Module 3 · Provider Performance · 3.9
Corrective Action & Improvement Planning
The full CAP / PIP lifecycle — a managed improvement process with documented milestones, accountability, and escalation paths. Funnel-stage conversion floors extend the base trigger criteria.
Funnel-stage triggers (Stage C)Stage 2→3 engagement conversion: < 60% → CAP-eligibleStage 4→5 measurement completion: < 85% → CAP-eligible
CAP / PIP board
Initiated 1
In Progress 1
Under Review 1
Completed 1
Escalated 1
Trigger monitor — meet criteria, no active plan
Any measure below floor for 2 consecutive periodsComposite score below 60 for 1 periodNever event occurrencePROMs collection rate below 50% for 2 periodsProvider-requested improvement support
Dr. Ahmed Al-Shehri (P08)
Any measure below floor for 2 consecutive periods
D4-01 med reconciliation 82% < 85% floor for Q2 & Q3
Dr. Layla Al-Qahtani (P07)
PROMs collection rate below 50% for 2 periods
EQ-5D collection 47% then 45%
Al-Hada Rehabilitation Program
Provider-requested improvement support
Vendor requested MCID coaching ahead of tenure lock