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.

Monitors at least five clinical quality measures across four categories

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Monitors at least two measures of resource stewardship

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Assesses performance on availability of major appointment types to meet patient needs and preferences for access.

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Monitors patient experience

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Assesses health disparities using performance data stratified for vulnerable populations

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The practice uses a standardized, validated patient experience survey tool with benchmarking data available.

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The practice obtains feedback on experiences of vulnerable patient groups.

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Sets goals and acts to improve upon at least three measures across at least three of the four specified categories

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Sets goals and acts to improve performance on at least one measure of resource stewardship.

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Sets goals and acts to improve on availability of major appointment types to meet patient needs and preferences.

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