Baseline Performance Measurement (% or #): 15/563 = 2.7% Numeric Goal (% or #): 1.7% (please note that this is an inverse measure- decrease in percentage demonstrates improvement) 4. Actions taken to improve Action: Ran reports monthly to identify 2 year olds that needed a WCC. Called and work toward goal; dates parents to schedule an appointment. If unable to reach parents by phone, letters of initiation (6D 2) were mailed to parents. (Only 1 action required) Date Action Initiated: 09-01-16 Additional Actions: Also ran monthly reports in NCIR (North Carolina Immunization Registry) to identify 2 year olds who were not up-to-date on vaccines, which also sometimes correlated with being behind on well-child checks. 5. Remeasure performance. Date: 02-01-17 End Date: 02-01-17 (*please note that (6E 1,2) our system does not have the capability to run this report as a date range, at the time but instead as the number of all active patients for our practice of the report) Performance Re-Measurement (% or #): 8/550 = 1.5% 6. Assess actions and describe By running reports and contacting patients that needed 2 year well-child checks, improvement. (6E 1) our goal was to decrease the percentage by 1%. During the period of 08-23-16 to 02-01-17, we did demonstrate improvement in 2 year olds without a WCC by decreasing from 2.7% to 1.5% which surpassed our goal of 1.7%. Use ONE Measure Identified in 6B Reason: Medication reconciliation, especially during a transition of care, creates the Measure 1: 1. Measure selected for most accurate list possible of the patient’s medications. We chose this measure Medication improvement; reason for because this is very important for patient health and safety. Reconciliation selection Baseline Start Date: 10-06-15 Baseline End Date: 01-05-16 2./3. Baseline performance measurement; numeric Baseline Performance Measurement (% or #): 239/295 = 81%
Baseline Performance Measurement (% or #): 15/563 = 2.7% Numeric Goal (% or #): 1.7% (please note that this is an inverse measure- decrease in percentage demonstrates improvement) 4. Actions taken to improve and work toward goal; dates of initiation (6D 2) (Only 1 action required) Action: Ran reports monthly to identify 2 year olds that needed a WCC. Called parents to schedule an appointment. If unable to reach parents by phone, letters were mailed to parents. Date Action Initiated: 09-01-16 Additional Actions: Also ran monthly reports in NCIR (North Carolina Immunization Registry) to identify 2 year olds who were not up-to-date on vaccines, which also sometimes correlated with being behind on well-child checks. 5. Remeasure performance. (6E 1,2) Date: 02-01-17 End Date: 02-01-17 (*please note that our system does not have the capability to run this report as a date range, but instead as the number of all active patients for our practice at the time of the report) Performance Re-Measurement (% or #): 8/550 = 1.5% 6. Assess actions and describe improvement. (6E 1) By running reports and contacting patients that needed 2 year well-child checks, our goal was to decrease the percentage by 1%. During the period of 08-23-16 to 02-01-17, we did demonstrate improvement in 2 year olds without a WCC by decreasing from 2.7% to 1.5% which surpassed our goal of 1.7%. Use ONE Measure Identified in 6B Measure 1: Medication Reconciliation 1. Measure selected for improvement; reason for selection Reason: Medication reconciliation, especially during a transition of care, creates the most accurate list possible of the patient’s medications. We chose this measure because this is very important for patient health and safety. 2./3. Baseline performance measurement; numeric Baseline Start Date: 10-06-15 Baseline End Date: 01-05-16 Baseline Performance Measurement (% or #): 239/295 = 81%
NCQA-PCMH-2014-Quality-Measurement-and-Improvement-Worksheet-11.21.2016.docx