| Monthly QAPI Data-Pack Workbook | W.G.M. Rivero MD · FPCP · DPSN · · renalcarematters.com · 2026 |
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Clinician & Quality-Officer Form · Monthly QAPI
Monthly QAPI Data-Pack Workbook
Collect once at the chair-side, type once into the Scorecard — a fill-in form whose fields map 1:1 to the online QAPI Scorecard, for the Dialysis Unit Quality Program.
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📋
W.G.M. Rivero MD
FPCP · DPSN Nephrology
renalcarematters.com
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9 QAPI domains covered, matching the field manual |
35 Fields — every one feeds the online Scorecard |
~10 min To fill once a month's charts are closed |
✍️ 1 · Collect Fill this workbook by hand across the month — at the nursing station, off the water log, off the labs. |
💻 2 · Transfer Type the month-end totals into the online QAPI Scorecard before the meeting. |
🗂️ 3 · Bring Bring this workbook and the printed Scorecard to the monthly CQI meeting. |
Every metric below is worded exactly as it appears in the Dialysis Unit QAPI Scorecard (renalcarematters.com/guides/calc-dialysis-qapi-scorecard.html) and the field manual Dialysis Center QAPI vs. CQI, Section 6. Leave any field blank if you don't have that number yet — the Scorecard scores it as "no data" and excludes it rather than penalising the unit.
Any hepatitis B/C seroconversion · water bacteria ≥ 100 CFU/mL or endotoxin ≥ 0.25 EU/mL · an overdue chemical water analysis · chloramine over limit at breakthrough · any intradialytic or immediate death. Each of these forces a Root Cause Analysis (RCA) regardless of any other score — notify the DCH the same day, don't hold it for the monthly form.
| Unit / facility name | Reporting month | Prepared by | Date prepared |
| Educational data-collection aid. Not a validated accreditation instrument or a substitute for your DOH/PhilHealth/PSN documentation or registry software. Confirm every target against your current governing documents. | renalcarematters.com Page 1 of 6 · renalcarematters.com/guides/dialysis-qapi-vs-cqi.html |
Monthly QAPI Data-Pack Workbook — continued Census & Context · Adequacy & Dose · Vascular Access |
Page 2 of 6 · renalcarematters.com |
| Metric | This month | Note |
|---|---|---|
| Prevalent patients | count | |
| Patient-months this month | = prevalent patients this month | |
| Modality mix (HD % / PD %) | / | % |
| Mean Charlson comorbidity score (optional, case-mix) | see calc-charlson-comorbidity |
| Metric | This month | Target |
|---|---|---|
| % patients spKt/V ≥ 1.2 | % | ≥ 90% |
| Mean spKt/V (single-pool) | ≥ 1.4, min 1.2 | |
| % URR (urea reduction ratio) ≥ 65 | % | ≥ 90% |
| Missed / shortened treatments | count — track & minimise |
| Metric | This month | Target |
|---|---|---|
| % prevalent AVF / AVG (fistula-first) | % | ≥ 60–70% |
| % prevalent CVC > 90 days | % | ≤ 10% |
Access-related infection rate and thrombosis/intervention rate are logged with the infection-domain line list on page 4 — record each event as it happens, not just the month-end count.
| Educational data-collection aid. Not a validated accreditation instrument. Confirm every target against your current governing documents. | renalcarematters.com Page 2 of 6 · renalcarematters.com/guides/dialysis-qapi-vs-cqi.html |
Monthly QAPI Data-Pack Workbook — continued Anemia Management · CKD-MBD, Nutrition & Volume |
Page 3 of 6 · renalcarematters.com |
| Metric | This month | Target |
|---|---|---|
| % Hb (hemoglobin) 10–11.5 g/dL | % | maximise in-range |
| % Hb < 9 g/dL | % | minimise |
| % Hb > 12 g/dL | % | minimise |
| % TSAT (transferrin saturation) in target | % | TSAT > 20–30% |
| Metric | This month | Target |
|---|---|---|
| % phosphate in range | % | ≥ 60% |
| % albumin ≥ 3.5 g/dL | % | ≥ 80% |
| Mean IDWG (interdialytic weight gain, % body wt) | % | < 4–4.5% |
| % sessions with UFR > 13 mL/kg/h | % | ≤ 5% |
Intradialytic hypotension rate — track alongside these and note the trend, even though it is not separately scored on the Scorecard.
| Educational data-collection aid. Not a validated accreditation instrument. Confirm every target against your current governing documents. | renalcarematters.com Page 3 of 6 · renalcarematters.com/guides/dialysis-qapi-vs-cqi.html |
Monthly QAPI Data-Pack Workbook — continued Infection Prevention & Control |
Page 4 of 6 · renalcarematters.com |
| Metric | This month | Target |
|---|---|---|
| BSI (bloodstream infection) events this month | rate computed in Scorecard | |
| Access-related BSI events | trend down; CVC-focused | |
| Hand-hygiene / aseptic-connection audit | % | ≥ 90% |
| Vaccination coverage (eligible patients) | % | ≥ 90% |
| Any HBV/HCV seroconversion this month?HARD RED | ☐Yes ☐No | zero tolerance — RCA if Yes |
| Date | Event type | Patient / access (no PHI beyond initials) | Notes / RCA status |
|---|---|---|---|
Log every BSI, access-site infection, IV antibiotic start, and near miss here as it happens — the month-end counts above are the totals from this log. Near misses are gold: log them too, even though nothing reached the patient.
| Educational data-collection aid. Not a validated accreditation instrument. No patient-identifying information beyond initials belongs on this sheet. | renalcarematters.com Page 4 of 6 · renalcarematters.com/guides/dialysis-qapi-vs-cqi.html |
Monthly QAPI Data-Pack Workbook — continued Water & Dialysate Quality (Technical KPIs) |
Page 5 of 6 · renalcarematters.com |
| Metric | Latest result | Target |
|---|---|---|
| Product-water bacteria (CFU/mL)DOH/PSN | < 100 (action 50) | |
| Product-water endotoxin (EU/mL) | < 0.25 | |
| Chemical water analysis current?DOH/PSN — 6-monthly | ☐Yes ☐No | must be current |
| Chloramine within limit at breakthrough? | ☐Yes ☐No | checked each shift |
| Preventive maintenance on schedule | % | ≥ 95% |
Bacteria ≥ 100 CFU/mL, endotoxin ≥ 0.25 EU/mL, or an overdue chemical analysis each force an immediate Root Cause Analysis (RCA) — do not wait for the monthly meeting to escalate a water result.
| Educational data-collection aid. Verify every result against your DOH-accredited laboratory report and AAMI/ISO 23500. | renalcarematters.com Page 5 of 6 · renalcarematters.com/guides/dialysis-water-treatment-systems.html |
Monthly QAPI Data-Pack Workbook — continued Outcomes & Mortality · Experience & Safety · Ready for the Meeting |
Page 6 of 6 · renalcarematters.com |
| Metric | This month | Note |
|---|---|---|
| Deaths this month | count | |
| Hospital admissions | count; trend down | |
| Expected deaths (optional, for SMR) | case-mix adjusted | |
| Intradialytic / immediate deathsRCA each | investigate every one | |
| PRDR/REDCOP annual report submitted?Annual | ☐Yes ☐N/A this month | required for LTO |
| Metric | This month | Note |
|---|---|---|
| Grievances this month / resolved | / | count |
| Falls | trend to zero | |
| Needlestick injuries | trend to zero | |
| Medication errors | trend to zero | |
| KDQOL / PROM captured this cycle? | ☐Yes ☐No | 6–12 monthly |
| ☐Census & context collected ☐Adequacy & dose collected ☐Vascular access collected ☐Anemia collected ☐CKD-MBD / nutrition / volume collected | ☐Infection prevention & control collected ☐Water & technical collected ☐Outcomes & mortality collected ☐Experience & safety collected ☐All totals transferred to the online Scorecard |
| Prepared by | Reviewed by (DCH) | Date reviewed |
Type these totals into the Dialysis Unit QAPI Scorecard (renalcarematters.com/guides/calc-dialysis-qapi-scorecard.html) for the color-coded scorecard, the Unit QAPI Index, and an auto-drafted PDSA charter for every red metric. Then open the Monthly CQI Meeting Walkthrough (renalcarematters.com/guides/calc-qapi-meeting-wizard.html) to run the standing agenda and generate the minutes.
| Educational data-collection aid. File this workbook alongside your DOH/PSN-required attendance and complications logbooks. Does not replace individualised clinical assessment or your registry software. | renalcarematters.com Page 6 of 6 · renalcarematters.com/guides/dialysis-qapi-vs-cqi.html |