or evaluating your QAPI program? Our Hospice Consulting team can guide you step-by-step—from problem identification to survey-ready documentation.

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