The Quality Improvement Plan shows where a single provider should focus their efforts to improve quality.

The top table shows how many points the provider scored on the most recent QM update from CMS. You can see how many points they need to move up a star and also how many they can lose before they go down a star.

The rest of the report is broken down into two sections. The top section is to help you improve your quality score. The bottom section is to see where things could go worse.

Improve quality

When you want to choose where to spend your QAPI efforts look at the 2nd table. It shows the QMs ranked in order of “mathematically easiest to improve.” It may be that the top QMs in that table aren’t what best suit a provider’s capabilities, but its where they’d have the easiest time picking up more quality points.

Try to find one or two QMs to focus on in the next quarter.

Reading the table from left to right, you see the QM, the points the provider currently has, the number of incidents they need to fix to move up to more quality points, the number of points they’lly gain by moving up, and the number of points they get for each incident they fix. Then we show their current rate of incidence, the next better cut point, and the % difference between the two. We exclude the QMs where the provider is already scoring 100 points.

Protect your performance

The 3rd section shows in which QMs a provider could lose points in. The table is ranked in order from most dangerous to least. If a provider isn’t using restraints, then its usually at the top of this table. It is very similar to the improvement table. The only difference being that is shows where and how you can lose points rather than gain them.

Table column descriptions

You can click on the column headings to sort the columns. All QMs are “lower is better” unless specified next to the QM name.

The 2nd & 3rd tables show:

Column Name Description
QM The name of the QM.
Trend A plot of the recent performance in the QM.
Point Analysis Section Some analysis of the score earned in the QM.
Current points The points earned by the provider in the most recent CMS data release.
Fix (Cause) Fix this many incidents to move up (down) to the next performance level.
Gain (Lose) How many points you gain moving up (down) to the next performance level.
Points per Incident How many points the provider gets per incident fixed (or avoided).
Cut point analysis Since QMs are measured as rates of occurrence we analyze those percentages here.
Current rate The current rate of occurrence in the facility.
Nearest cut point The rate they would have to achieve to move up (down) and gain (lose) points.
Distance to cut point The % the provider needs to improve to achieve the next better (worse) point level.

Use with providers

Since this is not a comparison report just choose a provider from the Analyze menu at the top left or click on a search result and open this report.

Use with groups

This report cannot be used with groups right now.