NCQA 2014 Standards
Documented Process Submission - Policies and Procedures
Based on April 2015 Update
June Levine MSN, BSN RN
Not all factors associated with specific elements require submission of Documented Processes. A Documented
Process is defined as: Written procedures, protocols, processes, & workflow forms (not explanations). The
same factors and/or other factors will require the submission of other documents.
However, in submitting the NCQA required reports, records, files and/or information materials the practice
may want to have policies and procedures to help assure practice continuity and consistency.
The names of the policies and procedures identified below are titles that would be applicable to the intent of
the Factor. However, you may have policy and procedures with a different name that includes or can include
the required information. They should be reviewed against the standard explanation and required
documentation for each applicable element.
NCQA has these requirements when submitting policies, procedures and processes.
“Policies, procedures and processes must be in place for at least 3 months prior to survey submission
 Intended for practice staff to ensure a systematic approach to patient care and practice operations
 If the documented process has been updated, the practice must provide:
 New and previous documented process or where changes have occurred
 Date of update”

See more at:
http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/DuringEarnItPCMH/OtherPCMHResources/DocumentationReportingPe
riodsPCMH2014FAQs.aspx#sthash.70Znny7P.dpuf
Documented Process Submission - Policies and Procedures
June 2015
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Standard
1. Patient-Centered Access
Element
A. Patient Centered Appointment
Access
B. 24/7 Access to Clinical Advice
C. Electronic Access
Standard
2. Team Based Care
Element
A. Continuity
B. Medical Home Responsibilities
C. Culturally and Linguistically
Appropriate Services
D. The Practice Team
Documented Process Submission - Policies and Procedures
Policy & Procedure for a Documented Process
Factors 1-6. PP: Appointment Scheduling
One PP could document requirements for all 6 factors.
Labeling each section would distinguish
requested information & provide clarity for submission.
Factors 1-4. PP: Access to Clinical Advice
One PP could document requirements for all 4 factors.
Labeling each section would distinguish
requested information & provide clarity for submission.
Factors 1-6. No documented process required
Policy & Procedure for a Documented Process
Factor 1. PP: Selection of a Personal Provider
Factor 3. PP: Orienting Patients to the Practice
Factor 4. PP: Preventive, Acute and Chronic Care
Management for the Adolescent & Young Adult
Factors 1-8. PP: Orienting Patients to the Practice
The same PP (under 2A) above can address this Element. A
policy and procedure that addresses
Factor 3: PP: Interpretive Services
Factors 1, 5, 6, 7. PP: Clinical Staff Roles or dated
descriptions of staff positions
Factor 3 & 8. PP: Staff Meetings or Huddles. You could
include Huddles in a PP titled Staff Meetings if Huddles
are limited to only certain providers &/or are limited in
their scope.
Factor 9. PP: Quality Improvement
Factor 10. PP: Patient/Family Involvement in Practice
Improvement
June 2015
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Standard
3. Population Management
Element
A. Patient Information
B. Clinical Data
C. Comprehensive Health
Assessment
D. Use Data for Population
Management
E. Implement Evidence-Based
Decision Support
Standard
4. Care Management &
Support
Standard
5. Care Coordination & Care
Transitions
Element
A. Identify Patients for Care
Management
B. Care Planning & Self-Care
Support
C. Medication Management
D. Use Electronic Prescribing
E. Support Self-Care & Shared
Decision Making
Policy & Procedure for a Documented Process
Factor 14. PP: Capturing Data for Population Management
(the data asked for is outlined in factors 1-13)
No specific PPs required
No specific PPs required
No specific PPs required
No specific PPs required
Policy & Procedure for a Documented Process
Factors 1-5. PP: Identifying Patients for Care Management
No specific PPs required
No specific PPs required
No specific PPs required
No specific PPs required
Element
A. Test tracking and Follow-Up
Policy & Procedure for a Documented Process
Factor 1-6 PP: Test Tracking and Follow-up
B. Referral Tracking & Follow-Up
C. Coordinate Care Transitions
Factors 5,6,8,10. PP: Referral Tracking and Follow-up
Factor 1. PP: Identifying patients who have been
hospitalized or have had an ER visit.
Factor 2 PP: Patient Clinical Information Provided to
Hospitals and ERs.
Factor 3. PP: Obtaining hospital discharge summaries.
Documented Process Submission - Policies and Procedures
June 2015
Page 3 of 4
5. Care Coordination & Care
Transitions, continued
C. Coordinate Care Transitions,
continued
Factor 4. PP: Patient follow-up after a hospital
admission or ER visit
Factor 5. PP: Two-way Communication with Hospitals.
Factor 6. PP: Release of Patient Information.
Standard 6
Element
6. Performance Measurement A. Measure Clinical Quality
& Quality Improvement
Performance
B. Measure Resource Use & Care
Coordination
C. Measure Patient/Family
Experience
D. Implement Continuous QI
Improvement
E. Demonstrate Continuous Quality
Improvement
F. Implement Continuous QI
Improvement
G. Use Certified EHR Technology
Factors: Document process for:
Factors 1 – 4. No documented processes required
Documented Process Submission - Policies and Procedures
June 2015
Factor 1 & 2. No documented processes required
Factors 1-4. No documented processes required
Factors 1-7. No documented processes required
Factors 1 – 4. No documented processes required
Factors 1-4. No documented processes required
Factors 1-10. No documented processes required
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