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 documentation that clearly describes the resources and methods that your organization uses to collect, analyze, report, and use performance data. That documentation should also describe your approach to data quality for each. Your documentation likely will include your QM program description, data reports, work flows, and committee meeting minutes.
Validation Review
The reviewer will 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.