Fillable Printable QI Annual Report Template
Fillable Printable QI Annual Report Template
QI Annual Report Template
QI Annual Report Template Instructions
The following template has been created to help Providers who receive IPRS and local funding
from The Durham Center with writing of Quality Improvement Annual Reports. The template is for
your convenience only. If you prefer not using this form, your reports will be accepted in another
format, provided that elements 1 through 5 of this template are adequately addressed, containing
information required by the Quality Management Department of The Durham Center.
If your fiscal year ends in June your QI Report will be due annually by September 1
st
.
If your fiscal year ends in December your QI Report will be due annually by March 1
st
.
For additional copies of this template go to our website at: www.durhamcenter.org, click on
Provider Community, then on Provider Manual/Forms. You will see a link for a Quality Report
Template. Completed reports are to be sent to LisaCaitlin Perri, Quality Management Department,
501 Willard St., Durham, NC 27701. You may fax to LisaCaitlin at 560-7250.
Agency Name:___________________________________________________________________
Address:_______________________________________________________________________
Name of person to contact regarding this completed report:_______________________________
Phone:__________________________ Email Address:_________________________________
Do not complete this section – for The Durham Center staff only
Date report was received by The Durham Center:
QI Template for FY 2008
Revised 5-07
1
QI Template for FY 2008
Revised 5-07
2
Quality Improvement Annual Report Template
1. Provide a description of your QI projects and address each of the numbered items below.
For each project described, please indicate if the project is related to a plan of correction.
1. Data or information used as a basis for this project
2. Define the project purpose
3. Indicators measured
4. Methodology
5. Results (i.e. percentages, averages or other appropriate numerical format)
6. Project impact (i.e. improvements that have occurred or changes implemented as a result of this
project)
QI Template for FY 2008
Revised 5-07
3
2. Provide results data for each of the following elements, which you described in your QI
Plan. Identify any change in methodology that you may have encountered.
1. Record review
2. Consumer Review/Participation
3. Consumer Satisfaction
4. Fidelity Scale Assessments for Evidence Based Practices (if applicable)
5. Program Specific Outcome Evaluation updates for services other than Evidence Based
Practices
QI Template for FY 2008
Revised 5-07
4
3. Include copies of your QI Committee minutes for the past 12 months.
4. Attach a copy of your program evaluation sheet (element #16 of the QI Plan Template)
and discuss what changes have occurred related to the original outcomes you defined,
measured and tracked (for those providers without Evidence Based Practices).
If new outcomes have been established since you submitted your plan, please define
them on the evaluation sheet and attach to this report. Please highlight changes.
5. If your agency has experienced any changes related to elements 1 through 15 of the QI
Plan Template, attach a revised QI Plan with this report.
