No. Comment sections or “free text” questions on a patient experience survey do not meet the requirement as a method of collecting qualitative feedback from patients and their families.
FAQ Directory
Here are some of the most frequently asked questions about NCQA’s various programs. If you don’t see what you are looking for in one of the entries below, you can ask a question through My NCQA.
Filter Results
-
Save
Save your favorite pages and receive notifications whenever they’re updated.
You will be prompted to log in to your NCQA account.
Save your favorite pages and receive notifications whenever they’re updated.
You will be prompted to log in to your NCQA account.
-
Email
Share this page with a friend or colleague by Email.
We do not share your information with third parties.
Share this page with a friend or colleague by Email.
We do not share your information with third parties.
-
Print
Print this page.
Print this page.
5.29.2018 QI 04B May practices use the “comments” section in the patient experience survey to meet this requirement?
5.29.2018 QI 12 When remeasuring to show improvement, what is an acceptable period of time between the initial measurement and the follow-up measurement period?
5.29.2018 QI 11 May practices focus on improving the number of patient experience survey responses it receives back from patients?
No. A measure looking to increase the number of patients who complete the satisfaction survey would not meet the requirement. Practice should look at improving an area identified using the patient experience data collected in QI 04.
This applies to the following Programs and Years:
PCMH 20175.29.2018 CC 10 (PP 04) Our practice has agreements with and shares patient records with behavioral healthcare providers, but we do not share the same EHR or physical location. Do we meet the requirement for integrating behavioral healthcare in our practice?
No. Although there is no requirement for a behavioral healthcare provider to be physically in the practice’s office, the behavioral healthcare provider must have at least partial access to the practice’s systems. Although the arrangements mentioned meet the intent of CC 09 (maintaining agreements with behavioral healthcare providers), they do not meet the requirements for this criterion.
If a practice site in an organization has integrated behavioral healthcare, the other sites in the organization may receive credit if there is also a process for their patients to access those behavioral healthcare services.
This applies to the following Programs and Years:
PCMH 20175.29.2018 QI 12 How do practices assess the effectiveness of improvement actions?
Assessing effectiveness of improvement actions includes remeasurement to compare results over time and evaluation of what is driving change. Results may be quantitative (numerical data that demonstrate performance and can be compared to benchmarks) or qualitative (conceptual data that describe why performance is high or low), but practices must look at the goals set, actions taken to improve and previous or baseline results.
This applies to the following Programs and Years:
PCMH 20175.29.2018 QI 06 Are practices required to use an NCQA-Certified survey vendor to administer CAHPS PCMH?
5.29.2018 CC 01 What is the minimal information required to meet the requirements of the laboratory and radiology items outlined in CC 01?
There is no minimum data requirement. To meet this core requirement, practices must meet all six items outlined in CC 01. Practices must consider how best to demonstrate their process for each item to meet the intent as described in the guidance section of this criterion.
This applies to the following Programs and Years:
PCMH 20175.29.2018 CC 06 & CC 07 May a practice use credentialing information to meet CC 06 and CC 07?
No. Credentialing—although important to a clinician’s ability to practice—is not a specific indicator of performance or quality information. Practices must use performance data to evaluate the quality of specialists or consultants to whom they send patients. Performance data can be qualitative or quantitative and may be gathered from external reporting sources (e.g., PCSP recognition, CMS public reporting) or may be internal based on criteria defined by the practice (e.g., evaluating a specialist’s timeliness in returning referral reports, evaluating whether patients had a positive experience).
This applies to the following Programs and Years:
PCMH 20175.29.2018 CC 08 Our practice is part of an integrated health system. Do we need to show agreements between primary care providers and specialists?
Yes. Practices must have an agreement or documented process outlining the responsibilities of the referring provider and the specialist, even in an integrated system. It is essential that each provider understands the expectations and responsibilities of the referral, including the frequency and methods of communication.
This applies to the following Programs and Years:
PCMH 20175.29.2018 CC 04C Our PCPs and specialists use the same integrated EHR. Do we need to show tracking and follow-up?
Yes. Practices that use integrated systems must demonstrate how specialists are notified of a referral request and how the referral status will be tracked (including the specialist’s report). Even if the same EHR is used by both the primary care practitioner and the specialist, evidence must clearly demonstrate how the requirements are met within the system.
This applies to the following Programs and Years:
PCMH 20175.29.2018 CC 04C May practices use a “tickler file” for this item within CC 04?
No. The tracking system needs to include a record of both the order and receipt of results. A tickler system includes a copy of the order and is removed when results are received; it does not meet the requirement of the CC 04C because it does not maintain a record of receiving results.
This applies to the following Programs and Years:
PCMH 20175.29.2018 CC 12 How do practices document co-management arrangements?
The practice must demonstrate at least three examples demonstrating co-management arrangements, such as de-identified referral forms that include the arrangements or sections of the medical record specifying the clinician responsible for each component of care. For example, for a diabetic patient who is referred to a medical oncologist, the arrangement would identify which clinician manages the diabetes and which clinician manages the side-effects of the oncology treatment and their expectation for timely sharing of patient information.
