4665 Business Center Dr.
Fairfield, CA 94534
Template A
Quality Improvement Program
Operations Measures Reporting Template: Third Next Available Appointment (3NA)
Submit quarterly data either using this template via email at QIP@partnershiphp.org or fax at (707) 8634316
Measurement Period
Quarter 1: July 1, 2014-September 30, 2014
Quarter 2: October 1, 2014- December 31, 2014
Quarter 3: January 1, 2015- March 31, 2015
Quarter 4: April 1, 2015- June 30, 2015
Provider Site:
Name of Staff:
Due Date
October 31, 2014
January 31, 2015
April 30, 2015
July 31, 2015
Date of Submission:
Please describe how this data is used internally at your site:
Provider 1 name:
Provider 2 name:
Provider 3 name:
Date of Day Zero (the date of the first clinic):
Date and time of third open appointment:
Third Next Available Appointment (Days):
Date of Day Zero (the date of the first clinic):
Date and time of third open appointment:
Third Next Available Appointment (Days):
Date of Day Zero (the date of the first clinic):
Date and time of third open appointment:
Third Next Available Appointment (Days):
Add additional rows as necessary.
Average 3NA:
4665 Business Center Dr.
Fairfield, CA 94534
Template B
Quality Improvement Program
Operations Measures Reporting Template: Days from Scheduling to Check In
Provider Site:_
Name of Staff:
Date of Submission:
Please describe how this data is used internally at your site:
Rendering Provider
Average Date
Scheduled
Provider 1 name:
Provider 2 name:
Provider 3 name:
Provider 4 name:
Add additional rows as necessary.
Average Date of Check
In
Average Days between
Scheduling and Check In
4665 Business Center Dr.
Fairfield, CA 94534
Template C
Quality Improvement Program
Operations Measures Reporting Template: Provider/Team Continuity
Provider Site:
Name of Staff:
Date of Submission:
Please describe how this data is used internally at your site:
Name of Provider/Care Team 1:
Denominator (Total number of pre-scheduled appointments for a provider visit within the last full
month of the reporting quarter. Exclude walk-ins; same day appointments DO NOT count as a walk-in
and can be included in your denominator):
Numerator (Of the total number of visits in the denominator, the number of these visits where their
patients’ visits saw them or a member of their care team):
Percent of visits to assigned provider/care team (Num/Denom*100):
Name of Provider/Care Team 2:
Denominator:
Numerator:
Percent of visits to assigned provider/care team:
Add additional rows as necessary.
4665 Business Center Dr.
Fairfield, CA 94534
Template D
Quality Improvement Program
Operations Measures Reporting Template: No Show Rate
Provider Site:
Name of Staff:
Date of Submission:
Please describe how this data is used internally at your site:
Denominator (Total number of pre-scheduled appointments for a provider visit within the last full
month of the reporting quarter. Exclude walk-ins; same day appointments DO NOT count as a walk-in
and can be included in your denominator):
Numerator (Total number of appointments that were not kept by patients in the last month of the
reporting quarter):
No Show Rate (Num/Denom*100):
4665 Business Center Dr.
Fairfield, CA 94534
Template E
Quality Improvement Program
Operations Measures Reporting Template: Call Abandonment Rate
Provider Site:
Name of Staff:
Date of Submission:
Please describe how this data is used internally at your site:
Denominator (Total number of incoming phone calls during business hours, as measured by phone
management system. Measured for all incoming phone calls that occur during a week of the reporting
quarter):
Numerator (Number of incoming phone calls that did not stay on hold long enough for their call to be
answered by a clinic staff person:
Call Abandonment Rate (Num/Denom*100):