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.

Goals and Actions to Improve Patient Experience (QI 11)

Sets goals and acts to improve performance on at least one patient experience measure.

Sample

Improved Performance (QI 12)

Achieves improved performance on at least two performance measures.

Sample

Goals and Actions to Improve Disparities in Care/Service (QI 13)

Sets goals and acts to improve disparities in care or services on at least one measure.

Sample

Improved Performance for Disparities in Care/Service (QI 14)

Achieves improved performance on at least one measure of disparities in care or service.

Sample

Reporting Performance within the Practice (QI 15)

Reports practice-level or individual clinician performance results within the practice for measures reported by the practice.

Sample

Reporting Performance Publicly or with Patients (QI 16)

Reports practice-level or individual clinician performance results publicly or with patients for measures reported by the practice.

Sample

Patient/Family/Caregiver Involvement in Quality Improvement (QI 17)

Involves patient/family/caregiver in quality improvement activities.

Sample

Reporting Performance Measures to Medicare/Medicaid (QI 18)

Reports clinical quality measures to Medicare or Medicaid agency.

Sample

Value-Based Contract Agreements (QI 19)

Is engaged in Value-Based Agreement.

Sample
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