Quality Assessment/Performance Improvement

The Centers for Medicare and Medicaid Services (CMS), a federal agency, requires that all hospices maintain an ongoing Quality Assessment/Performance Improvement (QAPI) program. This QAPI program encompasses all areas and departments of Shepherd’s Cove Hospice, and ALL employees of Shepherd’s Cove Hospice have a role in maintaining this successful program.

  • Medicare, Medicaid and other hospice governing bodies have strict criteria and guidelines that have to be monitored and documented within set time frames in order to ensure timely and efficient patient care.
  • In an attempt to provide ‘exceptional individualized care’ as stated in the Shepherd’s Cove Hospice Mission Statement, and to comply with Federal and State regulations, Shepherd’s Cove Hospice created a position in Oct. 2011 for a full time clinical auditor. The clinical auditor monitors all aspects of clinical practices and documentation– the Hospice Care Aides (HCA’s), the nurse’s, the volunteers and the chaplains.
  • Random weekly, monthly and quarterly audits are completed to ensure that all documentation reflects the high standards in patient care that Shepherd’s Cove Hospice requires, and is known for completing.
  • All nurses are required to go through a yearly competency skills evaluation.
  • All staff are required to participate in ongoing education provided in an effort to maintain excellence in patient care, and to keep staff on top of any changes in treatment that might benefit Shepherd’s Cove Hospice’s patients.
  • Shepherd’s Cove Hospice strives for our patients to feel comfortable and confident in their nurses’ abilities and judgment.