Performance Measurement & Quality Improvement

In an effort to provide increasingly exceptional patient care, our department implemented several quality improvement measures over the last 18 months:

HPV Vaccinations

Measure: Increase the percentage of eligible patients that receive their HPV vaccination.
Baseline Start Date: 01/01/2016 Baseline End Date: 03/31/2016
Baseline Performance Rate (% or #): 6/312 = 2%
Numeric Goal Rate (% or #): ≥4%

Action: Make a note of all patients on the schedule who are eligible to receive their HPV vaccination on the provider’s schedule during chart prep.
Date Action Initiated: 04/01/2016
Remeasurement Start Date: 04/01/2016 End Date: 06/30/2016
Rate (% or #): 17/350 = 5%

Assessment: During a 3‐month measurement period from January‐March 2016, two percent of all eligible patients had received their HPV vaccination(s). By flagging eligible patients during the chart prep process, we were able to increase the total percentage of patients that received their HPV vaccination to 5 percent during the remeasurement period of April–June 2016.

Family Medicine HPV Vaccinations: 01/01/16-03/31/16Family Medicine HPV Vaccinations: 04/01/16-06/30/16

 

Wellness Checks

Measure: Increase the percentage of patients that receive their annual wellness checks (preventive care visits).
Baseline Start Date: 04/01/2016 Baseline End Date: 06/30/2016
Baseline Performance Rate (% or #): 1,886/5,909 = 32%
Numeric Goal Rate (% or #): ≥50%

Action: Recruit and hire more primary care providers for the clinic, to ensure adequate access for our patients, and increase the amount of preventive visits available.
Date Action Initiated: 07/01/2016
Remeasurement Start Date: 07/01/2016 End Date: 09/30/2016
Rate (% or #): 2,328/4,165 = 56%

Assessment: During a 3‐month measurement period from April‐June 2016, 32 percent of all patients had received their recommended annual wellness check. By recruiting and hiring five additional physician and allied health professionals, we were able to increase the total percentage of patients that received their annual wellness check to 56 percent during the remeasurement period of July–September 2016.

Family Medicine Wellness Checks: 04/01/16-06/60/16Family Medicine Wellness Checks: 07/01/16-09/30/16

 

Diabetic Foot Exams

Measure: Increase the percentage of our diabetic patients that receive their annualfoot exam.
Baseline Start Date: 07/01/2016 Baseline End Date: 09/30/2016
Baseline Performance Rate (% or #): 792/1434 = 55%
Numeric Goal Rate (% or #): ≥60%

Action: A foot exam template was shared in the EMR with all providers for them to access easily inside any visit with their diabetic patients.
Date Action Initiated: 10/01/2016
Additional Actions: Notes reminding the providers to perform foot exams, and information for accessing the template, were attached to every provider’s computer in the clinic hallways.
Remeasurement Start Date: 10/01/2016 End Date: 12/31/2016
Rate (% or #): 1,018/1,703 = 60%

Assessment: During a 3‐month measurement period from July‐September 2016, 55 percent of all diabetic patients had received their recommended yearly foot exam. By sharing an easy‐to‐access foot exam template in the EMR, and placing reminder notes for the foot exams on the providers’ computers, we were able to increase the total percentage of diabetic patients that received their annual recommended foot exam to 60 percent during the remeasurement period of April–June 2016.

Family Medicine Diabetic Foot Exams: 07/01/16-09/31/16Family Medicine Diabetic Foot Exams: 10/01/16-12/31/16

 

Access

Measure: Increase the number of patients who call in and are able to obtain an appointment for care they needed right away.
Baseline Start Date: 09/01/2016 Baseline End Date: 11/30/2016
Baseline Performance Rate (% or #): 3.4/4.0
Numeric Goal Rate (% or #): 4.0

Action: Increase the number of same‐day only appointments available for patients needing to be seen right away.
Date Action Initiated: 12/01/2016
Additional Actions: Recruit and hire a nurse practitioner whose schedule will consist only of same‐day and evening appointments.
Remeasurement Start Date: 12/01/2016 End Date: 02/28/2017
Rate (% or #): 3.8/4.0

Assessment: During a 3‐month measurement period from September–November 2016, we received a score of 3.4/4.0 on our Patient Experience Survey for the question: “In the last 12 months, if you phoned Family Medicine to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?”. By hiring a new nurse practitioner whose schedule consisted of only same‐day and evening appointments. As a result of this, our score for the aforementioned question increased 0.4 points to be 3.8/4.0 for the remeasurement period of December 2016–February 2017.

Family Medicine Access: 01/01/16-03/31/16Family Medicine Access: 04/01/16-06/30/16