Disparity: Uninsured receive fewer mammograms performance: Uninsured patients receive fewer mammograms than insured patients 2./3. Baseline performance measurement and numeric goal for improvement (6D 7) Baseline Date: 07/2015 Baseline End Date: 12/2015 Baseline Performance Measurement for Vulnerable Population (% or #): 25/100 = 25% of uninsured receive mammograms Baseline Performance Measurement for General Population (% or #): 600/1000 = 60% of insured women receive mammograms Numeric Goal (% or #): 50% of uninsured women receive mammograms 4. Actions taken to improve and work toward goal; dates of initiation (6D 7) (Only 1 action required) Action: Identified community resources for free or low-cost mammograms and shared with uninsured patients Date Action Initiated: 1/2016 Additional Actions: 5. Remeasure Performance Note: Continuing QI is encouraged, but is not required for 6D 7. Start Date: End Date: Performance Re-Measurement (% or #): 6. Assess actions; describe improvement Note: Continuing QI is encouraged, but is not required for 6D 7. During a 1-year measurement period from July–Dec 2015, was a 30 percentage point difference in screening rates between insured and uninsured women. After compiling a list of community resources and sharing the information with our uninsured population, we saw a 15 percentage point increase in the number of uninsured women receiving mammograms during the remeasurement period of Jan–July 2016. Practice Name: Wake Forest Pediatric Associates, PLLC Date Completed: 02-28-17
scheduled appointments to come in for the vaccine. If unable to reach parent(s) by phone, a letter was mailed to the parent Date Action Initiated: 09-01-16 Additional Actions: If unable to the patient by phone/mail or if the patient never came to the appointment for the vaccine, the provider was notified and a pop-up reminder was placed in the chart in EHR. 5. Remeasure performance (6E 1,2) Start Date: 02-21-17 End Date: 02-21-17 (*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 #): 51/565 = 9% 6. Assess actions; describe improvement (6E 1) NCIR and EHR reports for 2 year old DTaP vaccine administration were reviewed monthly. Patients who were not up-to-date on this vaccine were reminded via phone or mail to comply with CDC guidelines. Parents were advised of the importance and need for this vaccine. Our reports demonstrate that our actions did improve compliance with DTaP vaccination recommendations. Our percentage of patients that were not up-to-date decreased from 11% to 9%, surpassing our goal of 10%. Measure 3: Active patients who are 2 years old without a Well-Child Check (WCC) 1. Measure selected for improvement; reason for selection Reason: According to guidelines from Bright Futures/American Academy of Pediatrics, 2 year olds should have a Well-Child Check (WCC). The Bright Futures/AAP 2016 “Recommendations for Preventive Pediatric Healthcare” states “The AAP continues to emphasize the great importance of continuity of care in comprehensive health supervision and the need to avoid fragmentation of care.” https://brightfutures.aap.org/ 2./3. Baseline performance measurement, numeric goal for improvement. (6D 1) Baseline Start Date: 08-23-16 Baseline End Date: 08-23-16 (*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)
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%