CMS-10209 QIP_Reporting_Tool

Quality Improvement Project (QIP) Reporting Tool
A. Medicare Advantage Organization (MAO) Information
MAO Name
Contract #

Identification #

MAO Location
Contact Person

Name

Title

Telephone

MAO Plan Type:

HMO

Email

PPO

PFFS

SNP:

Other ________

___ Chronic
(type) ______________
___ Dual Eligible
___ Institutional

Project Cycle: (drop down) __ Baseline __ Year 1 __ Year 2 __ Year 3 __ Other

B. Background
Quality Improvement Project (QIP) Topic: ____________________________________
Clinical___

Non-clinical___

Domain: ___________________________ (if applicable)

Clinical – An organizational improvement project focused on the structure and processes that will enhance care and
services to Medicare Advantage Organization (MAO) plan enrollees in order to improve health outcomes. These
include but are not limited to: prevention and wellness programs; care management; utilization management criteria
and guidelines; peer review; medical technology review; pharmaceutical management procedures; medical record
criteria; and processes to enhance communication and continuity of care between practitioners and providers.
Non-clinical – An organizational project focused on improving and enhancing health plan policies and procedures,
benefit and coverage information and service standards (customer service, appeals and grievances) in order to
ensure timely access and delivery of services to the MAO enrollees.

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 0938-1023. The time required
to complete this information is estimated to average 5 hours per response. If you have comments concerning the accuracy of the
time estimate or suggestions for improving this form, please write to: CMS 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Baltimore, Maryland 21244-1580.

QIP Reporting Tool

PLAN
C. Data Sources Used for Problem Identification (Check all that apply)
__Medical Records
__Claims (Medical, Pharmacy, Laboratory)
__Appointment Data
__Plan Data (complaints, appeals, customer
service)
__Health Risk Assessment (HRA) Tools
__Surveys (enrollee, beneficiary satisfaction,
other)
__Minimum Data Set (MDS) - Institutional SNP

__MAO Part C Reporting Requirements
__Encounter Data
__Audit Findings
__Health Effectiveness Data Information Set
(HEDIS®)
__Health Outcomes Survey (HOS)
__Consumer Assessment of Healthcare
Providers and Systems (CAHPS®)
__ Registries
__Other Sources _______________________

D. Based on Model of Care (Check all that apply)
__ Not Applicable

__ MOC Training

__ Description of SNP Population

__ HRA

__ Measurable Goals

__ Individualized Care Plans

__ Staff Structure & Care Management Roles

__ Communication Network

__ Interdisciplinary Care Team (ICT)

__ Care Management for the Most Vulnerable
Populations

__ Provider Network Having Special Expertise &
Use of Clinical Practice Guidelines

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__ Performance & Health Outcome Measurement

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E. Basis of Selection
Please provide an overall description of the QIP for the year:
E1. Description of
the QIP

E2. Impact on
Member

E3. Anticipated
Outcome

E4. Rationale for
Selection

__ Health Outcomes
__ Member Satisfaction
__ Other

F. Prior Focus
Describe any previous attempts to address the problem.
_______Previous Cycle

_________ Other (Previously studied but
not presented as a QIP)

F1.Cycle/
Year

F2. Intervention

F3. Outcome
Achieved

(actions taken to achieve goal)

F4. Priority
Assessed

G. Project Goal and Benchmark
G1. Target Goal and Benchmark:
G1a. Target Goal:

G1b. Benchmark:

__ Baseline

__ Internal

__ External

G1c. Rationale:

G1d. Planned Intervention

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G1e. Inclusion
Criteria

3

G1f.
Methodology

G1g.
Timeframe

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G2. Risk Assessment:
G2a.
Intervention

G2b.Target
Audience

G2c. Anticipated Barrier

G2d. Mitigation Plan

Auto Populate

H. Plan Project Approval: (Medical Director)
This section to be completed by the responsible person.
Name of Individual

Title

E-mail
Address

Phone

Date of
Approval

I. CMS Regional Office Approval
Yes ___
No ___ Reason: _______________________________________________
Name of Individual

Title

Date of Approval

The above information will remain in the system for reporting in subsequent years.

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DO
J. Project Implementation Review and Revisions
J1. Goal and Benchmark:
J1a. Goal:

Auto populate

J1b. Benchmark:

J1c.
Intervention

Auto populate

J1d.
Target
Audience

Actions taken to
achieve the goal
(Auto Populate
from Plan Section)

J1e.
Timeframe

(Auto Populate
from Plan Section)

J1f.
Barriers Encountered

(Auto Populate
from Plan Section)

J2. Mitigation Plan for Risk Assessment:
J2a. Mitigation Plan
Complete all applicable sections.

J2b.
Intervention

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J2c.
Timeframe

J2d.
Target
Audience

J2f.
Rationale

J2g.
Anticipated
Impact on
Goal

J2e.
Measurement
Methodology

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Study
K. Results
K1. Intervention: Auto Populate from Plan Section
K2.
Project
Cycle/Year

K3.
Time
Frame
(Auto
populate
from
Plan
section)

K4.
Sample
Size
or Total
Populatio
n
(Number)

K5.
Numerato
r
(skip if not
applicable)

K6.
Denominator
(skip if not
applicable)

K7.
Results
and/or
Percentage

K8.
Other
Data or
Results

K9.
Target
Goal
(Auto
populate
from Plan
section)

K10.
Benchmar
k (Auto
populate
from Plan
section)

Baseline

Remeasurement
Period #1

Remeasurement
Period #2

Remeasurement
Period #3

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ACT
L. Summary of Findings or Study Conclusions
L1. Study Findings/
Conclusions

(Narrative)

L2. State if any “Best
Practices” resulted from the
findings.

(Narrative)

L3. Describe any “Lessons
Learned”

(Narrative)

M. Root Cause Analysis Description Goal/Progress Not Achieved:
M1. Intervention

M2. Root Cause Analysis

(Auto Populate from Plan
Section)

M3. Action Plan
(Drop down boxes)

__ Revise intervention
__ Revise methodology
__ Change goal
__ Other ________________

N. Action Plan Description
N1. Next Steps

N2. Action Plan
(Description of how next steps will be implemented)

O. Next Steps Goal Met/Progress Demonstrated (Check all that apply):
__Adopt change
__Revise process
__Apply lessons learned to other areas
__Implement policy change
__Issue resolved, no need for further study
__Other (describe) ___________________________

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