Core 4.0

C-PMI 1-4: Data Management and Performance Reporting

Submited by: Tom Goddard

The Basics

This standard focuses on the data side of the QM program. Your QM documentation needs to clearly identify:

  • how you collect performance indicator data;
  • how you analyze those data; and
  • how and to whom you report data.
In addition, the performance indicators must be relevant to your organization's performance and must be quantifiable. You'll need to benchmark your performance on these performance indicators.
Finally, this standard requires that you insure the integrity of the performance data collection and analysis before those data are used in the management of key processes.

Management Tips

The manager's job with respect to this standard is to ensure that your documentation clearly identifies the collection, analysis, and reporting of quantifiable performance indicators. Additionally, you must ensure data quality at all stages of the process.
These standards apply to all the various performance indicators referenced in the previous standard, including access, complaints, satisfaction, and/or outcome data. 

Accreditation Tips

Desktop Review
Submit a combination of documents (e.g., policies, QM plan, reports, workflows) that clearly illustrate to the reviewer how you manage data used in the QM processes.
Validation Review
The reviewer may talk about data quality, collection, and analysis with both leadership and staff members involved in your QM program. 
Document review
The reviewer will examine meeting minutes and reports that show your organization's analysis of performance data.

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