CMS-10209 QIP Medicare Advantage Quality Improvement Project Reporting

Medicare Advantage Quality Improvement Project Reporting Template

OMB #0938 - Pending Approval.

This form is currently available for informational purposes. Use of this form is not required until OMB approval is obtained. This form is subject to change.

Medicare Advantage Quality Improvement Project Reporting Template

Instructions:

Beginning January 1, 2006, Medicare Advantage Organizations (MAOs) are required to initiate one self-selected Quality Improvement project per year and to submit reports on these projects in advance of the MAO’s routine CMS Audit. This reporting process replaces the submission of information via the web-based HPMS QAPI module. This reporting template must be used to submit information required by CMS in order to evaluate Medicare Advantage Quality Improvement projects.

• MAOs should submit a report for each project initiated since their last routine CMS audit, beginning with 2006.

• Provide information for all items under Parts A through I using as much space as is necessary to provide detailed information.

• MAOs may submit additional supporting documentation along with the information in the reporting template.

• Questions about QI project reporting can be submitted to Shaheen Halim, Ph.D. at:

QIP-CCIP@cms.hhs.gov or 410-786-0641.

A. Medicare Advantage Organization Information

1. Medicare Advantage Organization Name:

2. Medicare Advantage Contract Number:

3. State:

4. CMS Regional Office:

5. Contact information for person responsible for completion of this report:

Last name First name Middle Initial

Title

Phone Fax Email

B. QI Project General Information

1. Title of Quality Improvement Project

2. Date of project initiation

3. Date of project completion or expected project completion

4. Indicate whether the project was initiated in order to participate in a local, regional or national quality improvement collaborative or incentive program (if yes, describe the larger program and its goals):

5 . Project Focus Area Type [Select all that apply and briefly describe]

Clinical Focus Area (i.e.: prevention of acute/chronic conditions, treatment or care of acute/chronic conditions, high-volume services, high-risk services, continuity/coordination of care).

Non-Clinical Focus Area (i.e.: Availability, Accessibility, Cultural Competency of Services, Complaints, Grievances, Appeals).

6. Describe the target population for this QI project. State the criteria for inclusion and any exclusion criteria for this target population:

C. Relevance of QI project topic to Medicare population

1. Provide an explanation of why this QI project topic is relevant to your MA organization’s Medicare population. Describe the information used in making this determination i.e.: literature reviewed, comparisons with other Medicare Advantage Organizations, cost analyses, adverse events, HEDIS data, enrollee survey data, provider survey data, or external reviewer information.

2. Describe your organization’s prioritization process for selecting this specific topic:

D. Quality Improvement Indicators

For each QI indicator you are submitting for this project, complete checkboxes and items 1 through 7 (copy and paste as many times as needed for multiple indicators). If HEDIS, CAHPS or HOS is checked, plans do not need to complete items #2 through #5 for the indicator.

HEDIS (Administrative), Measurement Year: _______

HEDIS (Hybrid), Measurement Year _______

CAHPS, Measurement Year _______

HOS, Measurement Year _______

Other

1. Indicator Name:

2. Numerator description:

3. Denominator description:

4. Inclusion Criteria:

5. Exclusion Criteria:

6. Performance Target:

7. Rationale/Justification for Performance Target:

E. Data Sources and Collection Methodology

(skip section if indicators used are from standard HEDIS, CAHPS and HOS collections):

1. Identify the sources of data utilized in quality indicators/measures in this quality improvement project

Medical records

Claims or encounter data

Complaints or customer service data

Appeals

Administrative – call center data

Administrative - appointment/access data

Pharmacy data

Survey data (attach the survey tool and describe the sampling process, sample size, and the survey administration protocol. Provide response rates)

Other (list and describe):

2. Data Collection Cycle

Once a year

Twice a year

Once a quarter

Once a month

Once a week

Once a day

Continuous

Other (describe):

3. Data Analysis Cycle

Once a year

Twice a year

Once a quarter

Once a month

Other (describe):

4. Describe the baseline data collection methodology, collection periods, sampling, sample size, and efforts to assure reliability and validity.

5. Describe any changes in data collection methodology, collection periods, sampling, sample size, data sources, numerator and denominator definitions, inclusion and exclusion criteria or analysis that have occurred since the initiation of this project. Include a rationale for each change and an assessment of the impact of these changes on the quality improvement indicators.

F. Results:

1. Complete the results table below with the measurement periods and results for each measurement cycle for each quality indicator for this project. Add additional rows for additional measurement cycles and indicators as needed.

	Measurement Period
	Start date	End Date	Eligible Population N	Number Excluded	Numerator	Denominator	Rate	Performance Goal Reached? (Y/N)
Indicator #1
Baseline Measurement
Remeasure-ment 1
Remeasure-ment 2
Indicator #2
Baseline Measurement
Remeasure-ment 1
Remeasure-ment 2
Indicator #3
Baseline Measurement
Remeasure-ment 1
Remeasure-ment 2
(Repeat rows for additional Indicator as needed)

2. Describe barriers (if any) to improving your quality indicators, and the strategies employed to overcome them (Optional).

3. Describe improvements achieved (if any) in your quality indicators and how they impact the health outcomes and/or delivery of health care to your Medicare Advantage enrollees.

G. Interventions:

1. Complete the intervention & intervention modification timetable below with the implementation date, duration, target group, staff/partners used in implementation, and any barriers that the interventions were meant to address.

Intervention Description (or description of Modification)	Implement-ation Date	Duration, OR indicate if ongoing	Target group for Intervention	Staff/Partners in implement-ation	Barriers addressed by the intervention

H. External Consultation and Delegation

1. Did you seek Consultation and/or Technical Assistance from the Quality Improvement Organization / QIO in your State?

Yes

No

1.a. Indicate QIO involvement on this QI Project: (Select all that apply)

Performance Improvement Project Review

Study Design Development

Liaison with CMS

Continuous Quality Improvement (CQI) Training

Data Analysis

Development, Testing, and Training on Electronic and/or Paper Abstraction Tools

Design & Development of Intervention Materials (graphic design and printing)

Dissemination of Intervention Materials (mailing to all physicians and/or beneficiaries)

Facilitation of Group Collaborative Projects (focus group, provider meetings)

Brief consultation

Collaborative Project

Other

2. Did you seek Consultation and/or Technical Assistance from another organization, outside of your QIO?

Yes

No

2.a. Identify the organization ________________

2.b. External Consultation/Technical Assistance from Other Organization: (Select all that apply)

Performance Improvement Project Review

Study Design Development

Liaison with CMS

Continuous Quality Improvement (CQI) Training

Data Analysis

Development, Testing, and Training on Electronic and/or Paper Abstraction Tools

Design & Development of Intervention Materials (graphic design and printing)

Dissemination of Intervention Materials (mailing to all physicians and/or beneficiaries)

Facilitation of Group Collaborative Projects (focus group, provider meetings)

Other

3. Are any aspects of your organization’s Quality Improvement Program delegated or outsourced? If so list the delegated tasks and the contractor/delegated entity performing the tasks:

3a. Explain how these delegated entities are monitored for compliance with Federal and State requirements, and how often.

3b. Explain how these delegated entities are monitored for general quality assurance purposes, and how often.

I. Lessons Learned (Optional)

1. State any “lessons learned” from conducting this QI project:

2. What system-level changes were made and/or planned as a result of this project:

3. What opportunities for future improvement were identified in the course of conducting this project:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938- Pending Approval. The time required to complete this information is estimated to average 4 hours 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have comments concerning the accuracy of the time estimate of suggestions for improving this form, please write to: CMS 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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Last revised March 2007.

CMS #10209 - QIP.