AIM
Quality dimension
Effective
Measure
Objective
Improve rate of
cancer screening.
Unit /
Measure/Indicator Population
Percentage of patients % / PC
aged 50-74 who had a organization
fecal occult blood test population
within past two years, eligible for
sigmoidoscopy or
screening
barium enema within
Percentage
ofawomen % / PC
five years, or
aged
21 to 69within
who
organization
colonoscopy
had
a
Papanicolaou
population
the past 10 years
(Pap) smear within the eligible for
past three years
screening
Improve rate of
HbA1C testing for
diabetics
Percent of
respondents who
responded positively
to the question:
"When you see your
doctor or nurse
practitioner, how
often do they or
someone else in the
office give you an
opportunity to ask
questions about
% / PC
organization
population
(surveyed
sample)
Current
Source / Period Organization Id performance
See Tech Specs / 91432*
62
Annually
91432*
62
69
18
96.54
Patient Experience
Improve Patient
Experience: Patient
involvement in
decisions about
care
Percent of patients
who stated that when
they see the doctor or
nurse practitioner,
they or someone else
in the office
Improve Patient
Percent
of patients
(always/often)
involve
Experience:
who
themresponded
as much as they
Primary care
positively
want to betointhe
providers spending question:
"Whentheir
you
decisions about
enough time with
see
or
careyour
and doctor
treatment?
patients
nurse practitioner,
how often do they or
someone else in the
office spend enough
time with you?"
% / PC
organization
population
(surveyed
sample)
97.57
% / PC
organization
population
(surveyed
sample)
98.28
Target
65.00
65.00
70.00
20.00
100.00
Change
Target
Planned improvement
justification
initiatives (Change Ideas) Methods
As indicated last
year, we hope to
engage clerical
staff to assist
with the
identification of
Now
thatdue
we for
patients
have
a new NP
screening
onboard, we
hope to surpass
last year's
performance
Traditionally we
have found
patient
engagement
difficult in the
Diabetes
The
majority
of
Program,
so we
healthy
people
are aiming
for ain
the
community
modest
but
still
choose
not to
steady
target
get
seasonal
flu
increase
of 1%.
shots
we
will
We
will continue
Maintain
current
continue
towe
offer,
to raise as
but
expect
improve. no
more than a
modest increase
of 2%. Interest
depends on when
the vaccines
become available
and what's 'going
around' prior to
that.
100.00
maintain current
100.00
maintain current
Process measures
Comments