Quality Improvement Activity Form

Quality Improvement Activity Form (an electronic version is available on NCQA’s 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:
Numerator:
Denominator:
First measurement period dates:
Baseline Benchmark:
Source of benchmark:
Baseline goal:

Quantifiable Measure #2:
Numerator:
Denominator:
First measurement period dates:
Benchmark:
Source of benchmark:
Baseline goal:
Quantifiable Measure #3:
Numerator:
Denominator:
First measurement period dates:
Benchmark:
Source of benchmark:
Baseline goal:
C. Baseline Methodology.

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This section asks you to define your rationale for selecting this activity for improvement.
• Why was it chosen over others?
• Why is it important to your members or practitioners?
• Why is it worth the resources your organization is spending on it?
Using objective information provide as much information that is specific to your organization as possible.
You do not have to provide generic defenses for most clinical or service issues. For example, do not include explanatory phrases such as “member services departments serve many important functions”, or “neuropathy of the foot is a serious condition that affects thousands of diabetics nationwide.”
Nor is it necessary to provide literature source cites on the importance of a clinical or service issue to members unless it is an unusual topic. Focus on the importance of the activity to your organization.