NCQA Quality Improvement Activity Form (an electronic version is available on NCQAs Web site)
Activity Name:
Section I: Activity Selection and Methodology
A. Rationale. Use objective information (data) to explain your rationale for why this activity is important to members or practitioners and why there is an opportunity for improvement.
B. Quantifiable Measures. List and define all quantifiable measures used in this activity. Include a goal or benchmark for each measure. If a goal was established
list it. If you list a benchmark state the source. Add sections for additional quantifiable measures as needed.
Quantifiable Measure #1: Team Cohesiveness
QUALITY IMPROVEMENT FORM
NCQA Quality Improvement Activity Form (an electronic version is available on NCQAs Web site)
Activity Name:
Section I: Activity Selection and Methodology
A. Rationale. Use objective information (data) to explain your rationale for why this activity is important to members or practitioners and why there is an opportunity for improvement.
B. Quantifiable Measures. List and define all quantifiable measures used in this activity. Include a goal or benchmark for each measure. If a goal was established
list it. If you list a benchmark state the source. Add sections for additional quantifiable measures as needed.
Quantifiable Measure #1: Team Cohesiveness
Numerator:
Denominator:
First measurement period dates:
Baseline Benchmark:
Source of benchmark:
Baseline goal:
Quantifiable Measure #2: Safe Staffing (mainly in the Constant Care Unit [CCU])
Numerator:
Denominator:
First measurement period dates:
Benchmark:
Source of benchmark:
Baseline goal:
Quantifiable Measure #3: Staff Retention
Numerator:
Denominator:
First measurement period dates:
Benchmark:
Source of benchmark:
Baseline goal:
C. Baseline Methodology.
C.1 Data Sources.
[ ] Medical/treatment records
[ ] Administrative data:
[ ] Claims/encounter data [ ] Complaints [ ] Appeals [ ] Telephone service data [ ] Appointment/access data
[ ] Hybrid (medical/treatment records and administrative)
[ ] Pharmacy data
[ ] Survey data (attach the survey tool and the complete survey protocol)
[ ] Other (list and describe):
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
C.2 Data Collection Methodology. Check all that applies and enter the measure number from Section B next to the appropriate methodology.
If medical/treatment records check below:
[ ] Medical/treatment record abstraction
If survey check all that apply:
[ ] Personal interview
[ ] Mail
[ ] Phone with CATI script
[ ] Phone with IVR
[ ] Internet
[ ] Incentive provided
[ ] Other (list and describe):
_______________________________________________
_______________________________________________ If administrative check all that apply:
[ ] Programmed pull from claims/encounter files of all eligible members
[ ] Programmed pull from claims/encounter files of a sample of members
[ ] Complaint/appeal data by reason codes
[ ] Pharmacy data
[ ] Delegated entity data
[ ] Vendor file
[ ] Automated response time file from call center
[ ] Appointment/access data
[ ] Other (list and describe):
_________________________________________________________________
_________________________________________________________________
C.3 Sampling. If sampling was used provide the following information.
Measure Sample Size Population Method for Determining Size (describe) Sampling Method (describe)
C.4 Data Collection Cycle.
Data Analysis Cycle.
[ ] Once a year
[ ] Twice a year
[ ] Once a season
[ ] Once a quarter
[ ] Once a month
[ ] Once a week
[ ] Once a day
[ ] Continuous
[ ] Other (list and describe):
_________________________________________________________
_________________________________________________________ [ ] Once a year
[ ] Once a season
[ ] Once a quarter
[ ] Once a month
[ ] Continuous
[ ] Other (list and describe):
_________________________________________________________
_________________________________________________________
C.5 Other Pertinent Methodological Features. Complete only if needed.
D. Changes to Baseline Methodology. Describe any changes in methodology from measurement to measurement.
Include as appropriate:
Measure and time period covered
Type of change
Rationale for change
Changes in sampling methodology including changes in sample size method for determining size and sampling method
Any introduction of bias that could affect the results
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Section II: Data / Results Table
Complete for each quantifiable measure; add additional sections as needed.
#1 Quantifiable Measure: Team Cohesiveness
Time Period
Measurement Covers
Measurement
Numerator
Denominator Rate or Results Comparison Benchmark Comparison
Goal Statistical Test and Significance*
Baseline:
Remeasurement 1:
Remeasurement 2:
Remeasurement 3:
Remeasurement 4:
Remeasurement 5:
#2 Quantifiable Measure: Safe Staffing
Time Period
Measurement Covers
Measurement
Numerator
Denominator Rate or Results Comparison Benchmark Comparison
Goal Statistical Test and Significance*
Baseline:
Remeasurement 1:
Remeasurement 2:
Remeasurement 3:
Remeasurement 4:
Remeasurement 5:
#3 Quantifiable Measure: Staff Retention
Time Period
Measurement Covers
Measurement
Numerator
Denominator Rate or Results Comparison Benchmark Comparison
Goal Statistical Test and Significance*
Baseline:
Remeasurement 1:
Remeasurement 2:
Remeasurement 3:
Remeasurement 4:
Remeasurement 5:
* If used specify the test p value and specific measurements (e.g. baseline to remeasurement #1 remeasurement #1 to remeasurement #2 etc. or baseline to final remeasurement) included in the calculations. NCQA does not require statistical testing.
Section III: Analysis Cycle
Complete this section for EACH analysis cycle presented.
A. Time Period and Measures That Analysis Covers.
B. Analysis and Identification of Opportunities for Improvement. Describe the analysis and include the points listed below.
B.1 For the quantitative analysis include the analysis of the following:
Comparison with the goal/benchmark
Reasons for changes to goals
If benchmarks changed since baseline list source and date of changes
Comparison with previous measurements
Trends increases or decreases in performance or changes in statistical significance (if used)
Impact of any methodological changes that could impact the results
For a survey include the overall response rate and the implications of the survey response rate
B.2 For the qualitative analysis describe any analysis that identifies causes for less than desired performance (barrier/causal analysis) and include the following:
Techniques and data (if used) in the analysis
Expertise (e.g. titles; knowledge of subject matter) of the work group or committees conducting the analysis
