Real-World PIP Examples for Hospice Agencies: From Documentation to Patient Satisfaction
- Stefano Fronte
- Aug 4
- 3 min read
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.
