About this course
This course teaches hospice quality assessment and performance improvement to hospice aides, nurses, social workers, chaplains, schedulers and administrative staff. Part one covers the Condition of Participation at 42 CFR 418.58 in plain language - what effective, ongoing, hospice-wide and data-driven each require, why contracted services are inside the program, who the governing body must designate to run it, and the difference between the assessment half and the improvement half. Part two covers the data: the three Hospice Quality Reporting Program streams (the HOPE assessment that replaced the Hospice Item Set on October 1, 2025; the claims-based Hospice Visits in the Last Days of Life and Hospice Care Index measures; and the CAHPS Hospice Survey completed by bereaved family caregivers), followed by the much larger body of internal data - adverse events, infections, falls, medication errors, missed visits and complaints - that exists only because staff wrote it down. Part three walks a real problem from a number on a quarterly report through cause analysis into a documented performance improvement project, teaches root cause thinking with a worked five-whys example, distinguishes strong from weak corrective actions, and sets out the just culture distinction between human error, at-risk behaviour and recklessness. Part four is the staff-level core of the course: documentation as data, mandatory and voluntary incident reporting including the immediate reporting duty at 418.52(b)(4), and how to raise a concern or a cross-patient pattern in IDG so that it lands. Suitable for new-hire orientation, annual refresher training, and hospice survey readiness.