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Concept: Performance Measurement and Quality Improvement (QI)

• The practice establishes a culture of data-driven performance improvement on clinical quality, efficiency and patient experience, and engages staff and patients/families/caregivers in quality improvement activities.

• 3 Competencies• 19 Criteria:

• 9 Core• 10 Elective (16 credits)

• 3 New to 2017 criteria

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• Competency A: The practice measures to understand current performance and to identify opportunities for improvement.

• Competency B: The practice evaluates its performance against goals or benchmarks and uses the results to prioritize and implement improvement strategies.

Performance Management and Quality Improvement (QI)

Criteria Core Elective # Credits

QI01: Monitors at least 5 clinical quality measures across the four categories (must monitor at least one measure of each type)

X

QI02: Monitors at least 2 measures of resource stewardship (must monitor at least 1 of each type) X

QI03: Assesses performance on availability of major appointment types to meet patient needs and preference for access

X

QI04: Monitors patient experience through: A. Quantitative Data B. Qualitative Data X

QI05: Assesses health disparities using performance data stratified for vulnerable populations (must choose from each section): A. Clinical Quality B. Patient Experience

X 1

QI06: The practice uses a standardized, validated patient experience survey tool with benchmarkingdata available

X 1

QI07: The practice obtains feedback on experience of vulnerable patient groups X 2

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•S - Specific

•M - Measureable

•A - Achievable/Attainable

•R - Relevant

•T - Time Basedhttp://www.iom.edu/About-IOM/Making-a-Difference/Community-

SMART Goals

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Quality Improvement vs. Process Improvement• Quality Improvement (QI) and Process Improvement (PI) are often

used interchangeably, but it is important to understand the differences between the two.

Quality Improvement is the overarching strategic process of applying a formal approach to the analysis of performance and the systematic efforts to improve it. (DMAIC)

Process Improvement is the planning and execution of tasks; and the implementation of cyclic tests of change to support QI. (PDSA/Pilot Studies)

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• Plan – Do – Study – Act • The PDSA cycle is shorthand for testing a

change—by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method, used for action-oriented learning.

(https://innovations.ahrq.gov/qualitytools/plan- do-study-act-pdsa-cycle)

Process Improvement-What is PDSA?

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• By using the PDSA cycle to incrementally test change in an effort to improve, we are able to apply pragmatic steps of Process Improvement toward reaching the strategic level goals of Quality Improvement.

How to Use PDSA

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FMEA Example

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QI08: Goals and Plan/DoSelect 3 from 3 different types of measures you reported in Q101

QI09: Goals and Plan/DoSelect 1 from measures you

reported in QI02

QI10: Goals and Plan/DoSelect from report in QI03

QI12. Improve and ActImprovement on 2 measures

from QI 8,9,11)

QI14: Improve and ActShow improvement on 1

measure from QI13

QI12: StudyStudy measures over time

from QI 8,9,11

QI14: StudyStudy all measures from QI14

QI B. Goals and Plan/Do QIB: Improve and Act

QI11: Goals and Plan/DoSelect from 1 measure reported

in QI04

QI13: Goals and Plan/DoSelect 1 from QI05

QI01: CLINICAL (min. 1 of each) Immunizations

Other preventive careChronic/Acute careBehavioral Health

QI02: : Resource Use and stewardship (min. 1 of each)

Care CoordinationMeasures affecting Health Care

Costs

QI03: Appt. AvailabilityAccess to appointment types to meet patient preferences and

needs

QI A. Do you have data?

QI04: Pt. ExperienceQuantitative DataQualitative Data

QI05: Health Disparities (min. 1 from each section)

Clinical QualityPt. Experience

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• The practice establishes a culture of data-driven performance improvement on clinical quality, efficiency and patient experience, and engages staff and patients/families/caregivers in quality improvement activities.

• Competency C: The practice is accountable for performance. The practice shares performance data with the practice, patients and/or publicly for the measures and patient populations identified in the previous section. .

Performance Management and Quality Improvement (QI)

Criteria Core Elective # Credits

QI15: Reports practice level or individual clinician performance results within the practice for measures reported by the practice

X

QI16: Reports practice-level or individual clinician performance results publicly or with patients formeasures reported by the practice

X 1

QI17: Involves patient/family/caregiver in quality improvement activities X 2

QI18: Reports clinical quality measures to Medicare or Medicaid agency X 2

QI19: Is engaged in Value-Based Arrangements X Max. 2

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QI 15 (Core)

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QI15: Reports Clinician or Site Level Performance Data within the Practice

• Employee engagement• Relevance• Prioritize• Pt. care vs. “check the box”

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QI 16 (1 Credit)

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QI16: Reports performance results publicly or with patients

• 1 site= UDS• Patient engagement• Be selective

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QI 17 (2 Credits)

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QI17: Involves patient/families in QI Activities• CHCs: 51% of your BOD is

patients-but are you truly dong QI?

• Customer Focus Groups• PAC• Focus, Focus, Focus

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QI 18 (2 Credits)

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QI18: Reports clinical quality measures to Medicare or Medicaid agency

• ACO• CPC• PQRS• MU

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QI 19 (Maximum 2 Credits)

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QI19: Participates in Value Based Arrangements

• Up-side risk vs. Two side risk• Are you a PCMH???

• A sign of things to come

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QI: Your Transformational Application

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BREAK