The COAP Quality Improvement Plan describes two levels of participation. A hospital that is “participating in full compliance with community QI standards” has met community standards for data completeness, timeliness and reliability. Additionally, if one or more process or outcome measures are significantly outside the state mean, an acceptable improvement plan is in place, and outliers have not exceeded the threshold upon re-measurement. A hospital that does not meet all of these criteria is considered to be “participating in partial compliance with community QI standards.” Participation status is assessed and updated twice a year.