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):
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