Example: Clinical Measure Measure 1: Colorectal cancer (CRC) screening 1. Measure selected for improvement; reason for selection Reason: The USPSTF has recommended screening for colorectal cancer as a preventive test for adults. We want to increase percentage of patients who receive screening for CRC. 2./3. Baseline performance measurement; numeric goal for improvement (QI 01) Baseline Start Date: 5/1/16 Baseline End Date: 5/30/16 Baseline Performance Measurement (% or #): 56/547 = 32.0% Numeric Goal (% or #): 58% 4. Actions taken to improve and work toward goal; dates of initiation (QI 08) (Only 1 action required) Action: Pop-up reminders were added to our EMR for patients due/overdue screening Date Action Initiated: 7/1/16 Additional Actions: Provider quality compensation metric put in to incentivize providers to ensure appropriate health screening. 5. Remeasure performance (QI 12) Start Date: 5/1/17 End Date: 5/30/17 Performance Remeasurement (% or #): 380/550 = 69.1% 6. Assess actions; describe improvement. (QI 12) July 2016, there has been an increase of 37.1 percentage points in patients receiving CRC screening due to incentivizing providers and use of clinical decision support of EMR to indicate when patients are due for screening. Example: Identify a Disparity in Care for a Vulnerable Population Vulnerable population: Uninsured women 1. Identify a disparity in care for a vulnerable population Describe a comparison of a vulnerable population against the general population in which the vulnerable population received care/service at a lower performance: Uninsured patients receive fewer mammograms than insured patients
Measure 1: 1. Measure selected for improvement; reason for selection Reason: 2./3. Baseline performance measurement; numeric goal for improvement (QI 03) Baseline Start Date: Baseline End Date: Baseline Performance Measurement (% or #): Numeric Goal (% or #): 4. Actions taken to improve and work toward goal; dates of initiation (QI 10) (Only 1 action required) Action: Date Action Initiated: Additional Actions: 5. Remeasure performance Note: Continuing QI is encouraged, but is not required for QI 10. Start Date: End Date: Performance Remeasurement (% or #): 6. Assess actions; describe improvement. Note: Continuing QI is encouraged, but is not required for QI 10. Use FIVE Measures Identified in QI 08, QI 09 and QI 11 Measure 1: 1. Measure selected for improvement; reason for selection Reason: 2./3. Baseline performance measurement; numeric Baseline Start Date: Baseline End Date: Baseline Performance Measurement (% or #):
5. Remeasure performance (QI 12) Date: End Date: Performance Remeasurement (% or #): 6. Assess actions; describe improvement. (QI 12) Use ONE Measure Identified for Disparity in Care or Service Vulnerable population: Disparity: 1. Measure selected for improvement; reason for selection Describe a comparison of a vulnerable population against the general population in which the vulnerable population received care/service at a lower performance: 2./3. Baseline performance measurement, numeric goal for improvement. (QI 05) Baseline Start Date: Baseline End Date: Baseline Performance Measurement for Vulnerable Population (% or #): Baseline Performance Measurement for General Population (% or #): Numeric Goal (% or #): 4. Actions to improve and work toward goal; dates of initiation (QI 13) (Only 1 action required) Action: Date Action Initiated: Additional Actions: 5. Remeasure performance. (QI 14) Date: End Date: Performance Re-Measurement (% or #): 6. Assess actions and describe improvement. (QI 14)