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QAPI meeting agenda and minutes template

A combined agenda and minutes template for QAPI and QAA committee meetings. It records attendance, data reviewed, adverse events, performance improvement projects and corrective action status. It also records decisions with owners and due dates, and the report to the governing body. The minutes show the program runs on its data and acts on it.

Updated Oct 5, 20268 sectionsFree to print
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Before you start

When to use it

  • Nursing home QAA committee meetings, which must happen at least quarterly and as needed.
  • Regular QAPI meetings at surgery centers, hospitals, hospice and home health agencies.
  • Getting ready for a survey: minutes are proof the program meets, reviews data and acts on it.
  • A special meeting after a serious event, an abuse allegation or a corrective action that did not work.
  • Preparing the QAPI report to the governing body.

How to fill it out well

  1. Send the agenda and data a few days ahead so the meeting is for decisions, not reading.
  2. Take attendance by name and role. Record who is absent and who covered.
  3. Open with the open and overdue actions. Ask for evidence, not updates.
  4. Show data as trends against a target, with the period named, not raw counts.
  5. Record decisions, owners and due dates. Leave out the discussion unless it explains a decision.
  6. Approve the minutes at the next meeting. Keep them with the data and attachments under your retention policy.
  7. Record the date you reported to the governing body, and what you reported.

QAPI meeting agenda and minutes template

Organization: ______________________   Site: ______________________

1. Meeting details
Meeting date
Start time
End time
Meeting typeRegularSpecial: called after an eventAnnual program review
FormatIn personVideoHybrid
Chair
Recorder
2. Attendance
SettingNursing homeSurgery center (ASC)HospitalHospiceHome healthBehavioral healthOther
Members present (name and role)
Members absent (name and role) and who covered
Director of nursing services, medical director or designee, and infection preventionist present (nursing homes)A nursing home QAA committee must include the director of nursing services, the medical director or designee, the infection preventionist and at least three other staff (42 CFR 483.75(g)(1)).
Administrator, owner, board member or other leader presentAt least one of the other three staff must be a leader.
Quorum met under the committee charterCheck your charter. Record who covers when a required member is out.
Guests and presenters
3. Previous minutes and open actions
Previous minutes reviewed and approved
Corrections to previous minutes
Open actions reviewed (action, owner, status)Read every open and overdue item. Ask for evidence, not updates.
Actions open
Actions overdue
Actions completed since last meeting, with evidence and any effectiveness resultAn action is complete when the evidence is attached and the effectiveness check has passed.
4. Data reviewed
Data period covered and sources
Incidents and adverse events (counts by type and harm level)Include falls, medication errors, infections, skin injuries, transfers, wrong-site events and near misses. Compare with last period.
Trends by location, shift and causeLook for clusters: one wing, one shift, one piece of equipment, one drug.
Quality indicators and performance measures (value, target, trend)Name each measure, its target and which way it moved since the last meeting.
Feedback, grievances and complaints from residents, patients, families and staffNursing homes must have ways to get and use feedback from staff, residents and representatives (42 CFR 483.75(c)(1)).
Drug regimen review and pharmacy findings (nursing homes)The QAA committee must regularly review data, including drug regimen review data (42 CFR 483.75(g)(2)(iii)).
Audit results (hand hygiene, medication pass, environmental rounds, other)
5. Adverse events and serious incidents
Serious events since last meeting (summary, harm and status of investigation)
Sentinel or reportable events this period
Root cause findings presentedSummarize causes and attach the analysis. Name conditions, not people.
Abuse and neglect allegations reviewed: each reported on time and each investigation completedNursing homes: 2 or 24 hours to report, and results to the State Survey Agency in 5 working days.
Reports made to regulators or accreditors (agency and date)
Near misses reviewed and what they showed
6. Performance improvement projects
Active project title or titles
Why this project: the data that selected itTie each project to a high-risk, high-volume or problem-prone area your data found (42 CFR 483.75(e)(1); 42 CFR 416.43(c)(1)).
Aim and measure (target and date)
Progress since last meeting (baseline, current, change)
StatusOn trackBehind: plan adjustedComplete: sustainedComplete: not effectiveStopped: reason recordedNew: approved today
A project on a high-risk or problem-prone area is in place for the year (nursing homes)Nursing homes must include, at least yearly, a project on high-risk or problem-prone areas found through data (42 CFR 483.75(e)(3)).
7. Decisions and new actions
Decisions madeWrite what was decided, not what was discussed.
New action 1 (what, owner, due date, evidence, effectiveness check date)
New action 2 (what, owner, due date, evidence, effectiveness check date)
Additional actions
Policy or process changes approved, and resources requested
8. Governing body report and sign-off
Items to report to the governing bodyThe nursing home QAA committee reports to the governing body on its work, including QAPI (42 CFR 483.75(g)(2)).
Date reported to the governing body
Next meeting date
Minutes recorded by
Chair
Recorder
Date minutes approved
Editable copy

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Tips

  • Pick one or two topics for a deeper look each meeting. Rotate them, and always cover adverse events and open actions.
  • Make the minutes show the loop: data, decision, action, owner, check. A reader should follow one problem from meeting to meeting.
  • Invite front-line staff to present. Their feedback is part of what the rule asks you to collect and use.
  • Keep minutes factual and free of blame. Ask counsel how state peer review or quality improvement protections apply before you decide what to attach.

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Questions

About this template.

Something we missed? Ask us, and a person answers.

How often must a QAPI committee meet?

A nursing home QAA committee must meet at least quarterly and as needed (42 CFR 483.75(g)(2)(i)). Surgery centers, hospitals, hospice and home health need an ongoing, data-driven program overseen by the governing body. Check your accreditor and state, and set the schedule in your QAPI plan.

Who must be on a nursing home QAA committee?

The director of nursing services, the medical director or designee, and the infection preventionist. Also at least three other staff, one of them the administrator, owner, board member or another leader (42 CFR 483.75(g)(1)).

What should QAPI meeting minutes include?

Date, attendees and absences. Approval of the last minutes. Open actions. Data reviewed, with trends. Adverse events and lessons. Project progress. Decisions with owners and due dates. The governing body report. Show a loop of data, decision, action and check.

What does a performance improvement project have to document?

ASCs: the reasons for each project and its results (42 CFR 416.43(d)). Hospitals: projects, reasons and measurable progress (42 CFR 482.21). Nursing homes: distinct projects, with at least one a year on a high-risk or problem-prone area found through data (42 CFR 483.75(e)(3)).

Do surveyors get to see QAPI committee records?

In nursing homes, 42 CFR 483.75(h) says a State or the Secretary may not require QAA committee records except as related to compliance with that section. CMS adds that a facility must disclose what shows compliance. Refusal brings an F865 citation. Ask counsel how state law applies.

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