How to Start Your First Performance Improvement Project (PIP) in Home Health

In home health, compliance and quality improvement are not optional—they’re requirements for maintaining certification, improving patient outcomes, and staying competitive in a highly regulated industry. Medicare-certified home health agencies must have an ongoing Quality Assessment and Performance Improvement (QAPI) program, and one of the most practical ways to show progress is through a Performance Improvement Project (PIP).

If your agency is preparing to launch its very first PIP, you may feel unsure where to start. This guide breaks down the process step-by-step so you can design a project that is both meaningful and survey-ready.

What Is a Performance Improvement Project (PIP)?

A PIP is a focused effort to identify, study, and improve a specific process or outcome within your agency. Unlike broad QAPI activities, PIPs zero in on one issue at a time, making them manageable and measurable.

For example, a PIP might address:

• Reducing hospital readmissions for heart failure patients

• Improving timeliness of initial visits within 48 hours of referral

• Increasing staff compliance with medication reconciliation documentation

• Enhancing patient satisfaction scores

The ultimate goal is to improve patient care, increase efficiency, and demonstrate compliance with CMS requirements.

Step 1: Identify the Focus Area

Start with data. Use reports from OASIS outcomes, patient satisfaction surveys, incident reports, and chart audits. Look for patterns that reveal a problem or opportunity for improvement.

Tips for selecting your first PIP:

• Choose something measurable. (E.g., “Reduce missed visits” vs. “Improve teamwork”)

• Pick a priority that aligns with patient safety, clinical outcomes, or regulatory compliance.

• Make sure the problem is within your agency’s control to change.

Example: Your agency identifies that only 70% of new patients receive their initial nursing visit within the required 48 hours. That’s a measurable, compliance-related problem perfect for a PIP.

Step 2: Define the Project Aim

Every PIP needs a clear aim statement. This should answer:

• What are we trying to accomplish?

• How will we know the change is an improvement?

• What steps will we take to achieve it?

Example Aim Statement:
“To increase compliance with completing initial visits within 48 hours of referral from 70% to 90% by the end of the next quarter.”

Step 3: Form a PIP Team

Performance improvement isn’t a one-person job. Build a small team that includes:

• A clinical lead (e.g., Director of Nursing or QAPI coordinator)

• Field staff directly involved in the process (e.g., nurses, therapists)

• An administrative staff member for scheduling or intake processes

• Leadership support for oversight

The team ensures buy-in, offers multiple perspectives, and helps sustain the project beyond the planning phase.

Step 4: Collect and Analyze Data

Before making changes, you need to understand the root cause. Collect baseline data to see the full picture.

For the example project on initial visits:

• Review referral logs for timeliness of visits

• Identify why delays occur (staffing shortages, communication gaps, late physician orders, transportation issues)

• Use simple tools like a cause-and-effect (fishbone) diagram to map contributing factors

Data-driven insights keep you from guessing and instead guide targeted interventions.

Step 5: Develop an Action Plan

Once the problem is defined, outline specific strategies to improve. The plan should include:

• Interventions (what you’ll change)

• Responsibilities (who will do it)

• Timeline (when it will happen)

• Measurement tools (how success will be tracked)

Example Interventions:

• Assign a dedicated intake nurse to monitor referrals daily

• Set up automatic alerts in the EMR when a new referral is entered

• Implement weekly scheduling audits to catch delays early

Step 6: Test and Implement Changes

Start small with a pilot test. Apply your interventions for a short period (e.g., one week or one patient group) and see if they work.

If results are positive, expand implementation across the agency. If not, refine the process and test again. Remember: improvement is iterative.

Step 7: Monitor and Measure Results

A PIP is only successful if you can prove improvement. Collect post-intervention data and compare it to your baseline.

For the initial visit PIP, track:

• Percentage of patients seen within 48 hours each week

• Trends over time (is the percentage increasing?)

• Barriers that still exist

Regular team meetings should review progress, identify setbacks, and celebrate improvements.

Step 8: Document Everything

Surveyors want to see not only your results but also your process. Document:

• The problem identified

• Data analysis and baseline metrics

• Aim statement and action plan

• Interventions tested

• Results and comparison with baseline

• Ongoing monitoring plan

Proper documentation proves your agency is not only compliant but also committed to continuous improvement.

Step 9: Share Outcomes with Staff and Patients

Transparency builds trust. Share results in staff meetings, newsletters, or bulletin boards. If improvements affect patient care directly, communicate those changes in a way that builds confidence.

For example: “We’ve improved our on-time admission visits by 20% to ensure you receive care when you need it most.”

Step 10: Sustain the Improvement

The biggest mistake agencies make is treating PIPs as a “one-and-done” project. After reaching your goal, create policies, staff training, or monitoring tools to ensure changes become standard practice. Sustainability turns one project into long-term quality.

Starting your first Performance Improvement Project in home health may feel overwhelming, but by breaking it down into manageable steps—identifying the problem, setting an aim, analyzing data, testing interventions, and monitoring results—you create a powerful roadmap for success.

A well-designed PIP not only satisfies regulatory requirements but also strengthens your agency’s reputation for quality and reliability.

At SummitRidge Consulting, we guide home health agencies in designing effective QAPI programs and PIPs that are compliant, practical, and sustainable. Whether you’re just getting started or looking to refine your improvement efforts, our consulting expertise ensures your projects translate into measurable results.