QIPP Resources

Performance Requirements

Reporting Templates

Component One PIP Reporting Template (MS Word): Performance Improvement Plan (PIP): This document will be used to fulfill the condition of participation requirements wherein facilities must report monthly progress updates on monitoring their outcomes in the PIP. (Updated 11/17/2021)

Component Two: Staffing hours: HHSC does not prescribe specific template. Facilities must submit direct-care staffing information based on payroll or other auditable data through the QIPP Data Submission Portal as described in the Quality Metric Packet (PDF) and the Technical Specifications (PDF).

Component Two PIP Reporting Template (MS Word): Performance Improvement Plan (PIP): This document will be used to fulfill the condition of participation requirements wherein facilities must report monthly progress updates on monitoring their outcomes in the PIP. (Updated 11/17/2021)

Component Four: Nursing Facilities must collect audit data for each month within the program year and report summaries to HHSC in Quarters 1 and 3. For Quarter 1, NFs should report monthly data for September, October and November 2021, as available.  The Quarter 3 reporting period will then include audit data from December 2021 through May 2022.

  • Hand Hygiene Observational Audit Tracking Tool (Excel): This pre-programmed Excel workbook has been published by the Agency for Healthcare Research and Quality (AHRQ). It compiles hand hygiene observational data by individual, shift, position, location, and department to help staff regularly review opportunities for hand hygiene performance improvement. This tracking tool is used in conjunction with the Hand Hygiene Observational Audit Tracking Tool User Guide (PDF), available here.
  • Personal Protective Equipment (PPE) COVID-19 Observational Audit Tracking Tool (Excel): This pre-programmed Excel workbook has been published by the AHRQ. It compiles PPE audit data by individual, shift, position, location, and department, to help staff regularly review opportunities for improvement in donning and removing PPE. This tracking tool is best used in conjunction with Personal Protective Equipment (PPE) COVID-19 Observational Audit Tracking Tool User Guide (PDF), available here.
  • Antibiogram: Nursing Facilities are not required to use a specific template for reporting their antibiogram. AHRQ has offered a template here:
    • Toolkit 3. The Nursing Home Antibiogram Program Toolkit: How To Develop and Implement an Antibiogram Program. Content last reviewed November 2016. Agency for Healthcare Research and Quality, Rockville, MD.
  • Infection Control and Antibiotic Stewardship policies: Nursing Facilities are not required to use a specific template. Nursing facilities can utilize resources published by AHRQ, CDC and other agencies to tailor development and implementation of evidence-based policies and practices.

Reporting Timelines, Scorecards and Funding

Visit the QIPP Provider Finance website for following information about QIPP year 5 (SFY22):

  • QIPP Primary Contacts for Data Portal: This list will be updated periodically and contains the contact names and email addresses of the NF primary contacts for the QIPP data submission portal.
  • Published scorecards for incentive payments
  • QIPP Year 5 Scorecard Training Video: This video focuses on the "Scorecard" tab and is most useful for stakeholders who are new to the program.
  • Quick reference for due dates throughout the program
  • Estimated Component values and Suggested inter-governmental transfer (IGT) funding  
  • Changes of ownership (CHOW)
  • Nursing facility enrollment and eligibility

Rules

Webinars

Recommended Additional Resources for PIP

As Nursing Facilities (NFs) develop a PIP Charter, as described in the Component One and Two PIP Reporting Templates, following resources published by the Centers for Medicare and Medicaid Services (CMS) may be useful:

As NFs conduct root cause analysis to inform PIP charter and planned interventions, following resources published by the CMS may be useful:

As NFs select the PIP Topic, following resources published by the CMS may be useful:

As NFs submit documentation that demonstrates ongoing monitoring of planned interventions in Quarters 2, 3 & 4, following resources published by the CMS may be useful:

In Quarter 4, as NFs prepare documentation that records final tracking of completed interventions, following resources published by the CMS may be useful:

Other Resources for Quality Improvement