Performance Measurement and QI (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.

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.

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.

Sets goals and acts to improve performance on at least one patient experience measure.

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Achieves improved performance on at least two performance measures.

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Sets goals and acts to improve disparities in care or services on at least one measure.

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Achieves improved performance on at least one measure of disparities in care or service.

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Reports practice-level or individual clinician performance results within the practice for measures reported by the practice.

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Reports practice-level or individual clinician performance results publicly or with patients for measures reported by the practice.

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Involves patient/family/caregiver in quality improvement activities.

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Reports clinical quality measures to Medicare or Medicaid agency.

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Is engaged in Value-Based Agreement.

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