QAPI Report Builder Form

QUALITY IMPROVEMENT REPORT FORM

The Report Builder will ask you detailed questions about your Quality Study and the corrective actions implemented. We will review your submission and send you an edited version within 2 business days.
Your Name:*

First NameLast Name
Your email address:*
example@example.com
Enter the name of your facility:*
Please enter your passcode to access the form:*
If you do not have an access code, please contact support at 770-325-0140, for assistance.** Please note: passcode is case-sensitive **
Quality Improvement Study Report Title:*
Enter the name of your QAPI Study
Step 1: State the Purpose for the Study

Document your purpose for conducting the study
Clearly describe the known performance gap you want to address and explain why closing this gap matters. Use these guiding questions to help you write your statement:
- Is this a known problem or an opportunity for improvement?
- What data or evidence led you to decide to carry out this study or project?
- Why are you conducting this quality improvement (QI) study - why is it important?
- What specific issue are you addressing - What is the area of focus?
Write a clear purpose statement that includes who, what, where, when, and why this problem or improvement opportunity is important. Use complete sentences to ensure your purpose is specific and easy to understand.
Step 1: State the Purpose: *
Example: Our data shows that we reported 3 patient falls in the facility for 1st quarter 2025. The purpose of the study is to ensure that patient falls do not occur in the facility. The significance of this study is that patient falls are a serious risk issue due to potential for patient injury.
Step 2: Set the Goal

Document your goal and when you want to reach that goal
Clearly define what your organization wants to achieve. Use these guiding questions to help you write a clear, measurable goal:
- What specific result are you trying to achieve? (For example: Increase from X to Y or Decrease from X to Y)
- By when do you plan to reach this goal?
- What did your benchmarking reveal? Compare your performance with similar organizations to help set a realistic and meaningful target.
Write your goal using actual numbers or percentages, and include a target date for achieving it. Your data identified the problem — now express your goal in measurable terms and specify when it should be met. Document your performance goal and timeframe here. Use complete sentences to make sure your goal is clear and actionable.
Step 2. Set the Goal: *
Example: Our goal is to reduce patient falls to zero for 2nd quarter 2025.
Step 3: Identify Reasons for the Performance Gap

Document "why" the goal isn't met
Identify the Gap: Describe the reasons for the performance gap (why existing processes do not meet the goal) and explain why the gap exists. Use these guiding questions to help you analyze the issue and document it:
- Why is this problem happening?
- Why didn’t existing performance meet the initial goal?
- What is the root cause of not reaching the goal?
- Who did you consult to gather information?
- Is this mainly a knowledge issue, a skills gap, or a process problem?
Create a list of possible reasons why existing performance is falling short to show how you developed corrective actions to implement. Use complete sentences to clearly explain the causes you identified.
Step 3. Identify Reasons for the Performance Gap: *
Example: Patients are at risk for falls when they try to ambulate without assistance, such as when using the restroom or getting dressed. This risk is increased after patients are administered medication(s). It was identified that staff were allowing patients to restroom and dress without assistance in the PACU.
Step 4: First Corrective Action

Document only the initial corrective action(s) taken and the timeline of when they were implemented
Corrective Actions — Define and Implement: Clearly describe the corrective actions you will take and put them into practice. Use these tips to guide you:
- Make sure each action directly targets the reasons why the problem exists, as identified in the previous step.
- Focus your actions specifically on addressing the root causes of the problem.
- Avoid making too many interventions at one time — choose ones that are practical to implement and have the highest potential to close the performance gap.
Write out your corrective actions and include a clear timeline for when they were carried out. Use complete sentences to ensure your plan is clear and actionable.
Step 4. First Corrective Action(s) Implemented: *
Example: We educated staff at the end of March on facility protocols regarding patient safety and assistance. We implemented teaching protocols to instruct patients on ambulation safety.
Step 5: Remeasure after First Corrective Action

Document the current performance vs. the goal and your next steps whether you achieved or fell short of your performance goal. Document only the initial corrective action(s) taken and the timeline of when they were implemented.
Remeasure: Check your performance again to confirm whether improvement has been achieved and sustained. Use these tips to guide you:
- Did the new measurement show that you met your goal?
  - Yes — you met the goal! Congratulations! Document your results here and move on to Step 6, which is the final step. This includes communicating and sharing the results, and planning one or more future measurements to ensure the improvement is sustained.
  - No — you did not meet the goal. Document those results here. On the next step you will revisit the reasons why the problem persists. Adjust your corrective actions as needed and repeat cycles of implementing changes and measuring again to reach the goal or determine the issue no longer applies.
Document your current performance compared to the goal and describe your next steps, whether you met the goal or not. Use complete sentences to make your results and plan clear.
Step 5. Remeasure After Corrective Action(s):*
Example: After implementing corrective actions, we reported that there were 2 patient falls during 2nd quarter and our goal was not met. Additional corrective measures will be implemented. - OR - After implementing corrective actions, we found that there were no patient falls during the second quarter and our goal was met.
Goal was metGoal was not met
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Step 4b: Second Corrective Action

Document only the second corrective action(s) taken and the timeline of when they were implemented
Here you will implement an additional corrective action and repeat prior steps to determine if your corrective actions improved processes to meet your initial goal and describe the new data collected this time.

Corrective Actions — Define and Implement: Clearly describe the second corrective actions you will take and put them into practice. Use these tips to guide you:
- Make sure each action directly targets the reasons why the problem exists, as identified in the previous step.
- Focus your actions specifically on addressing the root causes of the problem.
- Avoid making too many interventions at one time — choose ones that are practical to implement and have the highest potential to close the performance gap.
Write out your corrective actions and include a clear timeline for when they were carried out. Use complete sentences to ensure your plan is clear and actionable.
Step 4b. Second Corrective Action(s) Implemented:
Example: We re-educated staff at the end of June on facility protocols regarding patient safety and assistance. Additionally, we observed staff during the patient teaching process to evaluate effectiveness.
Step 5b: Remeasure after Second Corrective Action

Document the current performance vs. the goal and your next steps whether you achieved or fell short of your performance goal. Document only the second corrective action(s) taken and the timeline of when they were implemented.
Remeasure: Check your performance again to confirm whether improvement has been achieved and sustained. Use these tips to guide you:
- Did the new measurement show that you met your goal?
  - Yes — you met the goal! Congratulations! Document your results here and move on to Step 6, which is the final step. This includes communicating and sharing the results, and planning one or more future measurements to ensure the improvement is sustained.
  - No — you did not meet the goal. Document those results here. On the next step you will revisit the reasons why the problem persists. Adjust your corrective actions as needed and repeat cycles of implementing changes and measuring again to reach the goal or determine the issue no longer applies.
Document your current performance compared to the goal and describe your next steps, whether you met the goal or not. Use complete sentences to make your results and plan clear.
Step 5b. Remeasure After Second Corrective Action(s):
Example: After implementing corrective action, we reported that there was 1 patient falls during 3rd quarter and our goal was not met. Additional corrective measures will be implemented. - OR - After implementing corrective action, we found that there were no patient falls during the 3rd quarter and our goal was met.
Goal was metGoal was not met
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Step 4c: Third (and Final) Corrective Action

Here you will document only the third (and final) corrective action(s) taken and determine if those actions improved processes to meet the goal. If the goal is not met following the action(s) documented below, this form will not continue.
Step 4c. Third Corrective Action(s) Implemented:
Example: We ordered no-slip socks for the patients and instructed staff to place the socks on every patient in the facility beginning 4th quarter. Our goal remains to have zero patient falls.
Step 5c: Remeasure after Third (and Final) Corrective Action

Document the current performance vs. the goal and your next steps whether you achieved or fell short of your performance goal. Document only the third corrective action(s) taken and the timeline of when they were implemented.
Step 5c. Remeasure After Third Corrective Action(s):
Example: After implementing corrective actions, we reported that there were no patient falls during the 4th quarter and our goal was met.
Goal was metGoal was not met - study ended
If your goal is still not met after this 3rd corrective action, perhaps you need to reconsider your goal. Reach out to our team at support@almss.com to strategize/discuss next steps.
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Step 6: Communication
Communicate! Share your study results widely — before, during, and after the project — to ensure engagement and sustainability. Use these tips to guide you:
- Present your findings to the governing body.
- Share information throughout the organization, as appropriate, to keep everyone informed and engaged.
- Make sure the governing body’s review of the report is properly documented.
- Communicate key findings to others within the organization and clearly document how you shared this information.
- Decide if additional education or training is needed based on the study’s results. If so, take those steps and document what was done.
Be sure to document how you shared the results with the governing body and across the organization, as well as any related educational activities. Use complete sentences to make your communication clear.
Communication:*
Example: Findings of the QAPI activities will be communicated to the Governing Board, as well as throughout the organization as appropriate, and have been incorporated into the organization’s educational activities, including clinical annual training.
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QUALITY IMPROVEMENT REPORT FORM

Step 1: State the Purpose for the Study

Step 2: Set the Goal

Step 3: Identify Reasons for the Performance Gap

Step 4: First Corrective Action

Step 5: Remeasure after First Corrective Action

Step 4b: Second Corrective Action

Step 5b: Remeasure after Second Corrective Action

Step 4c: Third (and Final) Corrective Action

Step 5c: Remeasure after Third (and Final) Corrective Action

Step 6: Communication