As a healthcare provider or organization, you may find yourself at some point needing to become accredited. Whether it may be to meet state-mandated regulatory requirements or to satisfy specific contractual requirements with other parties, pursuing accreditation might become a reality for your organization.
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By Jean Lockington, MA, RN, PLNC, PCMH CCE
For NCQA accreditation, there is often a requirement to submit a report that includes a quantitative and qualitative analysis. Where does one begin? At times organizations prepare a report that shows data in a graph/grid format, comparing data from year to year. Presenting data in this format alone does not meet the intent of the standards without a description about the data, what the data shows, and comparing data against a goal/benchmark. When data doesn’t meet the organizational goals, performing a qualitative analysis (what did the data indicate and possible reasons for not meeting goal?) is required.
When preparing a report requiring a full analysis cycle, the following components should be included:
Relevance of Project: It is always best to describe why a certain project or report is being developed by the Organization. Why is the project relevant and important for the membership of the Organization?
Data Utilized: Describe data being gathered for project; document where, when, who collects data; always present data with a numerator, denominator and percentage (50/100 is 50%);
Methodology: Explain how data collected; was a survey completed? Was it mailed or performed telephonically; is survey completed by organizational staff or performed by an outside vendor. if a sample is used, be sure to describe sampling methodology; if survey mailed, describe the number of surveys sent and the response rate for surveys. When performing a telephonic survey, is it performed by a live call, recording, vendor or internal staff from a certain department. Describe who answered survey questions such as staff in a practice or the actual clinician.
A valid methodology is a data collection technique that produces consistent, reproducible results and shows a clear relationship between collected data and conclusions drawn from the analysis the data.
Timeframe of Project: Explain timeframe for data in report such as calendar year of January 1 to December 31, 2017.
Performance Goal: a desired level of achievement measured by specific objectives and targets. Goals may be expressed as thresholds or industry best performance which is a benchmark. Goals change as performance improves or as the standard of care is refined.
Quantitative Analysis: Is a review and comparison of numeric results against a goal or benchmark, trended over time using charts, graphs or tables.; always develop a goal or benchmark with data and trend data over time such as CY 2014, 2015 and 2016. In addition to a narrative, can develop charts, graphs or table to display the data. Graphs tell a story in a picture. Be sure to document if any changes in methodology occurs such as previous year was mail survey and current year is a telephonic survey. Display of data alone in a graph is not sufficient but provide a narrative with a description of what the results of the data has revealed such as results have increased or decreased over time. Don’t rely on the graphs and grids to just tell your story! Did the data presented meet your goal or benchmark?
Qualitative Analysis: Is the review of deficiencies that can cause barriers or prevents organization from reaching their established goal. Within qualitative analysis, describe team who reviewed data such as Medical Director, QI Director, Provider Relations Manager, Customer Service Representative. If organization has met the goal, then state that if the Report. Review can explain possible reasons why organization met goal or didn’t meet goal. This is referred to as a barrier or causal analysis. Always include those individuals responsible for the execution of the program.
Opportunities for Improvement: Once qualitative analysis is performed; organizational staff can identify possible interventions which could be implemented to improve the metrics being measured and mitigate the barriers identified followed by possible improvement in the next re-measurement cycle
Implementation of Actions: Actions identified through the review of Opportunities such as a documented process, development of a member newsletter article or increase of care managers to handle members with multiple ER admissions. Always include dates of actions implemented with a date and year such as March 2018 or 1st quarter 2018.
Developing reports and performing a full quantitative and qualitative analysis provides organizations with the steps and information to make improvements and identify if their opportunities for improvement and actions implemented are making a difference with the individuals being serviced by the organizations. Analysis reports should be submitted to the Organization’s Quality Committee with the opportunity to provide comments and recommendations.
About the Author:
Jean Lockington, MA, RN, PLNC, PCMH CCE has worked for Professional Services Network as a consultant for many years. She has over 25 years’ experience working as a Senior Executive in managed care. Her areas of expertise include quality improvement, regulatory compliance, new business development, process improvement and accreditation preparation.
About Professional Services Network, Inc.
Professional Services Network, Inc. (PSN) works with clients nationwide in the search and recruitment of experienced healthcare professionals in managed care and clinical roles for temporary assignments and direct hire opportunities. Additionally, PSN’s consultants work with organizations and providers seeking accreditation or re-accreditation with URAC or NCQA. For additional information regarding our services contact us at 301-460-4089 or email us at This email address is being protected from spambots. You need JavaScript enabled to view it..
The NCQA Patient Centered Medical Home is a voluntary recognition program for physician practices that provide a medical “home,” or coordinating point, for their patients. Building on the joint principles developed by the primary care specialty societies (American College of Physicians, American Academy of Family Physicians, American Academy of Pediatrics and American Osteopathic Association), the NCQA Medical Home standards assess whether the practices are functioning as medical homes.
The standards require documentation and measurement of the practice’s ability to strengthen the physician-patient relationship by promoting improved access, coordinated care, and enhanced patient/family engagement.
What can NCQA Patient-Centered Medical Home (PCMH) Recognition do for you?
What can PSN provide?
For information about NCQA Accreditation programs, please visit www.ncqa.org. If you would like assistance from one of our expert accreditation consultants who will guide you through to sucess, please email an inquiry to This email address is being protected from spambots. You need JavaScript enabled to view it.
Meet our consultants at: https://www.psninc.net/consulting/consultants/
Professional Services Network, Inc. (PSN) works with clients nationwide in the search and recruitment of experienced healthcare professionals in managed care and clinical roles for temporary assignments and direct hire opportunities. Additionally, PSN’s consultants work with organizations and providers seeking accreditation or re-accreditation with URAC or NCQA. For additional information regarding our services contact us at 301-460-4089 or email us at This email address is being protected from spambots. You need JavaScript enabled to view it..